Based on resident council interviews, review of resident council grievances, staff interviews, and policy reviews, the facility failed to demonstrate acting upon 1 of 1 sampled grievances filed by the resident council regarding food. The findings include: A meeting was held with the Resident Council members in the facility on 5/7/25 at 2:20 PM, which included Residents 2, 17, 30, 32, and 55. During the meeting, the residents voiced ongoing concerns about the variety and quality of the food served by the facility. The residents stated the food was sub-par and the menu changed based on what the kitchen has available. The only alternate meal items that are available were a grilled cheese sandwich, egg salad sandwich, tuna sandwich, or peanut butter and jelly sandwich. They have voiced several complaints about the food and do not always receive the monthly resident choice meal either. They can no longer have fried chicken because the facility cannot purchase oil to fry the chicken, and they bake the chicken instead. They stated that families bring in food from outside to the residents. The Resident Council meeting minutes dated 2/27/25 revealed the residents wanted meal changes and different food. The Resident Council minutes dated 12/2024 revealed that the residents wanted a change of their food menu. A grievance filed by the Resident Council dated 3/19/25 and documented by the Social Services Director revealed a concern with the lack of variety of food and having the same dinners over and over. The findings of the investigation stated,Pictures of portion sizes and repetitive menu items sent to corporate. Plan to resolve grievance: facility will work with contracted company to improve portion size and variety of menu items offered. Expected results of actions taken: corporate to work with agency providing kitchen food services to improve food offered to residents. Post-investigation follow-up notes indicate that the grievance was not resolved and the facility continues to work with the agency to provide better food options. The original complainant stated they were not satisfied and had ongoing concerns with food. The investigation results and resolution steps were reported to Resident Council dated 3/26/25. An interview was conducted with the Dietary Manager on 5/8/25 at 9:55 AM. She stated that the Resident Council has complained about portion sizes and the quality of the food served by the facility. She had no knowledge of the grievance filed by the Resident Council on 3/19/25. She stated the menu was changed to the summer menu but that was not in response to the grievance and was a routine process this time of year. She stated the last resident choice monthly meal was served in February 2025 and she had not received the requested meals from the Activities Director monthly. An interview was conducted with the Social Services Director on 5/8/25 at 10:15 AM. She stated the Resident Council had ongoing concerns with the food and lack of variety. The staff were to take pictures of the food and send to corporate. She stated a contractor has a budget for the food and oversees the purchases for the food supply. She stated the grievance was reported to the corporate entity and she was not able to provide any evidence of measures the facility took to resolve the grievance or follow-up regarding the food. The facility policy for Grievances (dated 9/7/23) states, The center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews, and staff interviews, the facility failed to maintain resident equipment in a safe and sanitary manner in 1 of 20 rooms. (room [ROOM NUMBER]) The findings include: On 05/05/25 at approximately 12:00 pm, upon observation of room [ROOM NUMBER], it was noted that the base boards visible from the entrance of the room were damaged, cracked, and held together with blue painter's tape and that the bed frame of one of the residents in this room had extensive rust covering more than half the length of the bed. On 05/06/25 at approximately 12:50pm, an interview was performed with Maintenance Employee A and the Administrator about maintenance issue tracking. Employee A stated that he rounds daily to make sure exit doors are working properly, inspects the hallways for anything obvious that might need fixing, and checking the maintenance log that is located at each nurse's station. When asked about the rusted bed frame and baseboards from room [ROOM NUMBER], Employee A stated that he knows beds are on order and was not aware of the extent of rust on the bed and about the damaged based boards. The maintenance log at the nurse's station indicated that replacement light bulbs were needed in room [ROOM NUMBER] on 05/05/25. Employee A stated that he did enter the room that day to replace the bulbs but did not sign that he completed the work order, nor did he notice the rust on the bed or the broken base boards with blue painter's tape. On 05/07/25 at approximately 12:00pm, an interview took place with the Administrator about the bed frame. At approximately 12:20pm, the Administrator came to clarify that bed order information was requested. However, on 05/08/25 at approximately 2:00 pm, the Administrator confirmed that no beds have been ordered at this time.

Resident #51 On 05/08/25 at 09:08 AM, an observation of Resident #51 revealed the resident was sitting next to beauty salon waiting to get her hair done this morning. When asked if she felt that she was being treated with dignity and respect, she stated that they aren't treating me right. When asked who is not treating her right, she responded, all of them. The resident was well dressed and groomed. On 05/08/25 at 12:06 PM an interview was conducted with the daughter of Resident #51. She stated there were times when the aids were rough with her mother. She stated her mother complains a lot about the staff. She knows her mom has dementia, but she can still say what is going on around her. A review of the care plans for Resident #51 revealed there were no care plans in place for the resident behaviors or false allegations. Resident #51 has care plans risks for falls/injury related to falls related to History of falls, Impaired mobility, Poor balance, Poor safety awareness, Cognitive status increases risk, Forgets to use assistive devices, Antidepressant medications, antiplatelet medication use, Visual deficit and Risk for alteration in communication related to being Hard of Hearing. However, there are no care plan interventions in place for behaviors as described by the staff for Resident #51. On 05/08/25 at 12:31 PM, an interview was conducted with the DON. The DON stated Resident #51 complains about a lot about things. The facility has had many aides not coming back to work because of the demands the daughter has made. When asked why these behaviors are not in her care plan, she stated that the behaviors should have been care planned. Based upon observations, record reviews, and interviews, the facility failed to provide a comprehensive person-centered care plan process to meet the needs and services for six out of twenty-one residents reviewed. (Residents #5, #10, #27, #79, #31, and #51) The findings include: Resident #5 A record review on 5/6/25 of Resident #5 revealed diagnoses of Chronic obstructive pulmonary disease (COPD), Dementia, Schizophrenia, Cerebrovascular accident (CVA), Type 2 Diabetes, Epilepsy, and Heart Failure. A plan of care was initiated on 8/26/24 for review of functional abilities with goal to maintain current level of functioning abilities but no interventions were in place. Resident #5 had no plan of care in place prior to 5/7/25 for limited range of motion. This plan of care was initiated post interview with the Director of Nursing (DON) on 5/6/25. The DON stated that the facility only had a partial restorative program in place for dining activities only. Resident #10 A record review on 05/06/25 for Resident #10 revealed diagnoses of Chronic respiratory failure, Arteriosclerotic Heart Disease (AHD), systolic congestive heart failure, Paraplegia, Type 2 diabetes, and epilepsy. Resident #10 is on hospice services. Resident #10 requires oxygen at 2 liters per minute by nasal cannula continuously except when smoking. The plan of care does not reflect if Resident #10 is a safe smoker and does not reflect that she requires supplemental oxygen therapy. Resident #10 has a indwelling foley catheter with current interventions: position catheter and tubing below bladder and away from entrance room door and to monitor for pain and discomfort only. Resident #27 A record review on 5/7/25 for Resident #27 revealed diagnoses of CVA, Dementia, COPD, Atrial fibrillation (AFIB), Cognitive communication deficit and requires assistance with personal care. Resident #27 has a elopement risk plan of care initiated on 3/17/25 with interventions to include monitor for fatigue and secure unit. Resident #27 is currently not residing on a secure unit. She has a plan of care for alteration in functional performance with current interventions that include providing a wheelchair with partial / moderate assistance of 1 person and reporting changes as needed. Resident #27 does not have a plan of care for Dementia, CVA, behaviors related to psychotic disorders, or for communication deficit. Resident #79 A record review on 5/6/25 for Resident #79, who was admitted to facility on 1/12/25, revealed diagnoses of CVA, Dementia, phonological disorder, type 2 diabetes, and receiving hospice services. Resident #79 requires cueing, supervision, and minimal assistance with Activities of daily living. On 1/24/25, a care plan was initiated for alteration in functional status with intervention to report changes in functional performance. A plan of care for alteration in activities of daily living was not initiated until 05/05/2025. Resident #79 was admitted to the facility with hospice services, and a plan of care was initiated on 1/13/25 for end stage disease process. On 5/5/25, a plan of care was initiated for Hospice services with a terminal diagnosis. On 5/5/25 a plan of care was initiated for diabetes, incontinence of bladder, and incontinence of bowel, although he was admitted to facility on diuretic medication. Resident #31 A record review on 5/7/25 revealed Resident #31 had diagnoses of Atrial Fibrillation, Type 2 Diabetes, Epilepsy, AHD, Cardiac pacemaker, Cirrhosis of the liver, and Hepatic encephalopathy. There were no plans of care specific for each disease process for Resident #31. Resident #31 had a plan of care for antibiotic therapy initiated on 2/10/2025 with a goal for the resident to be free from complications related to infection. She is care planned for emotional and physical trauma with a goal that she will feel safe and supported. She is care planned for alteration in functional status with intervention for one staff member to assist with personal care and to report changes; high risk medication use with intervention to monitor for side effects of medications and report changes. On 5/8/25, an interview with DON was performed about the care plans. She acknowledged that these care plans did not directly address the residents' care needs.

Based upon observations, interviews and record reviews, the facility failed to meet the needs and services of resident number 27 who is unable to carry out activities of daily living. The findings include: An observations was conducted on 05/05/27 at 12:30 PM revealed resident 27 lying in bed with her head resting against the side rail, hair appears tangled, unkept, and messy with her bangs hanging over into her eyes. Resident 27 teeth appear to have yellowish colored substance build up around teeth and gums when she smiled, shirt unclean with notable stains on the front of the shirt. On 5/6/27 at 08:40 AM resident 27 is observed laying in bed with a yellow and white striped shirt on, pulled up to her upper torso just below her breast area, incontinent brief on, with a white thin sheet covering her lower extremities. Her teeth is observed with a thick yellowish substance around her teeth and gum line. Her hair is messy and unkept. An observation was made on 5/6/27 at 12:21 PM of resident 27 coming out of dining room with assistance from staff noted to be in a pair of black pull up pants, incontinent brief appearing over the top of her pants, white short with tan and brown stains on left arm sleeve of shirt, on the front of her shirt down to her torso area, shirt is pulled up exposing her abdomen area, hair is messy with food particles in her lap. At 01:30 PM and 04:01 PM resident is sitting I wheelchair at nurses station, slumped down in the wheelchair with her legs extended outward in front of her, eyes closed, her head is resting on the left hand, she is wearing the black pants and white stained shirt with food particles in her lap. An observation was made on 5/7/25 at 12:00 PM sitting in hallway in her wheelchair at nurses, she is dressed in a dark pink pair of capri pants and matching top, yellow non-skid socks on bilateral feet. She has food particles and stains on the front of her shirt and in her lap. Her hair is disheveled, and her bangs are hanging in her eyes. Her teeth continues to have thick yellowish build up around them and her gumline. On 05/07/25 at 03:30 PM and at 06:00 PM resident 27 is observed sitting up in wheelchair, with same dark pink clothing on with continued food stains and food particles on her clothing. She is in slouching position with feet extended outward in front of her; her upper back and neck area is resting against the back top of the wheelchair and has her head propped up against her left hand. On 5/08/25 at 08:10 AM an observation of resident 27 revealed her laying in bed with a pajama top on, navy blue with small different color flowers on it, food particles on her mouth, lips and on the front of her shirt. A white sheet is noted to be covering her from the waist down. Hair is messy and appears unkept. Her teeth has a thick yellowish substance around her gum line and teeth. At 11:45 AM an observation of resident sitting in dining room, hair appears to be brushed, staff member states, the therapist just brought her in here, she is in a shirt sleeve multicolored striped shirt and dark blue pants. Her teeth continues to have a thick yellowish substance around her gum line and teeth. Upon record review the MDS assessment with ARD date of 3/11/25 section GG indicates resident 27 requires moderate to maximum assistance with personal hygiene care, showers, incontinent care, dressing, toileting, and transfers. Resident 27 plan of care reveals resident 27 has an alteration in functional performance, requires assistance to complete self-care tasks with goal that resident 27 will maintain the highest practical level of functioning performance, Interventions include staff will provide assistance with hygiene, mobility, dressing, grooming, oral care, and toileting needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, interviews and record review, the facility failed to provide care and services for 1 of 1 residents reviewed for range of motion (Resident #5). The findings include: An observation of Resident #5 was made on 5/6/25 at 08:30 AM. The resident was lying in bed awake and alert, with the head of the bed (HOB) elevated at an approximately 90-degree angle. The bedside table was placed in front of Resident #5 across her lap area with her breakfast tray sitting on top. Resident #5 reached for her cup with her left hand. Her left hand had a contracture with the third, fourth, and fifth digits resting on her left inner palm. No splints or devices were observed on her left hand. At 12:00 PM, Resident #5 was observed sitting up in her bed with the HOB elevated at a 90-degree angle. Her lunch tray was sitting on top of the bedside table. Again she was observed without splints or devices to the left hand. Further observations on 5/6/25 at 2:00 PM and 4:30 PM; on 5/7/25 at 8:30 AM, 11:30 AM, 1:00 PM, and 3:30 PM; and on 5/8/25 at 8:33 AM, 9:30 AM, and 12:00 PM revealed that Resident #5 did not have any splints or devices in her left hand to address the contractures. On 5/8/25, Staff Member B (a Certified Nursing Assistant (CNA)) was at her bedside assisting resident 5 up out of bed. An interview was conducted with Staff Member B at that time. She revealed that she is the restorative aide for the facility. She was asked about Resident #5's contracture to her left hand. Staff Member B stated the resident has had these contractures since she was admitted to the facility. Staff B stated they provide range of motion and splints devices for Resident #5 when they have enough staff. Staff B stated she has to perform regular CNA duties at least three times a week if not more. Staff Member B stated they have not had a restorative program for a while, but she became the restorative aide in January of this year. Her job duties include splints, range of motion, dining, and all the monthly and weekly weights for the entire facility. Upon record review of the Minimum Data Set (MDS) assessment from 2/17/25, it was discovered that Resident #5 has a Brief Interview for Mental Status (BIMS) score of 6. The MDS revealed that Resident #5 has impairment to upper extremity and impairment to bilateral lower extremities. A review of physical and occupational therapy screenings revealed the resident's initial physical therapy screening was conducted on 8/20/24, revealing that Resident #5 had functional limitations due to contractures and limited range of motion to right hip, right knee, left hip, and left knee. Her Discharge summary dated [DATE] from physical therapy services reveals recommendation for 24-hour care, but no restorative and functional programs indicated at this time. The initial occupational therapy screening dated 8/24/24 revealed right and left upper extremity were Within Functional Limits with no contractures noted. The occupational Discharge summary dated [DATE] recommends 24-hour care but no restorative program or functional maintenance program not indicated at this time. A record review reveals a care plan for alteration in functional performance due to a history of CVA and left side hemiparesis with a left hand contracture that was initiated on 8/26/24. An interview with the Director and Assistant Director of Nursing was conducted on 5/7/25 at 02:20 PM. They stated that the facility had a partial restorative program for dining only. A care plan was initiated on 05/07/25 for alteration in musculoskeletal status related to left hand contracture and will remain free from pain and will remain free from complications related to left hand contracture.

Based on resident interview, record review, and staff interview, the facility failed to provide appropriate care and services of an arteriovenous (AV) fistula for 1 of 1 sampled residents receiving dialysis services. (Resident #39) The findings include: An interview was conducted with Resident #39 on 5/6/25 at 9:15 AM. She stated she had a new fistula in her left arm and the nursing staff did not touch, palpate, or assess the fistula. A review of the resident's medical record revealed the new AV fistula was placed on 4/10/25. The record revealed no physician's orders to check the bruit and thrill of the fistula until an order was placed on 5/7/25. (A thrill is a vibration felt when touching the fistula, and a bruit is a swishing or whooshing sound that can be heard with a stethoscope over the fistula. Both are indicators of normal blood flow through the fistula and are essential for its proper function.) A review of the hospital discharge instructions dated 4/10/25 revealed on page 7 that the fistula site should be checked daily to make sure the thrill feels the same. The record revealed the thrill was only assessed by nursing staff on 4/12/25, 4/13/25, and 4/20/25. An interview was conducted with the Director of Nursing (DON) on 5/8/25 at 11:12 AM. The DON stated the resident had no orders prior to 5/7/25 to monitor the bruit and thrill of the new fistula in her left arm. She stated the resident should have had the bruit and thrill monitored since the fistula was placed on 4/10/25.

Based on record review and staff interview, the facility failed to provide medication to prevent hepatic encephalopathy (swelling of brain caused by liver disease) as prescribed to Resident #31 who subsequently experienced a change in condition which required transfer to a hospital. The findings include: A record review conducted on 5/6/25 for Resident #31 revealed that the resident was admitted to the facility with a diagnosis of hepatic encephalopathy and liver cirrhosis (scarring of the liver affecting its function). Resident #31 was prescribed rifaximin 550 mg (milligrams) twice a day to treat hepatic encephalopathy . The nursing home medication administration record and progress notes revealed that Resident #31 did not receive rifaximin 1/27/25, 1/26/25, 1/24/25, or 1/18/25 due to the medication not being available from the pharmacy. On 1/31/25 a change of condition progress note revealed Resident #31 was experiencing increased tremors, increased confusion with sudden decline in self-care activities of daily living . A review of the hospital notes found on 1/31/25 Resident #31 was transferred to an acute care hospital for altered mental status exhibiting uncooperative behaviors and tearfulness. Upon further review the hospital discharge summary report dated 2/4/25 documented the nursing home was out of the rifaximin for the last several days. A review of the package insert for rifaximin found that an indication for use is to reduce the risk of overt hepatic encephalopathy (HE) recurrence. Symptoms of hepatic encephalopathy range from mild cognitive changes to severe neurological disturbances, including confusion, disorientation, and even coma. An interview conducted with Director of Nursing (DON) on 5/6/25 at approximately 10:00 AM revealed that Resident #31 has episodes of confusion but is cooperative with care and services. The DON further stated, on most days, Resident #31 will be up out of bed, dressed and groomed with her hair done and make-up on; with other days when she will sleep most of the day. The DON stated that Resident #31 becomes more confused and more emotionally upset when she does not get her liver medications. The DON stated the pharmacy sends only a five-day supply of rifaximin at a time because it is really expensive, costing over $100 dollars per day. The surveyor inquired about the several days of missing medication, and the DON responded that Resident #31 only missed that one day, on 1/31/25, when she went out to the hospital. The DON declined to comment on the multiple missed doses of rifaximin as indicated by the MAR.

Based on policy review, record review, and staff interview, the facility failed to provide documentation that 4 of 6 residents reviewed received education and were offered the pneumococcal immunization. (Resident #21, #76, #14, and #50) The findings included: Upon a review of Residents #21, #76, #14, and #50's medical records, it was discovered that they were missing documentation about Education and Consent or Declination of the Pneumococcal Immunization. After reviewing the paper and electronic medical record, an interview with the Assistant Director of Nursing (ADON) was conducted on 05/6/25 at 12:45pm about how often the flu and Pneumoncoccal vaccines are offered. The ADON stated they are offered yearly in the fall. If a resident declines immunizations, the ADON stated There should be a declination on the chart. An interview was conducted with the facility's Director of Nursing (DON), Assistant Director Of Nursing (ADON), and Administrator on 05/06/25 at approximately 2:30 pm. The DON stated that every resident receives education on immunizations on admission and, if they decline, there should be a declination form in the chart. When informed that no such forms were present for Residents #21, #76, #14, and #50, they attempted to locate these forms, However, they were unable to provide this documentation. The facility's policy titled Pneumonia Vaccine (effective date 09/07/2023) states: * Prior to or upon admission, residents are assessed for eligibility to receive the the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated *Assessments of pneumococcal vaccination status are conducted within five working days of the resident's admission if not conducted prior to admission. * Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination protocol

Based on policy review, record review, and staff interview, the facility failed to provide documentation that 5 of 6 residents reviewed received education and were offered the pneumococcal immunization. (Resident #72, #21, #76, #14, and #50) The findings included: Upon a review of Residents #72, #21, #76, #14, and #50's medical records, it was discovered that they were missing documentation about Education and Consent or Declination of the COVID Immunization. After reviewing the paper and electronic medical record, an interview with the Assistant Director of Nursing (ADON) was conducted on 05/6/25 at 12:45pm about how often the COVID vaccines are offered. The ADON stated they are offered yearly in the fall. If a resident declines immunizations, the ADON stated There should be a declination on the chart. An interview was conducted with the facility's Director of Nursing (DON), Assistant Director Of Nursing (ADON), and Administrator on 05/06/25 at approximately 2:30 pm. The DON stated that every resident receives education on immunizations on admission and, if they decline, there should be a declination form in the chart. When informed that no such forms were present for Residents #21, #76, #14, and #50, they attempted to locate these forms, However, they were unable to provide this documentation. The facility's admission Packet states that every resident is to be offered a form to be educated and offer a COVID vaccination if indicated. Resident or residents' representative is required a signature to indicate if patient will receive or decline a COVID immunization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to ensure each resident's bedroom was equipped to provide full visual privacy for 2 of 20 sampled resident rooms. (Room numbers 219 and 220) The findings include: An observation of rooms [ROOM NUMBERS] was conducted with the Maintenance Director and the Administrator on 5/7/25 at 1:35 PM. The Maintenance Director measured the privacy curtain between the occupied beds in room [ROOM NUMBER] and stated the curtain between the beds was about 2 feet too short in width to insure complete visual provacy. The Maintenance Director and Administrator then observed the privacy curtains in room [ROOM NUMBER]. The Maintenance Director measured the privacy curtain between the beds in room [ROOM NUMBER] and stated the curtain was about 18 inches too short in width to insure complete visual provacy. (Photographic evidence was obtained.) An interview was conducted with the Administrator on 5/7/25 at 1:24 PM. The Administrator stated she expected each room to be equipped to provide full visual privacy to each resident.

Based on record review and interview, the facility failed to ensure that employee performance reviews were completed every 12 months for 1 of 6 sampled Certified Nursing Assistant (CNA) staff members. (Staff Member D) Additionally, the facility failed to ensure that 1 of 6 staff members received annual training for responding to cognitively impaired residents with difficult behaviors every 12 months. (Staff Member D) The findings include: On 10/30/24 at approximately 10:55 AM, an interview was conducted with Staff Member D, a CNA. She was asked if she recalled her last training regarding resident rights and abuse prevention, working with cognitively impaired residents with difficult behaviors, dementia, and annual performance evaluation. She explained she knew she had had the trainings and evaluations but could not provide information regarding when the trainings and last performance evaluation occurred. On 10/31/24 at approximately 10:00 AM, a review of the employee file for Staff Member D was conducted. Staff Member D was hired on 10/20/22 according to the background screening on file and the employee list. A copy of the Mental Health Challenging Behaviors Competency Check Off dated 10/30/24 was provided. An employee evaluation dated 10/30/24 was provided. The facility did not provide any employee evaluations prior to 10/30/24. The facility did not provide any training in responding to cognitively impaired residents with difficult behaviors prior to 10/30/24. On 10/31/24 at approximately 10:20 AM, the Director of Nursing (DON) was interviewed. She was asked to provide a copy of the staff education plan. She was also asked when the performance evaluation and training was conducted for Staff Member D. The DON indicated the performance evaluation and training was completed yesterday evening. She was not able to provide information regarding completion of working with cognitively impaired residents with difficult behaviors training or annual performance evaluations for Staff Member D prior to 10/30/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to develop a care plan for 1 of 3 residents sampled for wound care. (Resident #7) The findings include: On 8/7/24, a review of Resident #7's medical record was conducted. Resident #7 was admitted to the facility on [DATE] and discharged on 7/31/24 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, morbid obesity, hypertension, chronic kidney disease, and need for assistance with personal care. A physician's order dated 5/30/24 stated, Cleanse open area to right scapula with wound cleanser and apply Duoderm every 3 nights and as needed. A review of the most recent plan of care, dated 6/6/24, revealed it did not include goals and interventions related to wound care. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in section M, Skin conditions, that resident #7 received nonsurgical dressings and applications of ointments/medications. On 8/8/24 at 4:28 PM, an interview was conducted with Staff R, a Registered Nurse and the facility's Minimum Data Set (MDS) coordinator. She reviewed Resident #7's plan of care and verified the resident should have been care planned for wounds on the most recent review because Resident #7 had wounds prior to that date. A review of facility's policy Care Plan-Comprehensive, dated 9/1/2022, was conducted. Policy stated, Overview: an individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy (Bullet 2) stated each resident's comprehensive care plan is designed to identify the professional services that are responsible for each element of care.

Based on record review and interviews, the facility failed to obtain laboratory results for 1 of 1 residents sampled for blood sample testing. (Resident #7) The findings include: On 8/8/24, a review of resident #7's medical record was conducted. A physician ordered laboratory blood sample tests for a CBC (Complete Blood count), BMP (Basic Metabolic Panel) and Hemoglobin A1c dated 7/22/24. A review of resident #7's Treatment Administration Record (TAR) revealed the blood sample was documented as completed on 7/22/24. Further review of medical records revealed no results were on file. Laboratory results were requested by the Director of Nursing (DON), but none were provided. On 8/8/24 at 12:08 PM, an interview was conducted with Staff R, Registered Nurse (RN). She reviewed Resident #7's full medical records and confirmed there were no lab results for 7/22/24. Staff R, RN confirmed there was a physician's order dated 7/22/24. She further explained laboratory staff had come in the morning. She verified that Resident #7 had a check mark on his TAR documentation, which meant the collection was completed, but the results were not received.

Based on observation, resident interview, and staff interview, the facility failed to promote resident dignity and care for each resident in a manner and in an environment that promotes enhancement of his or her quality of life for 9 of 32 sampled residents (#1, #5, #6, #8, #11, #14, #16, #18 and #31). The facility failed to allow 4 of 32 sampled residents to wear their own personal clothing (Residents #1, #6, #11, #14, #18), failed to provide enough clean clothes for 2 of 32 sampled residents (Residents #8, #16), and failed to allow 1 of 34 sampled residents to be out of his room at night (Resident #16). The findings included: On 8/7/24 at approximately 9:35 AM, a strong smell of urine was noted in Resident #6's room. Resident #6 was observed to be unclothed in her bed. There was a soiled gown laying on her bedside table. It was also noted that her toenails were long. When interviewed, Resident #6 started crying immediately telling the surveyor that staff will not come to help her. She said they would not give her a bath. She explained that she has not had a bath in some time and cannot remember her last bath. She frustratedly repeated that she was naked and staff would not help her. She pulled down her sheet and used her hands to show that she unclothed. She repeated: I am naked and they won't do nothing for me. On 8/7/24 at approximately 9:55 AM, an interview was conducted with Resident #5. There were no pillow cases on the pillow she was using. The bed linen was visibly soiled. She said that she had asked for a bed spread the other day and still has not gotten one. She explained that she attempted to bargain with staff telling them she didn't need pillow cases if they would just change her sheets yesterday. She explained that staff still has not come to change her sheets. She was using the same sheets since Thursday of last week. On 8/7/24 at approximately 10:00 AM, Resident #1 was observed in bed awake. He was wearing a patient gown. When asked if he prefers to wear a gown, Resident #1 indicated he wears a gown a lot and would prefer to get dressed in clothes. Resident #1 indicated that he would like to get out of bed more often. On 8/7/24 at approximately 10:00 AM, Resident #11 was dressed in a gown but was unavailable for interview at the time of the observation. On 8/7/24 at approximately 10:00 AM, Resident #18 was observed dressed in a gown. She indicated her husband does her laundry, but she would prefer to wear her own clothing. On 8/7/24 at 1:45 PM, during wound care, Resident #14 was also observed dressed in a gown. He was asked after the observation if he would like to wear his clothes. The resident indicated he would prefer his own clothing. On 8/7/24 at approximately 10:20 AM, an interview was conducted Resident #8. She said that staff does not bring her clean clothes often enough. She said had been wearing the clothes she has on now for 4-5 days. On 8/7/24 at approximately 1:55 PM, during an interview with Resident #16, it was noted that he was wearing a patient gown. He indicated that he does not mind wearing patient gowns but that it often takes several days to get his clothes washed. He also said that night shift staff is rude. Resident #16 said that night shift staff frequently has an attitude or rude tone about everything. He said staff on night shift does not want him to come out of his room at night. He explained that he likes to stay up late and would like to come out of his room since he is awake. He said the night shift staff told him it is a fire hazard to be out of his room at night. On 8/7/24 at approximately 1:42 PM, an interview was conducted with Resident #31. She indicated she has problems getting incontinence care supplies in a timely manner. She explained that does not want to go around smelling like urine. She said she has had the same pull up on since yesterday evening and she has not been able to get staff to bring her more incontinence supplies yet today. Further observations of Resident #1 were made on 8/7/24 at approximately 1:44 PM and 5:00 PM and on 8/8/24 at approximately 6:00 AM and 9:40 AM. He remained dressed in a gown during every observation made. On 8/8/24 at approximately 2:30 PM an interview was conducted with the Director of Nursing. The surveyor pointed out that there were dignity concerns at the facility due to the number of residents wearing gowns that indicated they prefer to wear their own clothes. She indicated that they went around the building recently and provided clothing to residents in need of clothes.

Based on observation, resident interview, and staff interview, the failed to provide adequate supplies of clean laundry in 4 of 5 linen storage areas observed affecting 8 of 32 current residents sampled (#1, #5, #6, #8, #14, #16, #19, adn #21). The failure had the potential to affect all 92 residents residing at the facility. The findings include: On 8/7/24 at approximately 10:00 AM, Resident #1 was in bed awake. During the observation, the surveyor noted that he was wearing a patient gown. When asked if he prefers to wear a gown, Resident #1 indicated he wears a gown a lot and would prefer to get dressed in clothes. On 8/7/24 at approximately 9:45 AM, an interview was conducted with Resident #5. There were no pillow cases on the pillow she was using. The bed linen on her bed was visibly soiled. The resident stated that she asked for a bed spread the other day but still has not gotten one. She explained that she attempted to bargain with staff telling them she would do without pillow cases if they would have changed her sheets yesterday. She explained that staff still has not come to change her sheets. She was using the same sheets since 8/1/24. On 8/7/24 at approximately 9:45 AM, an observation of Resident #6's room immediately had a strong smell of urine. Resident #6 was observed to be unclothed in her bed. There was a soiled gown laying on her bedside table. She pointed out to the surveyor that she was unclothed. She said: I am naked and they won't do nothing for me. On 8/7/24 at approximately 10:20 AM, an interview was conducted Resident #8. During the interview, Resident #8 said that staff does not bring her clean clothes often enough. She said she had been wearing the clothes she has on now for 4-5 days. On 8/7/24 at 1:45 PM, during wound care, Resident #14 was also observed dressed in a gown. He was asked after the observation if he would like to wear his clothes. The resident indicated he would prefer his own clothing. On 8/7/24 at approximately 1:55 PM, during an interview with Resident #16, it was noted that he was wearing a patient gown. He indicated that he does not mind wearing patient gowns but that it often takes several days to get his clothes washed. He also said that night shift staff is rude. On 8/7/24 at approximately 10:25 AM, Resident #19 was observed asleep on her bed. There were no sheets under her. On 8/7/24 at approximately 10:30 AM, Resident #21's bed had a strong smell of urine. The sheets appeared wet with urine. No pillow case was on the pillow on the on the bed at the time. (Photographic evidence obtained) On 8/7/24 at approximately 1:42 PM, an interview was conducted with Resident #31 who stated that they have not changed her sheets for a week. On 8/7/24 at approximately 9:38 AM, an interview was conducted with Staff E, a Certified Nursing Assistant (CNA). During the interview Staff E indicated that they are often low on linen supplies. She described the situation with linen as horrible. On 8/7/24 at approximately 10:40 AM, an interview was conducted with Staff F, CNA. During the interview, she indicated that staff have difficulty getting clean linen. She stated that the linen rooms are poorly stocked. She stated that often the fitted sheets do not fit on the beds. For example, on 8/6/24, there was not enough sheets available until the end of the day shift. There were no fitted sheets for staff to apply to beds yesterday. She reported that management complains that residents and staff are stashing linen. She said available supplies of clean linen is often an issue. On 8/7/24 at approximately 10:50 AM a tour was conducted of the inside laundry rooms. The first room observed had very little linen supply available. Four of the shelves were completely empty. The other shelves were minimally stocked. There were less than 20 chuck pads, 10 towels, 10-15 sheets, no pillow cases, less than 10 soft blankets, no bed spreads, less than 20 patient gowns, and only 1 small stack of washcloths. The other linen storage room also had empty shelves and was minimally stocked. There were 2 stacks of towels, 1 small stack of washcloths, about 10 patient gowns, less than 10 chuck pads, less than 10 fitted sheets, less than 10 flat sheets, less than 5 pillow cases, 3 bed spreads, and about 10 soft blankets. (Photographic evidence obtained) The supply carts on each hall did not have any linen stored on them. On 8/7/24 at approximately 11:10 AM, an interview was conducted with the Maintenance Director. He verified that he is in charge of laundry services and just started in the position about 3 months ago. He was shown the lack of linens available and that staff and residents were complaining about lack of available linen. The Maintenance Director performed a tour of the laundry areas outside. There was a good stock of linens of all types still in plastic bags in one of the laundry areas. When asked why the linens in plastic bags were not out in circulation for use, he explained that that was emergency stock. The Maintenance Director was informed of staff and residents hoarding linens and that observations were made of residents without pillow cases and bed spreads. He indicated that he ordered more linen for the facility on Monday, including flat sheets, fitted sheets, pillow cases, bed spreads, and gowns. He was asked to provide a copy of the order form. He indicated that he did not know for sure if the order has actually been placed yet because all orders must be approved. The order would have to be reviewed and approved by the Administrator before it is initiated. He stated he is allowed to order linen once a month. If additional linens are necessary, they must be approved by the administrator, but the administrator is currently out on leave and the order is awaiting approval.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and staff, and grievance policy review, the facility failed to ensure the prompt resolution of grievances for 7 of 10 grievances sampled from May to July 2024 (Residents #4, #5, #14, #16, #28, #29, and #30). The facility failed to document a grievance reported by Resident #16 in July, and failed to document any investigation for grievances filed by Residents #4, #5, #14, #28, #29, and #30 in July 2024. The findings include: A review of the grievances and grievance log for July 2024 revealed the following: There were 6 resident grievances for the month of July, 5 of which were noted on the log. Resident #28 filed a grievance on 7/15/24. This grievance stated that a night nurse snatched the resident's arm and stated, I'm not going to take care of you. The grievance form had no investigation or resolution noted, but it was signed by the Social Services Director (SSD). Resident #14 filed a grievance on 7/11/24. The grievance stated that, at night, nurses and aides were refusing to heat up water. The grievance form had no investigation or resolution. Resident #29 filed a grievance on 7/8/24. This grievance stated the resident did not have any clothes available and he was not able to eat in the dinner hall. The grievance form had no investigation or resolution. A family member of Resident #4 and #5 filed a grievance on 7/8/24. The grievance stated Resident #5 had not received medications in the past 3 hours and that Resident #4 had been wet for hours. The grievance forms had no investigation or resolution. Resident #30 filed a grievance on 7/4/24 related to missing clothes. The grievance form had no investigation or resolution. On 8/8/24 at 11:25 AM, an interview was conducted with Resident #16. Resident #16 stated he filed a grievance in July about Staff M, a Certified Nurse Assistant (CNA), being neglectful to him by not assisting him out of bed until 3:30 PM. Resident #16 stated he was supposed to get up between 9:00 - 9:30 AM. Resident #16 stated he sent text messages to the DON so he could have some proof. A review of the text messages between Resident #16 and the DON revealed the following exchange: On 7/20/24 at 11:13 AM: DON: hello, im grocery shopping, did you need something? You called me Resident #16: told I have to wait since breakfast to get cleaned up because I weigh too much DON wrote: [Staff S] (weekend supervisor) is coming to you to file grievance. We track and investigate, only way to change it [NAME] for calling me call me later after you talk [NAME] Resident #16- all right On 8/8/24 at 4:56 PM, an interview was conducted with the DON. The DON stated she was aware Resident #16 filed a grievance but the facility could not find any evidence of the grievance. The DON further stated that Staff S, RN, was the weekend supervisor and she was supposed to file a grievance. The DON added she never received one. The DON verified that the text messages provided by Resident #16 were a communication between her and the resident. The DON stated that the Social Services director who was responsible for the the grievances was terminated on Friday 8/2/24 secondary to not doing the grievances. The facility policy entitled complaint/grievance, dated 9/7/2023, was reviewed. The policy stated, The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. The grievance follow up should be completed in a reasonable time frame, this should not exceed 14 days. The findings of the grievance shall be recorded on the complaint/grievance form. The grievance official will log complaints/grievance on a monthly grievance log

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, record review, and policy review. the facility failed to provide timely assistance to residents in a timely manner for 1 of 15 residents sampled residents for oral care (Resident #1), 1 of 15 residents sampled residents for nail care (Resident #1), 3 of 15 residents sampled residents for podiatry care (Resident #1, #6, and #16), and 15 of 15 residents sampled for assistance with hygiene. (Resident #1, #5, #6, #8, #9, #12, #16, #19, #20, #21, #24, #31, #32, #33, and #34) The findings include: Resident #6 On 8/7/24 at approximately 9:35 AM, a strong smell of urine in the room was noted in Resident #6's room. She also was observed to be unclothed in her bed. There was a soiled gown that lay on her bedside table. Her feet were out from the sheets and visible. It was also noted that her toenails were long. When interviewed, Resident #6 started crying immediately saying that facility staff will not come to help her. She said they would not give her a bath. She explained that she has not had a bath in some time and cannot remember her last bath. She frustratedly repeated that she was naked and the staff would not help her. She pulled down her sheet and to show that she was unclothed. She repeated: I am naked and they won't do nothing for me. When asked if she would like staff to help her cut her toenails, Resident #6 indicated that she would appreciate having her toenails cut. She was unable to recall when she had seen a podiatrist. On 8/7/24, a review of the current care plan for Resident #6 was conducted. Resident #6 had an alteration in bowel continence. She had an indwelling Foley catheter. The care plan stated that Resident #6 was to receive incontinence care every 2 hours and as needed. She was to receive partial to moderate assistance with toileting, transfers, and hygiene. The care plan directed that Resident #6 receive Foley catheter care every shift. The care plan also stated that she required assistance with mouth care and assistance to perform activities of daily living and personal hygiene. A review of the current Minimum Data Set (MDS) information for Resident #6 indicated that she uses a manual wheelchair. She requires moderate assistance with toileting hygiene, showering/ bathing, and upper body dressing. She requires substantial assistance with lower body dressing, applying/removing footwear, and personal hygiene. She requires moderate assistance with standing from a chair and chair to bed transfer, transfer to toilet, and tub/shower. Resident #33 On 8/7/24 at approximately 9:38 AM, Resident #33 was seated in her wheelchair watching television in her room. The area around Resident #33 smelled strongly of urine. A review of her current MDS data was conducted. She uses a manual wheelchair. She requires supervision with oral hygiene, showering/bathing, personal hygiene, changing position from sitting to lying and sitting to standing. Resident #33 requires moderate assistance with toileting, hygiene, lower body dressing, applying/removing footwear, chair to bed and bed to chair transfers, toilet transfers, and tub to shower transfers. Resident #9 On 8/7/24 at approximately 9:40 AM, Resident #9 was in her bed asleep. Her room had a strong pungent odor of urine. A review of Resident #9's current MDS data was conducted. She requires set up and clean up after oral hygiene. She requires supervision for personal hygiene, applying/removing footwear, upper body dressing, sit to stand positioning, chair to bed and bed to chair transfers, and toilet transfers. She requires moderate assistance with toileting hygiene, shower/bathing self, lower body dressing, applying and removing footwear, and tub to shower transfers. Resident #12 On 8/7/24 at approximately 9:45 AM, an interview was conducted with Resident #12. She was asked about care and services. She reported that they need a lot more help, it often takes a long time to get any help in the evenings and at night. A review of current MDS data was conducted for Resident #12. She requires set up and cleanup for eating. She was dependent on assistance with showering and bathing. She requires substantial assistance with upper body/lower body dressing, applying/removing footwear. She requires moderate assistance with oral hygiene and personal hygiene. Resident #12 requires substantial assistance to roll left and right, is dependent for sit to lying assistance, dependent for lying to sitting on the side of bed, and dependent for sit to stand positioning. Resident #5 On 8/7/24 at approximately 9:55 AM, an interview was conducted with Resident #5. There were no pillow cases on the pillow she was using. The bed linen on her bed was visibly soiled. She told the surveyor that she asked for a bed spread the other day and still has not gotten one. She explained that she attempted to bargain with staff telling them she would go without pillow cases if they would have just changed her sheets yesterday. She explained that staff still has not come to change her sheets. She said that she was using the same sheets since Thursday of last week (8/1/24). She explained that the facility is very short of staff at times. She mentioned that sometimes staff is overwhelmed. She indicated that they often miss things. She explained that she believes that staff does not miss or ignore things purposely, but that they are just so busy that they forget. She said that other residents need more help than her so she tries to just be patient and wait. A review of the current MDS data for Resident #5 revealed that she used a manual wheelchair. She requires moderate assistance with personal hygiene, toileting hygiene, showering, and dressing her upper body, She requires substantial assistance with lower body dressing and applying/removing footwear. She requires partial assistance with bed to chair transfer, transferring to the toilet, tub/shower transfers, and sitting to standing positioning. Resident #1 On 8/7/24 at approximately 10:00 AM, Resident #1 was in bed awake. His lips looked dry and cracked. He was wearing a patient gown. His fingernails were long with debris under them. His toenails were long as well. When asked about how long it had been since his last bath, Resident #1 estimated it had been about two weeks since his last bath. When asked if he prefers to wear a gown, Resident #1 indicated he wears a gown a lot and would prefer to get dressed in clothes. Resident #1 indicated that he would like to get out of bed more often. He was unable to recall the last time he was assisted out of bed. Resident #1 was asked if his mouth was dry and if he had received assistance with mouth care. He said his mouth was dry and indicated he would appreciate assistance with mouth care. Staff was notified that Resident #1 requested assistance with mouth care. On 8/7/24 at approximately 5:00 PM and 8/8/24 at approximately 6:00 AM and 9:40 AM, Resident#1 was observed in bed dressed in a gown and positioned on his back during all 3 observations. On 8/7/24 at approximately 1:44 PM wound care was observed for Resident #1. He remained dressed in a gown. His nails and toenails were long during the observation. The Advance Practice Registered Nurse (APRN) conducted an assessment of the skin on both of Resident#1's feet. She made no comment regarding his nails after her assessment. An interview was conducted with the wound care nurse and the APRN regarding resident #1's finger nails and toe nails after wound care. The Wound care nurse explained that the unit manager goes around and checks and cuts residents nails once a month. The APRN said that there are standing podiatry orders for each resident to receive podiatry services as needed. A review of the current MDS data for Resident #1 revealed that he is completely dependent on staff for oral, care, bed mobility, bathing/showering, and transfers from bed to chair. On 8/8/24 at approximately 8:30 AM, a review of Resident #1's record was conducted. A review of the record from the hospital before admission on [DATE] indicated that the resident had a history of a cerebrovascular accident (CVA) after a subarachnoid hemorrhage. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) was conducted. He was diagnosed with generalized weakness, adult failure to thrive, blindness in the left eye, and expressive language disorder. He received feedings via percutaneous endoscopic gastrostomy tube (PEG tube). He was dependent for assistance with hygiene and activities of daily living and required assistance with bed mobility and transfer. He had a Foley catheter and had an order to receive Foley catheter care every shift. He had a stage 4 pressure wound on his sacrum with orders to check the dressing to the sacrum every shift. He also had a wound on his right heel that required staff to cleanse the area with wound cleanser and apply skin prep daily. A review of tasks for Resident #1 was conducted. The task sheet indicated that Resident #1 was dependent on staff for assistance with oral hygiene. A review of the task check sheets from 6/21/24 to 8/8/24 was conducted. The task was only checked off as completed on 3 dates: 6/21/24, 8/4/24, and 8/6/24. The bed to chair transfer task in the record indicated that Resident #1 was dependent for assistance with transfer from bed to chair. The task sheet was reviewed from 6/21/24 to 8/8/24. The task sheet indicated that he was only assisted out of the bed to a chair on three dates, on 7/12/24, 8/4/24, and 8/6/24. The assistance with toileting hygiene sheet indicated that Resident #1 required assistance with toileting hygiene. The task sheet was reviewed for 6/18/24 to 8/8/24. According to the task sheet, Resident #1 received assistance with toileting hygiene on 4 dates: 6/18/24, 6/21/24, 8/4/24, and 8/6/24. The task sheet indicated that Resident #1 required substantial maximal assistance with tub/shower transfers. The task sheet was reviewed from 6/18/24 to 8/7/24. This task was checked off as done during the reviewed dates. A review of the task sheet indicated that Resident #1 was dependent on staff for assistance with be mobility and rolling side to side in the bed. The task was reviewed for the dates 6/18/24 to 8/8/24. The task was checked off consistently as completed on the reviewed dates. Resident #8 On 8/7/24 at approximately 10:20 AM, an interview was conducted Resident #8. She was lying in bed at the time of the interview. There was a unused pull up brief at the bottom of her bed. She smelled very strongly of urine. She was asked about care and services. Resident #8 said, They are taking care of me badly. She explained that she fell twice last night when getting up to go to the bathroom. She said that no one came in to check on her all night. She explained that she laid on the floor for a long time until she got the strength to get herself back up onto the bed after each fall. She repeated that no one came to check on or help her all night. She said that staff is not aware of her falls. She got herself up and has not told anyone that she fell. She reported that her left side, her left rib cage, and her tail bone have been hurting. She explained that she has chronic pain but her pain is more severe this morning. She indicated that she normally gets up to the wheelchair by now and goes to the bathroom by herself, but, because she was in pain, she has not been able to get to go to the bathroom to change her brief. Resident #8 reiterated that she never gets enough help. She also said that no one ever brings water to her room. She also does not get ice. She explained that she goes to the tap in the bathroom to get her drinking water. She stated that she has to wash out the water pitcher herself with hand soap in the bathroom. She explained that she is legally blind in one eye and that tasks such as this are difficult for her. Resident #8 also indicated that she needs assistance with showers. She said she does not get showers often enough. She stated that she came into the facility in June 2024. She reported that she has only taken a shower 2-3 times since admission. She said that staff does not bring her clean clothes often enough. She said she has been wearing the same clothes she has on now for 4-5 days. Nurse A, a Registered Nurse, was notified that the resident complained of pain related to the unreported falls last night. A review of current MDS data for Resident #8 revealed that she is severely vision impaired and that she uses a walker to ambulate. She requires set up or clean up assistance with oral hygiene and toileting. She required moderate assistance with bathing lower body dressing, applying or removing footwear, and tub/shower transfers. Resident #19 On 8/7/24 at approximately 10:25 AM, Resident #19 was observed asleep on her bed. There were no sheets under her. Her room had a strong odor of urine. A review of her current MDS data was conducted and revealed that she was completely dependent for assistance with eating, oral hygiene, toileting hygiene, showering, bathing herself, upper body dressing, lower body dressing, applying/removing footwear, personal hygiene, bed mobility, tub/shower transfers, and chair to bed or bed to chair transfers. Resident #20 On 8/7/24 at approximately 10:30 AM, Resident #20 was observed asleep in his bed. The area around him smelled of urine. The sheets appeared wet with urine. No pillow case was on the pillow on the on the bed at the time. On 8/7/24, a review of the current care plan of Resident #20 indicated that he had an alteration in functional performance. He needed assistance to complete self-care tasks such as: oral care, eating, toileting, and hygiene. He had a history of cerebrovascular accident (VA) with right sided hemiplegia/hemiparesis. Resident #20 was non ambulatory and required a mechanical lift for transfers. A review of current MDS data for Resident #20 revealed he uses a motorized wheelchair. He requires moderate assistance with oral hygiene and personal hygiene. Resident #20 required substantial assistance with toileting hygiene, showering, upper body dressing, lower body dressing and applying and removing footwear. He requires substantial assistance with rolling right to left in bed. He was completely dependent for chair to bed and bed to chair transfer and tub/shower transfer. Resident #24 On 8/7/24 at approximately 11:30 AM, Resident #24 was up in her wheelchair. She was asked about her care and services. She said, They don't come to help here. She indicated that staff does not answer calls for help. A review of current MDS data for Resident #24 was conducted. The MDS indicated that Resident #24 required moderate assistance to bathe and applying/removing footwear. She required substantial assistance with lower body dressing. She required supervision with oral hygiene, toileting hygiene, personal hygiene and upper body dressing. Resident #16 On 8/7/24 at approximately 1:55 PM, an interview was conducted with Resident #16. He was asked about care and services at the facility. He explained that he has lived at the facility for 1 month. He stated he is there for a long-term admission. He said there is definitely not enough staff. Resident #16 explained that he has had difficulty getting assistance in a timely manner on the 11:00 PM - 7:00 AM shift and sometimes the 3:00 PM - 11:00 PM shift. He explained that he was unable to get assistance with a shower on his scheduled shower day, but did get assistance with a shower on the following day. He said that missing showers is a frequent occurrence at the facility. In the month he has lived at the facility, he stated he has missed 3-4 showers. He explained that sometimes staff does not come in to check on him at all for the entire night. According to Resident #16, staff never brings water on any shift other than day shift. He also stated that he has been waiting to see a podiatrist for the entire month. Since his admission to the facility, he has asked to see the podiatrist repeatedly. He also indicated that it takes several days to get his clothes washed. He also said that night shift staff is rude and overall, most staff do not care. Resident #16 said that night shift staff frequently has an attitude or rude tone about everything. He said staff on night shift do not want him to come out of his room at night. He explained that he likes to stay up late and would like to come out of his room at night. He said the night shift staff told him it is a fire hazard for him to be out of his room at night. He said he filed a grievance about neglect because a nursing assistant did not come to assist him to change his brief after an incontinence episode for 8 hours. He indicated that the Director of Nursing (DON) gave him her cell phone number so that he can contact her directly for any problems. He texted the DON when the staff did not assist him with changing his brief for 8 hours. On 8/7/24, a review of the current care plan for Resident #16 was conducted. The care plan indicated that Resident #16 has a self-care performance deficit related to diagnosis of spinal muscular atrophy type III. Resident #16 is totally dependent on staff to provide a shower three times a week and as necessary. Resident #16 is totally dependent on 1-2 staff for repositioning and turning in bed every 2 hours and as necessary. Resident #16 is totally dependent on 1-2 staff for dressing. For eating, Resident #16 is dependent and required staff to assist with feeding. He is totally dependent on assistance with personal hygiene/oral care and required assistance of staff to complete personal hygiene/oral care tasks. Resident #16 was totally dependent on 2 staff for assistance with transferring using a Hoyer lift. He uses an electric wheelchair independently for locomotion. He has a history of incontinence, pressure ulcers, and dry fragile skin. Resident #16 requires incontinence care every two hours and as needed. He needs turning and repositioning assistance of staff every 2 hours. A review of current MDS data for Resident #16 was conducted. The MDS data indicated that Resident #16 is dependent for eating, oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing, applying/removing footwear, and personal hygiene. He is also dependent for bed mobility, bed to chair transfer, chair to bed transfer, and transfer to a shower. On 8/7/24 at approximately 4:46 PM, an interview was conducted with Resident #16. The resident reiterated that he can stay continent if he gets assistance in a timely manner to use the urinal. He indicated it is difficult to get staff to answer the call bell. He said recently his roommate tried to assist when he was trying to get someone to help him with the urinal. His roommate went looking for a staff member to assist but fell in the process. Resident #16 consented in writing to have pictures of his nails taken. He also provided images of the text messages he sent to the Director of Nursing (DON) to complain about care. A review of the text messages provided by Resident #16 showed the following: Saturday 7/20/24 at 11:13 AM: DON: Hello, I'm grocery shopping, did you need something? You called me Resident #16: untold I have to wait since breakfast to get cleaned up because I weigh too much DON: ., weekend supervisor is coming to you to file grievance We track and investigate, only way to change it DON: Ty for calling me DON: Call me later after you talk ty Resident #16: All right 7/10/24 at 12:28 PM Resident #16: Just calling you back, didn't get a shower last night but going to give me one when she has time Sunday 7/21/24 11:18 AM: Resident #16: They are tempting to coerce me to get into bed, they are also saying they don't have the manpower to adjust me in my chair . is my C.N.A . is my nurse, I' trying to my best to keep my composure but I'm just going to start calling AHCA here soon DON: wait just a sec Resident #16: Yes ma'am Resident #16: I can recite everything that was said verbatim if that would help DON: Who told you what Resident #16: . told me that she was coming to put me into bed that what's been happening the past few nights with me being lifted and stuff isn't going to fly, she then stated that the nurse wants me to go to bed, then they brought in another [NAME] with bedding and I told her I was going to bed I just need to my cushion moved in my chair she then said that they would have to get manpower to do it, then made the offhand comment once again DON: Call me I tried to call you hello? Resident #16: Hey I just got back down to my room Resident #16: Other staff members came and help me DON: Okay, we will talk tomorrow Please let care staff get you in bed so you sleep well Sunday 7/28/24 4:42 PM: Resident #16: I've been soaking in my own urine since a little after 7:00 this morning Resident #16: My patience has finally ran out DON: . Why have you waited to contact me We discussed this and you agreed to text me if you had any issue Resident #16: There hasn't been any staff, when the staff finally got here they were doing trays then I've been told they needed to find someone I was being very patient DON: O just spoke to . she is coming to you, I cannot fix a problem unless you tell me. Resident #16: Yes ma'am I understand DON- I'm waiting here on text until this is resolved Resident #16: I just wish all this wasn't necessary to be taken care of DON: I want to know when someone gets to your room DON: . it's not necessary all the the' but you agreed to let me know if you had any issue with care. I could have fixed this hours ago Resident #16: I am good to go now, I attempted to call you, I was just seeing how depraved they are, and they're depravity knows no bounds going forward I assure you I will leave my curiosities behind when it comes to my care Sunday 1:34 PM: Resident #16: I still haven't gotten me up today DON: Ok, let me contact ´ DON: They are coming Sunday 2:55 PM: Resident #16: Still not up out of bed DON: . is going to come speak with you now Resident #16: Okay I am up now DON: Good Monday 9:38 PM: Resident #16: Hi there, was told I'll probably not get a shower because of staff issues. Message delivery failure Resident #31 On 8/7/24 at approximately 1:42 PM, an interview was conducted with Resident #31. When asked about care and services, she explained that she has to receive assistance with bathing due to fall risks. She explained that staff normally assists her with showers about every 3 days. She indicated that she has requested to take showers more often. She said she prefers to shower every other day or every two days. The resident said they have not changed her sheets for a week. She explained that staff often stays too busy a lot of the time. She indicated that staff sometimes ignore her requests and walk away because they are so busy. She indicated she has problems getting incontinence care supplies in a timely manner. She explained that she does not want to go around smelling like urine. She said she has had the same incontinence brief on since yesterday evening. She stated the brief is wet and she has not been able to get staff to bring her more incontinence supplies yet today. She also complained that staff does not bring fresh water or ice. On 8/7/24 a review of Resident #31's current care plan was conducted. The care plan indicated that Resident #31 required assistance with mobility tasks related to bed mobility, transfers, ambulation, walker and wheelchair use. She had weakness and an unsteady gate with limited activity tolerance. She required assistance for toileting hygiene, toileting transfer, bed mobility, dressing/grooming, and oral care. The care plan indicated that Resident #31 is at risk for injury related to falls. She had a history of falls and poor balance. Resident #31 has alterations in bowel and bladder continence. She was occasionally incontinent of urine. Staff was directed to provide supervision and partial/moderate assistance for toileting transfer and hygiene. A review of Resident #31's MDS data indicated that Resident #31 used a manual wheelchair. She required set up and clean up for oral hygiene, personal hygiene, and upper body dressing. Supervision with toileting, showering and bathing, lower body dressing, applying and removing footwear. She required supervision with sitting to stand, chair to bed and bed to chair transfer, transfer to toilet, and tub/shower transfer. Resident #24 On 8/7/24 at approximately 2:10 PM, Resident #24 was in the hallway calling out for someone to help her pull her pants down so she can use the bathroom. She stated that her light has been on and she is not getting help. A review of the current MDS data for Resident #24 revealed that she uses a manual wheelchair. She requires supervision with oral hygiene. She requires moderate assistance with toileting hygiene, showering/bathing, and upper body/lower body dressing, She required substantial assistance with applying/removing footwear. Resident #24 needs supervision with personal hygiene, moderate assistance with lying to sitting on side of bed, sit to stand, chair to bed and bed to chair transfer, toilet transfer, and tub/shower transfers. Resident #32 On 8/7/24 at approximately 2:10 PM, an interview was conducted with Resident #32. She was asked to describe care and services at the facility. She said there is not enough staff on the 3:00 PM-11:00 PM shift. She explained that she requires assistance with transfers. She said that she worries about the lack of help. She indicated that staff rarely come to check on her. She gave an example that she waited all night one night for someone to come and no one ever came. She was incontinent and wet all night. She reported the complaint to the administrator, but said that things have not improved. She explained that a lot of residents are upset and angry but will not share their opinions. She said they don't come to change her every 2 hours on evenings or night shifts. She explained that some staff work really hard to try to get it all done. She reiterated that there is not enough help to make up the difference for the staff who try so hard. She stated she never got a shower at all the previous week. She said staff often passes the buck because they can't get it all done. On 8/7/24, a review of the current care plan for Resident #32 was conducted. The care plan indicated that Resident #32 was always incontinent of bowel and bladder, wore adult briefs, and required that she be checked for incontinence episodes every 2 hours, and receive incontinence care provided after each episode. Resident #32 requires total and extensive assistance with activities of daily living due to weakness and left sided hemiparesis. The care plan indicated that Resident #32 had a history of a cerebrovascular accident (CVA) with Left sided hemiplegia. A review of current MDS data was conducted for Resident #32. She uses a manual wheelchair for locomotion. She requires substantial assistance with toileting hygiene, showering/bathing, upper body dressing/lower body dressing, and applying/removing footwear. She requires moderate assistance with personal hygiene and rolling form left to right in bed. She requires substantial mobility assistance in lying to sitting on side of bed, sit to standing position, chair to bed and bed to chair transfer, toilet transfer, and tub to shower transfers. Resident #34 On 8/7/24 at approximately 2:17 PM, Resident #34 was observed awake and sitting on his bed. His area smelled like urine. He had a long beard, approximately 2 inches in length. He reported that he wanted assistance with a bath and shaving. A review of the MDS data for Resident #34 revealed that he uses a manual wheelchair. He requires set up or cleanup for oral hygiene. He requires supervision with toileting hygiene, showers/bathing, and upper body dressing. He requires moderate assistance with lower body dressing applying/removing footwear, and personal hygiene. He also requires supervision with mobility tasks such as standing, chair to bed and bed to chair transfer, toilet transfer and tub/shower transfer. Resident #21 On 8/7/24 at approximately 4:44 PM Resident #21 was observed. He was receiving assistance with ADL care. The room smelled of feces. A review of current MDS data was conducted for Resident #21. He requires substantial assistance with eating, moderate assistance with oral hygiene, personal hygiene, and upper body dressing. He requires substantial assistance with toileting hygiene, shower/ bathing, lower body dressing, applying/removing footwear. Resident #21 needs moderate assistance with mobility tasks such as rolling right to left in bed, sit to lying, and substantial assistance with lying to sitting on the side of the bed. Staff interviews On 8/7/24 at approximately 9:38 AM, an interview was conducted with Staff E, a Certified Nursing Assistant (CNA). She has about 14 residents she oversees. She stated that they normally try to keep 3 CNAs and or Patient Care Assistants (PCA) on each hall to get everything done. But sometimes there are only 2 staff members. She indicated that there are several residents on enhanced supervision, like 15 minute checks and there are 2 residents on 1:1 observation on the 400 hall. She said they are not able to take care of the residents properly because of staffing shortages. She said that residents don't get turned as often as they should, and residents do not get shower as often as they should on night and evening shifts due to staffing shortages. The often have too many Patient Care Assistants (PCAs) scheduled to work on evening and night shifts. She explained that PCAs are not yet certified. They are inexperienced and cannot do all the tasks required to care for the residents. She said staff often come in early or leave late for their shifts, making the total number of care hours difficult to track. She said they are often low on linen supplies. On 8/7/24 at approximately 10:21 AM, an interview was conducted with Nurse A. She indicated that there is inadequate staffing on the 3:00-11:00 shift. They also schedule too many PCAs and not enough CNA's to provide care on evening shift. She indicated that the shortages are definitely impacting resident care. On 8/7/24 at approximately 10:40 AM, an interview was conducted with Staff F, another CNA. She was asked to describe facility staffing. She indicated that there are enough staff on day shift normally. She said that the evening and night shifts have inadequate staffing consistently. The facility completed two groups of PCA training. She said that sometimes there are only PCA's scheduled and no nursing assistants on the evening shift. In an effort to help get it all done PCA's are doing patient care tasks they should not be doing alone. She explained that there is not enough help to care for the most vulnerable residents in the facility. She indicated that residents are not getting out of be and they are not getting assistance with bathing and showers and activity of daily living (ADL) care as needed due to the staffing shortages. She verbalized concern for the residents who are the most vulnerable. On 8/7/24 at approximately 11:40 AM, an interview was conducted with Staff G, another CNA. She indicated that CNA's at the facility struggle to get everything done. She indicated that there are currently 2 residents on 1:1 observation in the facility currently. There are several residents with wounds t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interview, and record review, the facility failed to provide sufficient staff to provide for resident basic needs as required by the residents' care plans for 14 of 15 residents sampled for assistance with daily living (Resident #1, #5, #6, #8, #9, #12, #16, #19, #20, #24, #31, #32, #33 and #34). Interview conducted with 10 of 10 residents (#1, #5, #6, #8, #12, #16, #24, #31, #32 and #34) and 6 of 6 staff (Certified Nursing Assistant CNA E, F, G, Personal Care Assistant N, and nurses A and C) indicated insufficient staffing. The findings include: Resident #1 On 8/7/24 at approximately 10:00 AM, Resident #1 was in bed awake. His lips looked dry and cracked. He was wearing a patient gown. His fingernails were long with soil under them. His toenails were long as well. When asked about how long it had been since his last bath, Resident #1 estimated it had been about two weeks since his last bath. When asked if he prefers to wear a gown, Resident #1 indicated he wears a gown a lot and would prefer to get dressed in clothes. Resident #1 indicated that he would like to get out of bed more often. He was unable to recall the last time he was assisted out of bed. Resident #1 was asked if his mouth was dry and if he had received assistance with mouth care. He said his mouth was dry and indicated he would appreciate assistance with mouth care. Staff was notified that Resident #1 requested assistance with mouth care. During observations on 8/7/24 at approximately 5:00 PM and 8/8/24 at approximately 6:00 AM and 9:40 AM, Resident #1 was observed in bed dressed in a gown and remained positioned on his back. On 8/7/24 at approximately 1:44 PM, wound care was observed for Resident #1. He remained dressed in a gown. His nails and toenails were long during the observation. The Advance Practice Registered Nurse (APRN) conducted an assessment of the skin on both of Resident #1's feet. She made no comment regarding his nails after her assessment. An interview was conducted with the wound care nurse and the APRN regarding Resident #1's finger nails and toe nails after wound care. The wound care nurse explained that the unit manager goes around and checks and cuts residents nails once a month. The APRN said that there are standing podiatry orders for each resident to receive podiatry services as needed. A review of current MDS data for Resident #1 revealed that he is completely dependent on staff for oral, care, bed mobility, bathing/showering, and transfer from bed to chair. On 8/8/24 at approximately 8:30 AM, a review of Resident #1's record was conducted. A review of the record from the hospital before admission on [DATE] indicated that the resident had a history of a cerebrovascular accident (CVA) after a subarachnoid hemorrhage. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) was conducted. He was diagnosed with generalized weakness, adult failure to thrive, blindness in the left eye, and expressive language disorder. He received feedings via percutaneous endoscopic gastrostomy tube (PEG tube). He was dependent for assistance with hygiene and activities of daily living and required assistance with bed mobility and transfer. He had a Foley catheter and had an order to receive Foley catheter care every shift. He had a stage 4 pressure wound on his sacrum with orders to check the dressing to the sacrum every shift. He also had a wound on his right heel that required staff to cleanse the area with wound cleanser and apply skin prep daily. A review of tasks for Resident #1 was conducted. The task sheet indicated that Resident #1 was dependent on staff for assistance with oral hygiene. A review of the task check sheet from 6/21/24 to 8/8/24 was conducted. The task was only checked off as completed on 3 dates: 6/21/24, 8/4/24, and 8/6/24. The bed to chair transfer task in the record indicated that Resident #1 was dependent for assistance with transfer from bed to chair. The task sheet was reviewed from 6/21/24 to 8/8/24. The task sheet indicated that he was only assisted out of the bed to a chair on three dates, on 7/12/24, 8/4/24, and 8/6/24. The assistance with toileting hygiene sheet indicated that Resident #1 required assistance with toileting hygiene. The task sheet was reviewed for 6/18/24 to 8/8/24. According to the task sheet, Resident #1 received assistance with toileting hygiene on 4 dates: 6/18/24, 6/21/24, 8/4/24, and 8/6/24. The task sheet indicated that Resident #1 required substantial maximal assistance with tub/shower transfers. The task sheet was reviewed from 6/18/24 to 8/7/24. This task was checked off as done during the reviewed dates. A review of the task sheet indicated that Resident #1 was dependent on staff for assistance with be mobility and rolling side to side in the bed. The task was reviewed for the dates 6/18/24 to 8/8/24. The task was checked off consistently as completed on the reviewed dates. Resident #5 On 8/7/24 at approximately 9:55 AM, an interview was conducted with Resident #5. There were no pillow cases on the pillow she was using. The bed linen on her bed was visibly soiled. She told the surveyor that she asked for a bed spread the other day and still has not gotten one. She explained that she attempted to bargain with staff telling them she would go without pillow cases if they would have just changed her sheets yesterday. She explained that staff still has not come to change her sheets. She said that she was using the same sheets since Thursday of last week (8/1/24). She explained that the facility is very short of staff at times. She mentioned that sometimes staff is overwhelmed. She indicated that they often miss things. She explained that she believes that staff does not miss or ignore things purposely, but that they are just so busy that they forget. She said that other residents need more help than her so she tries to just be patient and wait. A review of the current MDS data for Resident #5 revealed that she used a manual wheelchair. She requires moderate assistance with personal hygiene, toileting hygiene, showering, and dressing her upper body, She requires substantial assistance with lower body dressing and applying/removing footwear. She requires partial assistance with bed to chair transfer, transferring to the toilet, tub/shower transfers, and sitting to standing positioning. Resident #6 On 8/7/24 at approximately 9:35 AM, a strong smell of urine in the room was noted in Resident #6's room. She also was observed to be unclothed in her bed. There was a soiled gown that lay on her bedside table. Her feet were out from the sheets and visible. It was also noted that her toenails were long. When interviewed, Resident #6 started crying immediately saying that facility staff will not come to help her. She said they would not give her a bath. She explained that she has not had a bath in some time and cannot remember her last bath. She frustratedly repeated that she was naked and the staff would not help her. She pulled down her sheet and to show that she was unclothed. She repeated: I am naked and they won't do nothing for me. When asked if she would like staff to help her cut her toenails, Resident #6 indicated that she would appreciate having her toenails cut. She was unable to recall when she had seen a podiatrist. On 8/7/24, a review of the current care plan for Resident #6 was conducted. Resident #6 had an alteration in bowel continence. She had an indwelling Foley catheter. The care plan stated that Resident #6 was to receive incontinence care every 2 hours and as needed. She was to receive partial to moderate assistance with toileting, transfers, and hygiene. The care plan directed that Resident #6 receive Foley catheter care every shift. The care plan also stated that she required assistance with mouth care and assistance to perform activities of daily living and personal hygiene. A review of the current Minimum Data Set (MDS) information for Resident #6 indicated that she uses a manual wheelchair. She requires moderate assistance with toileting hygiene, showering/ bathing, and upper body dressing. She requires substantial assistance with lower body dressing, applying/removing footwear, and personal hygiene. She requires moderate assistance with standing from a chair and chair to bed transfer, transfer to toilet, and tub/shower. Resident #8 On 8/7/24 at approximately 10:20 AM, an interview was conducted Resident #8. She was lying in bed at the time of the interview. There was a unused pull up brief at the bottom of her bed. She smelled very strongly of urine. She was asked about care and services. Resident #8 said, They are taking care of me badly. She explained that she fell twice last night when getting up to go to the bathroom. She said that no one came in to check on her all night. She explained that she laid on the floor for a long time until she got the strength to get herself back up onto the bed after each fall. She repeated that no one came to check on or help her all night. She said that staff is not aware of her falls. She got herself up and has not told anyone that she fell. She reported that her left side, her left rib cage, and her tail bone have been hurting. She explained that she has chronic pain but her pain is more severe this morning. She indicated that she normally gets up to the wheelchair by now and goes to the bathroom by herself, but, because she was in pain, she has not been able to get to go to the bathroom to change her brief. Resident #8 reiterated that she never gets enough help. She also said that no one ever brings water to her room. She also does not get ice. She explained that she goes to the tap in the bathroom to get her drinking water. She stated that she has to wash out the water pitcher herself with hand soap in the bathroom. She explained that she is legally blind in one eye and that tasks such as this are difficult for her. Resident #8 also indicated that she needs assistance with showers. She said she does not get showers often enough. She stated that she came into the facility in June 2024. She reported that she has only taken a shower 2-3 times since admission. She said that staff does not bring her clean clothes often enough. She said she has been wearing the same clothes she has on now for 4-5 days. Nurse A, a Registered Nurse, was notified that the resident complained of pain related to the unreported falls last night. A review of current MDS data for Resident #8 revealed that she is severely vision impaired and that she uses a walker to ambulate. She requires set up or clean up assistance with oral hygiene and toileting. She required moderate assistance with bathing lower body dressing, applying or removing footwear, and tub/shower transfers. Resident #9 On 8/7/24 at approximately 9:40 AM, Resident #9 was in her bed asleep. Her room had a strong pungent odor of urine. A review of Resident #9's current MDS data was conducted. She requires set up and clean up after oral hygiene. She requires supervision for personal hygiene, applying/removing footwear, upper body dressing, sit to stand positioning, chair to bed and bed to chair transfers, and toilet transfers. She requires moderate assistance with toileting hygiene, shower/bathing self, lower body dressing, applying and removing footwear, and tub to shower transfers. Resident #12 On 8/7/24 at approximately 9:45 AM, an interview was conducted with Resident #12. She was asked about care and services. She reported that they need a lot more help, it often takes a long time to get any help in the evenings and at night. A review of current MDS data was conducted for Resident #12. She requires set up and cleanup for eating. She was dependent on assistance with showering and bathing. She requires substantial assistance with upper body/lower body dressing, applying/removing footwear. She requires moderate assistance with oral hygiene and personal hygiene. Resident #12 requires substantial assistance to roll left and right, is dependent for sit to lying assistance, dependent for lying to sitting on the side of bed, and dependent for sit to stand positioning. Resident #16 On 8/7/24 at approximately 1:55 PM, an interview was conducted with Resident #16. He was asked about care and services at the facility. He explained that he has lived at the facility for 1 month. He stated he is there for a long-term admission. He said there is definitely not enough staff. Resident #16 explained that he has had difficulty getting assistance in a timely manner on the 11:00 PM - 7:00 AM shift and sometimes the 3:00 PM - 11:00 PM shift. He explained that he was unable to get assistance with a shower on his scheduled shower day, but did get assistance with a shower on the following day. He said that missing showers is a frequent occurrence at the facility. In the month he has lived at the facility, he stated he has missed 3-4 showers. He explained that sometimes staff does not come in to check on him at all for the entire night. According to Resident #16, staff never brings water on any shift other than day shift. He also stated that he has been waiting to see a podiatrist for the entire month. Since his admission to the facility, he has asked to see the podiatrist repeatedly. He also indicated that it takes several days to get his clothes washed. He also said that night shift staff is rude and overall, most staff do not care. Resident #16 said that night shift staff frequently has an attitude or rude tone about everything. He said staff on night shift do not want him to come out of his room at night. He explained that he likes to stay up late and would like to come out of his room at night. He said the night shift staff told him it is a fire hazard for him to be out of his room at night. He said he filed a grievance about neglect because a nursing assistant did not come to assist him to change his brief after an incontinence episode for 8 hours. He indicated that the Director of Nursing (DON) gave him her cell phone number so that he can contact her directly for any problems. He texted the DON when the staff did not assist him with changing his brief for 8 hours. On 8/7/24, a review of the current care plan for Resident #16 was conducted. The care plan indicated that Resident #16 has a self-care performance deficit related to diagnosis of spinal muscular atrophy type III. Resident #16 is totally dependent on staff to provide a shower three times a week and as necessary. Resident #16 is totally dependent on 1-2 staff for repositioning and turning in bed every 2 hours and as necessary. Resident #16 is totally dependent on 1-2 staff for dressing. For eating, Resident #16 is dependent and required staff to assist with feeding. He is totally dependent on assistance with personal hygiene/oral care and required assistance of staff to complete personal hygiene/oral care tasks. Resident #16 was totally dependent on 2 staff for assistance with transferring using a Hoyer lift. He uses an electric wheelchair independently for locomotion. He has a history of incontinence, pressure ulcers, and dry fragile skin. Resident #16 requires incontinence care every two hours and as needed. He needs turning and repositioning assistance of staff every 2 hours. A review of current MDS data for Resident #16 was conducted. The MDS data indicated that Resident #16 is dependent for eating, oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing, applying/removing footwear, and personal hygiene. He is also dependent for bed mobility, bed to chair transfer, chair to bed transfer, and transfer to a shower. On 8/7/24 at approximately 4:46 PM, an interview was conducted with Resident #16. The resident reiterated that he can stay continent if he gets assistance in a timely manner to use the urinal. He indicated it is difficult to get staff to answer the call bell. He said recently his roommate tried to assist when he was trying to get someone to help him with the urinal. His roommate went looking for a staff member to assist but fell in the process. Resident #16 consented in writing to have pictures of his nails taken. He also provided images of the text messages he sent to the Director of Nursing to complain about care. A review of the text messages provided by Resident #16 showed the following: Saturday 7/20/24 at 11:13 AM: DON: Hello, I'm grocery shopping, did you need something? You called me Resident #16: untold I have to wait since breakfast to get cleaned up because I weigh too much DON: ., weekend supervisor is coming to you to file grievance We track and investigate, only way to change it DON: Ty for calling me DON: Call me later after you talk ty Resident #16: All right 7/10/24 at 12:28 PM Resident #16: Just calling you back, didn't get a shower last night but going to give me one when she has time Sunday 7/21/24 11:18 AM: Resident #16: They are tempting to coerce me to get into bed, they are also saying they don't have the manpower to adjust me in my chair . is my C.N.A . is my nurse, I' trying to my best to keep my composure but I'm just going to start calling AHCA here soon DON: wait just a sec Resident #16: Yes ma'am Resident #16: I can recite everything that was said verbatim if that would help DON: Who told you what Resident #16: . told me that she was coming to put me into bed that what's been happening the past few nights with me being lifted and stuff isn't going to fly, she then stated that the nurse wants me to go to bed, then they brought in another [NAME] with bedding and I told her I was going to bed I just need to my cushion moved in my chair she then said that they would have to get manpower to do it, then made the offhand comment once again DON: Call me I tried to call you hello? Resident #16: Hey I just got back down to my room Resident #16: Other staff members came and help me DON: Okay, we will talk tomorrow Please let care staff get you in bed so you sleep well Sunday 7/28/24 4:42 PM: Resident #16: I've been soaking in my own urine since a little after 7:00 this morning Resident #16: My patience has finally ran out DON: . Why have you waited to contact me We discussed this and you agreed to text me if you had any issue Resident #16: There hasn't been any staff, when the staff finally got here they were doing trays then I've been told they needed to find someone I was being very patient DON: O just spoke to . she is coming to you, I cannot fix a problem unless you tell me. Resident #16: Yes ma'am I understand DON- I'm waiting here on text until this is resolved Resident #16: I just wish all this wasn't necessary to be taken care of DON: I want to know when someone gets to your tom DON: . it's not necessary all the te' but you agreed to let me know if you had any issue with care. I could have fixed this hours ago Resident #16: I am good to go now, I attempted to call you, I was just seeing how depraved they are, and they're depravity knows no bounds going forward I assure you I will leave my curiosities behind when it comes to my care Sunday 1:34 PM: Resident #16: I still haven't gotten me up today DON: Ok, let me contact ´ DON: They are coming Sunday 2:55 PM: Resident #16: Still not up out of bed DON: . is going to come speak with you now Resident #16: Okay I am up now DON: Good Monday 9:38 PM: Resident #16: Hi there, was told I'll probably not get a shower because of staff issues. Message delivery failure Resident #19 On 8/7/24 at approximately 10:25 AM, Resident #19 was observed asleep on her bed. There were no sheets under her. Her room had a strong odor of urine. A review of her current MDS data was conducted and revealed that she was completely dependent for assistance with eating, oral hygiene, toileting hygiene, showering, bathing herself, upper body dressing, lower body dressing, applying/removing footwear, personal hygiene, bed mobility, tub/shower transfers, and chair to bed or bed to chair transfers. Resident #20 On 8/7/24 at approximately 10:30 AM, Resident #20 was observed asleep in his bed. The area around him smelled of urine. The sheets appeared wet with urine. No pillow case was on the pillow on the on the bed at the time. On 8/7/24, a review of the current care plan of Resident #20 indicated that he had an alteration in functional performance. He needed assistance to complete self-care tasks such as: oral care, eating, toileting, and hygiene. He had a history of cerebrovascular accident (VA) with right sided hemiplegia/hemiparesis. Resident #20 was non ambulatory and required a mechanical lift for transfers. A review of current MDS data for Resident #20 revealed he uses a motorized wheelchair. He requires moderate assistance with oral hygiene and personal hygiene. Resident #20 required substantial assistance with toileting hygiene, showering, upper body dressing, lower body dressing and applying and removing footwear. He requires substantial assistance with rolling right to left in bed. He was completely dependent for chair to bed and bed to chair transfer and tub/shower transfer. Resident #24 On 8/7/24 at approximately 11:30 AM, Resident #24 was up in her wheelchair. She was asked about her care and services. She said, They don't come to help here. She indicated that staff does not answer calls for help. On 8/7/24 at approximately 2:10 PM, Resident #24 was in the hallway calling out for someone to help her pull her pants down so she can use the bathroom. She stated that her light has been on and she is not getting help. A review of current MDS data for Resident #24 was conducted. The MDS indicated that Resident #24 required moderate assistance to bathe and applying/removing footwear. She required substantial assistance with lower body dressing. She required supervision with oral hygiene, toileting hygiene, personal hygiene and upper body dressing. Resident #31 On 8/7/24 at approximately 1:42 PM, an interview was conducted with Resident #31. When asked about care and services, she explained that she has to receive assistance with bathing due to fall risks. She explained that staff normally assists her with showers about every 3 days. She indicated that she has requested to take showers more often. She said she prefers to shower every other day or every two days. The resident said they have not changed her sheets for a week. She explained that staff often stays too busy a lot of the time. She indicated that staff sometimes ignore her requests and walk away because they are so busy. She indicated she has problems getting incontinence care supplies in a timely manner. She explained that she does not want to go around smelling like urine. She said she has had the same incontinence brief on since yesterday evening. She stated the brief is wet and she has not been able to get staff to bring her more incontinence supplies yet today. She also complained that staff does not bring fresh water or ice. On 8/7/24 a review of Resident #31's current care plan was conducted. The care plan indicated that Resident #31 required assistance with mobility tasks related to bed mobility, transfers, ambulation, walker and wheelchair use. She had weakness and an unsteady gate with limited activity tolerance. She required assistance for toileting hygiene, toileting transfer, bed mobility, dressing/grooming, and oral care. The care plan indicated that Resident #31 is at risk for injury related to falls. She had a history of falls and poor balance. Resident #31 has alterations in bowel and bladder continence. She was occasionally incontinent of urine. Staff was directed to provide supervision and partial/moderate assistance for toileting transfer and hygiene. A review of Resident #31's MDS data indicated that Resident #31 used a manual wheelchair. She required set up and clean up for oral hygiene, personal hygiene, and upper body dressing. Supervision with toileting, showering and bathing, lower body dressing, applying and removing footwear. She required supervision with sitting to stand, chair to bed and bed to chair transfer, transfer to toilet, and tub/shower transfer. Resident #32 On 8/7/24 at approximately 2:10 PM, an interview was conducted with Resident #32. She was asked to describe care and services at the facility. She said there is not enough staff on the 3:00 PM-11:00 PM shift. She explained that she requires assistance with transfers. She said that she worries about the lack of help. She indicated that staff rarely come to check on her. She gave an example that she waited all night one night for someone to come and no one ever came. She was incontinent and wet all night. She reported the complaint to the administrator, but said that things have not improved. She explained that a lot of residents are upset and angry but will not share their opinions. She said they don't come to change her every 2 hours on evenings or night shifts. She explained that some staff work really hard to try to get it all done. She reiterated that there is not enough help to make up the difference for the staff who try so hard. She stated she never got a shower at all the previous week. She said staff often passes the buck because they can't get it all done. On 8/7/24, a review of the current care plan for Resident #32 was conducted. The care plan indicated that Resident #32 was always incontinent of bowel and bladder, wore adult briefs, and required that she be checked for incontinence episodes every 2 hours, and receive incontinence care provided after each episode. Resident #32 requires total and extensive assistance with activities of daily living due to weakness and left sided hemiparesis. The care plan indicated that Resident #32 had a history of a cerebrovascular accident (CVA) with Left sided hemiplegia. A review of current MDS data was conducted for Resident #32. She uses a manual wheelchair for locomotion. She requires substantial assistance with toileting hygiene, showering/bathing, upper body dressing/lower body dressing, and applying/removing footwear. She requires moderate assistance with personal hygiene and rolling form left to right in bed. She requires substantial mobility assistance in lying to sitting on side of bed, sit to standing position, chair to bed and bed to chair transfer, toilet transfer, and tub to shower transfers. Resident #33 On 8/7/24 at approximately 9:38 AM, Resident #33 was seated in her wheelchair watching television in her room. The area around Resident #33 smelled strongly of urine. A review of her current MDS data was conducted. She uses a manual wheelchair. She requires supervision with oral hygiene, showering/bathing, personal hygiene, changing position from sitting to lying and sitting to standing. Resident #33 requires moderate assistance with toileting, hygiene, lower body dressing, applying/removing footwear, chair to bed and bed to chair transfers, toilet transfers, and tub to shower transfers. Resident #34 On 8/7/24 at approximately 2:17 PM, Resident #34 was observed awake and sitting on his bed. His area smelled like urine. He had a long beard, approximately 2 inches in length. He reported that he wanted assistance with a bath and shaving. A review of the MDS data for Resident #34 revealed that he uses a manual wheelchair. He requires set up or cleanup for oral hygiene. He requires supervision with toileting hygiene, showers/bathing, and upper body dressing. He requires moderate assistance with lower body dressing applying/removing footwear, and personal hygiene. He also requires supervision with mobility tasks such as standing, chair to bed and bed to chair transfer, toilet transfer and tub/shower transfer. Staff interviews On 8/7/24 at approximately 9:38 AM, an interview was conducted with Staff E, a Certified Nursing Assistant (CNA). She has about 14 residents she oversees. She stated that they normally try to keep 3 CNAs and or Patient Care Assistants (PCA) on each hall to get everything done. But sometimes there are only 2 staff members. She indicated that there are several residents on enhanced supervision, like 15 minute checks and there are 2 residents on 1:1 observation on the 400 hall. She said they are not able to take care of the residents properly because of staffing shortages. She said that residents don't get turned as often as they should, and residents do not get shower as often as they should on night and evening shifts due to staffing shortages. The often have too many Patient Care Assistants (PCAs) scheduled to work on evening and night shifts. She explained that PCAs are not yet certified. They are inexperienced and cannot do all the tasks required to care for the residents. She said staff often come in early or leave late for their shifts, making the total number of care hours difficult to track. She said they are often low on linen supplies. On 8/7/24 at approximately 10:21 AM, an interview was conducted with Nurse A. She indicated that there is inadequate staffing on the 3:00-11:00 shift. They also schedule too many PCAs and not enough CNA's to provide care on evening shift. She indicated that the shortages are definitely impacting resident care. On 8/7/24 at 4:55 PM, during a follow-up interview, Nurse A stated that the facility had high acuity residents, and the lack of staffing along with the high acuity has resulted in residents not getting baths and not being repositioned. On 8/7/24 at approximately 10:40 AM, an interview was conducted with Staff F, another CNA. She was asked to describe facility staffing. She indicated that there are enough staff on day shift normally. She said that the evening and night shifts have inadequate staffing consistently. The facility completed two groups of PCA training. She said that sometimes there are only PCA's scheduled and no nursing assistants on the evening shift. In an effort to help get it all done PCA's are doing patient care tasks they should not be doing alone. She explained that there is not enough help to care for the most vulnerable residents in the facility. She indicated that residents are not getting out of be and they are not getting assistance with bathing and showers and activity of daily living (ADL) care as needed due to the staffing shortages. She verbalized concern for the residents who are the most vulnerable. On 8/7/24 at approximately 11:40 AM, an interview was conducted with Staff G, another CNA. She indicated that CNA's at the facility struggle to get everything done. She indicated that there are currently 2 residents on 1:1 observation in the facility currently. There are several residents with wounds that need to be turned more often. She explained that, when they are short staffed, it is hard to turn the residents. It is difficult to get all the residents up out of bed. She reiterated that they really need more help and that coverage often varies. On 8/7/24 at approximately 4:22 PM, Nurse C, a Licensed Practical Nurse, was interviewed. She was asked to describe staffing at facility. She explained that they are short on staff at times, especially on night shift. There is not enough staff to provide for the residents on enhanced supervision. She explained that there are quite a few residents that need more assistance with care and the current staffing does not provide for the additional needs of the residents. She indicated that there are several residents on enhanced supervision, including two residents on 1:1 in the memory care On 8/7/24 at approximately 5:55 PM, an interview was conducted with Staff N, another PCA. She was asked abo[TRUNCATED]

Based on staff interview, family interview, medical record review, and policy review, the facility failed to ensure residents had advance directives included in the medical record for 1 of 2 residents reviewed for advanced directives. (Resident #43) The findings include: On 1/29/24 at 3:35 PM, a record review was conducted for Resident #43. Advance directives were not located in the medical record. On 1/30/24 at 3:48 PM, an interview was conducted with licensed practical nurse (LPN) EE who was asked to help locate the advance directives for Resident #43. After looking through the record, LPN EE confirmed the advanced directives were not there. LPN EE stated, If this resident had a medical emergency, I wouldn't know what to do. On 1/30/24 at 4:17 PM, an interview was conducted with the facility administrator (FA) regarding the lack of advance directives in Resident #43's record. The FA stated that all staff were trained that residents should be a full code if no advance directives could be found. The FA also stated that a copy of the advance directives could be located somewhere, and one would be provided. However, on 2/1/24, the FA acknowledged that a copy of the advanced directives for #43 was not found.

Based on staff interview, family interview, medical record review, and policy review, the facility failed to develop an Advanced Directive Care Plan in accordance with the residents preferences for 1 of 2 residents reviewed for advanced directives. (Resident #59) The findings include: On 1/29/24, a record review was conducted for resident #59. The physician order form documented the residents code status as Do Not Resuscitate (DNR) on 1/11/24. A review of the care plan dated 1/18/24 documented the resident was a full code and the resident had a Power of Attorney (POA). On 1/31/24, a review of the facility policy Florida Do Not Resuscitate (DNR), effective date 9/7/23. Page 1 item 3 states The properly execute DNRO will be placed in the resident's medical record. On 1/31/24 at approximately 1:44 PM, a telephone interview was conducted with the resident's son who is the POA. The POA stated the resident is supposed to be a DNR. On 1/31/24 at approximately 2:15 PM an interview was conducted with Registered Nurse (RN) N, a Unit Manager. RN N reviewed the residents medical record and verbally agreed the resident's orders and care plans conflicted about the resident's code status. The physician ordered a DNR, but the care plans indicated the resident was a full code. RN N could not offer an explanation as to how the orders and care plans did not match.

Based on resident interviews, staff interviews and record review, the facility failed to ensure that 1 of 1 sampled residents received assistance arranging services for evaluation and treatment of issues with vision (Resident #9). The findings include: On 1/31/24 at approximately 11:48 AM, Resident #9 indicated that he has asked repeatedly since admission to get an eye exam. He explained that he has been having significant trouble with his eyes. The resident explained that he has told the nurses several times. A review of the record of Resident #9 was conducted. The Minimum Data Set Data (MDS) submitted on 12/17/23 indicated that Resident #9 can see fine detail including regular print in newspapers and books and that he did not use corrective lenses. A review of the face sheet for Resident #9 revealed that he was admitted 5 years ago in early 2019. Resident #9 had been diagnosed with the following conditions: Chronic Kidney disease, Hypertension, and Diabetes Type II. There were no progress notes that indicated assessment or plans for the evaluation of vision. No consults were found that indicated an evaluation was conducted by an optometrist or ophthalmologist since admission. On 1/29/23 at approximately 2:00 PM, an interview was conducted with the Facility Administrator. The Facility Administrator indicated that they have not had a social worker at the facility for quite some time. The MDS nurse has been covering social services responsibilities as far as discharges. She was asked to provide further documentation regarding other social services responsibilities. On 2/2/24 at approximately 1:30 PM, an interview was conducted with the Administrator and the Director of Nursing (DON). The Administrator and DON were notified that Resident #9 stated he has been asking to get an eye evaluation. The DON indicated that the MDS nurse has been case managing for podiatry and dental services. The DON explained that she was not aware that Resident #9 was asking for glasses. She explained that she will notify the medical director that Resident #9 needs a vision evaluation and have the CNA (Certified Nursing Assistant) schedule the appointment. The Administrator indicated that they would be hiring a scheduler for the facility soon.

Based on observations, staff interviews and review of the Director of Nursing (DON) job description, the facility failed to designate an acting DON when the facility DON was on extended leave. The findings include: During the survey, from 1/29/24 to 2/1/24, the facility DON was not present at the facility. On 1/31/24 at 11:30 AM, an interview was conducted with the Administrator. The Administrator stated the DON had been on leave for 2 weeks and she was currently working from home. She further explained the plan was for the DON to have 2 weeks of leave and then 2 more weeks working remote from home. The Administrator was asked who was the acting DON and she replied that was herself. She was asked if she was licensed as a registered nurse and the Administrator replied she was not a nurse. On 2/01/24 at 5:42 PM, an interview was conducted with the DON via telephone. She stated her regular tasks consisted of overseeing medications, activities of daily living, care plans and nursing staff. Stated she had been on leave since 1/16/24. She further stated her return day was 2/14/24. She explained the plan was to be off for 2 weeks completely and working from home for 2 weeks. She indicated her duties while working from home were the transition to electronic medical records, working in training and policies, and answering phone calls. A review of the DON job description, undated, was conducted. The job function included supervising clinical nurses and nurse techs and carrying out the resident care policies established by the facility and duties and responsibilities included assurance with resident rights policies and working to resolve resident grievances.

Based on observation, staff interviews, and facility policy review, the facility failed to appropriately store medications. The findings include: On 2/01/24 at 1:08 PM, an observation was conducted of the facility's 200 hallway. The hallway did not have any rooms currently occupied by residents. There was a double door to access the hallway that was unlocked. There were some cardboard boxes in the middle of the hallway. One of the boxes contained dozens of bottles of various medications. (Photographic evidence was obtained) On 2/01/24 at 04:48 PM, an interview was conducted with Staff N, a Registered Nurse (RN) and unit manager. She stated all medications are securely stored inside the medication rooms or inside the medication carts. At this point, RN N was made aware of the medications inside the box at 200 hallway. She looked at the medication box and stated those were over the counter medications and should not be there. On 2/01/24 at 5:59 PM, a telephone interview was conducted with the facility's Director of Nursing (DON). During the interview, she was made aware of the medications stored in the 200 hallway and stated that should not have happened. A review of the facility's policy titled Medication Storage dated 12/8/23 was conducted. The policy stated that all medications shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 01/30/24 at 09:23 AM, a roach was observed in room [ROOM NUMBER]. An interview was conducted immediately with staff BB, a certified nursing assistant (CNA), who was in the room at the time. When asked if she sees roaches often, CNA BB replied, Roaches are a common problem here. CNA BB also stated that roaches are seen daily. Per CNA BB, housekeeping has just three employees, and they cannot keep up. She also stated, I clean every day because the residents deserve better, I can't just walk away from a room that is filthy or let them use a restroom that has urine on the floor. Based on observations, resident and family interviews and staff interviews, the facility failed to maintain an effective pest control program. The findings include: On 1/29/24 at approximately 11:30 AM, Resident #10 was interviewed. The resident stated that she saw the large kind of roaches in her room last night. On 1/29/24 at approximately 1:00 PM, an interview was conducted with Resident #40. He complaint of seeing roaches in his room all the time. He indicated that someone comes out to spray, but stated that the man who comes out to spray never comes into resident rooms when he is here. On 01/29/24 at 1:00 PM, a telephone interview was conducted with the daughter of Resident #311. She stated her father was admitted to the facility on [DATE] from the hospital following a stroke. She stated that she brought him home the very next day on 11/15/23 because her father called her screaming Get me out of here. She stated there were roaches in her father's room, and the room was so filthy she felt she had to clean it upon her father's admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, resident and family interviews, review of November 2023 medication training, and policy review, the facility failed to ensure procedures were in place and followed to assure the accurate administering of all drugs 5 of 21 residents sampled for Medication Administration Records (#9, #35 #45, #211 and #311 ). The findings include: Resident # 45 A review of Resident #45's medical record was conducted. Resident #35 had diagnoses including dementia and end stage renal disease. Physician's orders included Paxil 20 mg (milligrams) for anxiety at 9 PM, Donepezil 10 mg for dementia at bedtime, and Haloperidol 0.5 mg for mild psychosis at bedtime. A review of the Medication Administration Records (MAR) revealed Paxil 20 mg was not documented as given on 1/17/24 and 1/22/24, Donepezil 10 mg was not documented on 1/21/24, and Haloperidol 0.5 mg was not documented on 1/21/24. Resident # 35 A review of Resident #35's medical record was conducted. Resident #45 had diagnoses including hypertension, mood disorder, major depressive disorder, kidney disease and cerebrovascular disease. Physician's orders included Norvasc 10 mg for hypertension daily in the morning, Depakote 250 mg daily in the morning for mood, and Furosemide 20 mg once daily for edema. A review of MAR revealed Norvasc 10 mg , Depakote 250 mg, Furosemide 20 mg were not documented on 1/8, 1/14, 1/15, 1/17, and 1/22/24. On 1/31/24 at 09:39 AM, an interview was conducted with Staff N, Registered Nurse (RN), who was also facility's Infection Preventionist and Unit Manager. During the interview, she reviewed Resident # 35 and #45's MARs. RN N stated she had been telling the nurses to complete the MAR documentation because she was aware it was not being done. Resident #211 On 1/31/24 at approximately 2:00 PM a review of the record for Resident #211 was conducted. Resident #211 had been diagnosed with the following conditions: hypertension, acute kidney injury, hypertensive neuropathy, left ventricular hypertrophy, and ischemic stroke. A review of the Medication Administration Records (MARs) for the month of January 2024 was conducted for Resident #211. There were multiple doses of medications not signed on the MAR and no corresponding documentation recorded in the medical record to explain the missed doses of medications. Resident #211 had a physician order to administer a Lovenox injection 40 mg subcutaneous every day for deep vein thrombosis prophylaxis. The MAR was not signed off and the medication was not signed out on 1/11/24, 1/12/24 or 1/21/24 at 9:00 PM. Resident #211 had a physician order to administer Minoxidil 2.5 mg 1 tablet by mouth twice a day for hypertension (HTN, high blood pressure). The MAR had doses which were circled indicating they were not given 1/13 at 9:00 AM and 9:00 PM and 1/14/24 at 9:00 AM and 9:00 PM with no explanation documented. Doses were not signed out on the MAR on 1/15 at 9:00 AM, and 1/17/24 at 9:00 AM. Resident #211 had a physician order to administer Isosorbide 20 mg 1 tablet by mouth three times a day for HTN. Doses were not signed out on the [DATE]/11 at 10:00 PM, 1/12 at 10:00 PM, Doses were circled indicating they were not given but no reason was listed on the back of the MAR on 1/13 at 2:00PM and 10:00 PM, 1/14 at 6:00 AM, 2:00 PM and 10:00 PM, 1/15 at 6:00 AM. Doses were not signed out on the MAR on 1/15 at 2:00 PM, 1/17 at 2:00 PM, 1/18 at 6:00 AM, 1/19 at 6:00 AM, 1/21 at 10:00 PM, and 1/22/24 at 6:00 AM and 2:00 PM. Resident #211 had a physician order on 1/19/24 to administer Vancomycin 1 Gram in 500 ml (milliliters) intravenous daily at 250 milliliters per hour. The MAR was not signed off on 1/22/24 at 9:00 AM. Resident #211 had a physician order dated 1/26/24 to increase Vancomycin to 1.25 Grams daily. The MAR was circled on 1/27/24 and 1/31/24 indicating the medication was not administered, No reason was documented. Resident #211 had a physician order to administer Clonidine 0.1 mg by mouth every 8 hours for (HTN). Doses were not signed out on the medication administration record (MAR) on 1/15 at 2:00 PM, 1/17 at 2:00 PM, 1/19 at 6:00 AM, 1/21 at 10:00 PM 1/22/24 at 6:00 AM and 2:00PM. Resident #211 had a physician order to administer Carvedilol 25 mg twice a day for HTN. Doses were not signed out on the MAR on 1/11 at 9:00 AM and 9:00 PM, 1/14 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM, and 1/22/24 at 9:00 AM. Resident #211 had a physician order to administer Losartan 100 mg 1 tablet by mouth every day for HTN. Doses were not signed out on the [DATE]/15 at 9:00 AM, 1/17 at 9:00 AM, and 1/22/24 at 9:00 AM. Resident #211 had a physician order to administer Nifedipine 10 mg 1 tablet by mouth for HTN daily. The MAR was not signed off 1/15 at 9:00 AM, 1/17 at 9:00 AM, nor 1/22/24 at 9:00 AM. Resident #211 had a physician order to administer Sodium Bicarb 650 mg 1 tablet by mouth three times a day for supplement due to renal disease. The MAR was not signed off on 1/15 at 2:00 PM, 1/17 at 2:00 PM, 1/21 at 9:00 PM, or 1/22/24 at 6:00 AM and 2:00 PM. Resident #211 had a physician order to administer Sucralfate 1 GM by mouth at meals and bed time for gastrointestinal bleed. The MAR was not signed off 1/11 at 9:00 PM, 1/12 at 9:00 PM, 1/15 at 11:30 AM and 4:30 PM, 1/17 at 11:30 AM and 4:30 PM, 1/19 at 6:00 AM, 1/21 at 9:00 PM, and 1/22/24 at 6:00 AM 11:30 AM and 4:30 PM. Resident #211 had a physician order to administer Doxazosin 4mg, 2 tablets (8mg) daily for urinary retention. The MAR was not signed off on 1/15, 1/17 at 9:00 AM, and 1/22/24 at 9:00 AM. Resident #211 had a physician order to administer Folic Acid 400mg 1 tablet by mouth daily for supplement. The MAR was not signed off on 1/15 at 9:00 AM, 1/17 at 9:00 AM, nor 1/21/24 at 9:00 AM. Resident #211 had a physician order to administer Vitamin C 500 mg 1 tab by mouth twice a day for supplement. The MAR was not signed off on 1/15 at 9:00 AM, 1/21 at 9:00 AM, and 1/22/24 at 9:00 AM. Resident #211 had a physician order to administer Thiamine 100mg 1 tablet by mouth every day for supplement. The MAR was not signed off on 1/15 at 9:00 AM, 1/17 at 9:00 AM, nor 1/22/24 at 9:00 AM. Resident #211 had a physician order to administer Atorvastatin 40 mg 1 tablet by mouth at bedtime for hyperlipidemia, The MAR was not signed off on 1/10 at 9:00 PM, 1/11 at 9:00 PM, nor 1/21/24 at 9:00 PM. Resident #211 had a physician order for Duo Neb nebulizer treatments to be given every 6 hours for 10 days for shortness of breath (SOB) and wheezing. The MAR was not signed off on 1/22/24 for doses at 12:00 AM, 5:00 AM, 12:00 PM, and 6:00 PM were not signed out. Resident #211 had a physician order to administer Norco tablets 5mg/325 mg of acetaminophen for pain three times a day. The MAR was not signed off, and doses were not signed out on 1/21 at 10:00 PM, and 1/22/24 at 6:00 AM and 2:00 PM. Resident #211 had a physician order to flush the Peripherally Inserted Central Catheter (PICC) line every shift. The MAR was not signed off 1/21 on 7PM -7AM shift and 1/22/24 on 7AM -7PM shift. Resident #211 had a physician order to flush the PICC line with 5cc of heparin flush daily. The MAR was not signed off on 1/22/24. Resident #211 had a physician order to administer Meropenem 500mg/100ml intravenous every 6 hours for osteomyelitis. The MAR was not signed off on 1/20 at 12:00 PM or 6:00 PM, nor 1/22/24 at 12:00 AM, 6:00AM, 12:00 PM or 6:00 PM. Resident #211 had a physician order to check the residents blood pressure each shift. There was no pulse and blood pressure recorded on 1/12 on either shift, 1/13 7PM-7AM, 1/14 7PM-7AM, 1/15 7AM-7PM, 1/17 7AM-7PM, and 1/22 7AM-7PM. On 1/20/24 a blood pressure of 165/95 was recorded, 1/21/24 a blood pressure was recorded at 160/100 and on 1/24/24 a blood pressure of 202/100 is recorded. There was no recorded time for any of the blood pressure readings and no documentation that the physician had been notified. Resident #9 On 1/30/24 at approximately 4:00 PM an interview was conducted with Resident #9. He indicated that receiving staff assistance takes a long time. He said everything does not always get done as it should. The resident indicated that he does not always get all prescribed treatments or assistance with getting up out of bed. He explained that the staff will say that he is asleep and refuses but that is not the case. On 1/31/24 at approximately 2:00 PM, a review of the clinical record for Resident #9 was conducted. Resident #9 had diagnoses which included: Chronic Kidney disease, Hypertension (high blood pressure), Diabetes Type II, hyperlipidemia, and hypothyroidism. A review of the Medication Administration Records (MARs) for the month of January 2024 was conducted for Resident #9. There were multiple doses of medications not signed on the MAR and no explanation recorded in the medical record to explain the missed doses of medications. Resident #9 had a physician order to receive amlodipine tablet 10 mg by mouth every night at bedtime for hypertension (HTN). The MAR was not signed off on 1/21/24 at 9:00 PM. Resident #9 had a physician order to receive Tylenol/codeine 300/30 mg 1 tablet by mouth twice daily for pain. The MAR was not signed off on 1/14 at 9:00 AM and 1/17 at 9:00 AM, 1/21 at 9:00 PM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to take Atorvastatin 20 mg 1 tablet by mouth every night at bedtime for hyperlipidemia. The MAR was not signed off on 1/21/24 at 9:00 PM. Resident #9 had a physician order to receive Azelastine Spray 0.1% 2 sprays each nostril once daily for allergic rhinitis. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Vitamin D 1000 units, 1 capsule by mouth once daily for vitamin deficiency. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Docusate Sodium 100mg tablet twice daily for constipation. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM and 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Flonase Spray 50 micrograms 2 sprays each nostril once a day for allergic rhinitis. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Folic Acid 400 micrograms was to be taken once daily for anemia. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Lasix 80 mg 1 tablet by mouth twice a day for Congestive Heart Failure and edema. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Gabapentin 300 mg 1 capsule twice a day for neuropathy. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Glipizide 10 mg 1 tablet by mouth twice daily for diabetes. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Iron tablet 325 mg one tablet three times a day for anemia. The MAR was not signed off on 1/8/24 at 2:00 PM. Resident #9 had a physician order to receive Levothyroxine tab 88 micrograms, one tablet by mouth once daily for hypothyroidism. The MAR was not signed off on 1/22/24 at 6:00 AM. Resident #9 had a physician order to receive Loratadine 10 mg 1 tablet by mouth once daily for allergic rhinitis. The MAR was not signed off on 1/21/24 at 9:00 PM. Resident #9 had a physician order to receive Meclizine 25 mg 1 tablet by mouth twice a day for vertigo. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Omega 3 acid cap 1 GM twice a day for hyperlipidemia. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/18 at 9:00 PM,1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Multivitamin with mineral 1 tablet by mouth once daily. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive MiraLAX Dissolve 17 Grams in 6-8 ounces of water/juice and give by mouth twice daily was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Flomax 0.4 mg capsule by mouth once daily. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Vitamin D3 50,000, units one capsule weekly on Wednesdays. The MAR was not signed off on 1/17/24 at 9:00 AM. Resident #9 had a physician order to receive Vitamin C 500 mg 1 tablet by mouth once daily. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive ferrous sulfate 325 mg 1 tablet by mouth daily. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to screen for pain every shift and record this was not signed off on 1/8 7AM-7PM shift, 1/15 7AM-7PM shift, 1/17 7AM-7PM shift, and 1/22/24 7AM -7PM shift. Resident #9 had a physician order to receive 10 units of Baslagar (insulin Glargine) by subcutaneous injection once daily for Diabetes Type II. The was not signed off on 1/22/24. Resident #9 had a physician order to check for bowel movement every shift and give laxative as ordered. The MAR contains no documentation on 1/4 7PM-7AM, 1/8 7 AM-7 PM, 1/15 7AM-7PM, 1/17 7AM-7PM, 1/21 7PM-7AM, and 1/22/24 7AM-7PM. On 1/31/24 at approximately 3:30 PM, an interview was conducted with RN N who was shown the MAR for Residents #211 and #9. RN N explained that the doses should have been addressed and signed by the nurses responsible for giving the medications and treatments or an explanation documented on the back of the MAR. A copy of the Medication Administration Policy and Pharmacy Contract was requested from the Facility Administrator. On 1/31/24 a review of the Medication Administration Policy dated 8/7/2023 was conducted. The policy directed nurses to document necessary medication administration /treatment information when medications are given. (e.g. when mediations are given, injection site of a medication, when medications are refused.) Resident #311 On 01/29/24 at 1:00 PM, a telephone interview was conducted with the daughter of Resident #311. She stated her father recently passed away at home. She stated her father was admitted to the facility on [DATE] from the hospital following a stroke. She stated that she brought him home the very next day on 11/15/23 because her father called her screaming Get me out of here. She stated the food was terrible, the dishes were not clean, her father also did not receive any of his medications during his stay at the facility. She also alleged there were roaches in her father's room, and the room was so filthy she felt she had to clean it upon her father's admission. A record review of the face sheet for Resident #311 revealed the resident was admitted on [DATE] with diagnoses including Congestive Heart Failure, Coronary Artery Disease post Coronary Artery Bypass Grafting times 3, Chronic obstructive pulmonary disease, Atrial Fibrillation (Afib), Hypertension (HTN), Hyperlipidemia (HLD), sleep apnea, prior cerebral vascular accident (CVA) (stroke) with prior retinal detachment, and recent heart failure in October of 2023. A review of the Physician Orders received from the hospital dated 11/14/23 revealed the following medications were ordered: Eliquis 2.5mg tab twice a day for Afib Aspirin 325mg tab every morning for CVA Atorvastatin 80mg every night at bedtime for Hyperlipidemia Coreg 3.125mg twice a day with meals for HTN Cyancocobalamin 2500mcg daily for a Vitamin B12 deficiency Finasteride 5mg every day for Benign prostatic hyperplasia (BPH) Lidocaine 5% patch, apply topically to neck (transdermal) every morning, off every evening for nonacute pain Namenda 10mg tab twice a day for dementia Flomax 0.4mg every day for BPH Tramadol 50mg every night at bedtime for non acute pain A review of the Medication Administration Record (MAR) revealed there were no medications administered during the time Resident #311 was at the facility on 11/14/23 or 11/15/23. (Photographic evidence obtained) On 01/30/24 at 2:54 PM, an interview was conducted with RN N about the MAR for Resident #311. She was asked why there were no medications administered for this Resident. She stated Resident #311 arrived at 1:30 PM on 11/14/23 and left the facility at 10:01 AM on 11/15/23. On 01/30/24 at 03:16 PM, an interview was conducted with the Administrator about the medications ordered and provided to Resident #311. The Administrator stated that she checked with staff about this resident's medications and was told that the nurse failed to order the medications and failed to obtain the medications from the emergency kit supply for Resident #311. This nurse received a written reprimand and was provided inservice training because of this incident. At this time, the Administrator confirmed Resident #311 did not receive any medications, including the ordered blood thinners, during his stay at the facility. On 01/31/24 at 9:12 AM, a follow up interview with the Administrator was conducted, she stated she did not have any other paperwork to include the investigation into why this happened or the personnel actions taken. Review of the Flash Inservice for Administering Medications Upon admission for LPNs and RNs provided 11/15, 11/16, 11/17, 11/18, 11/19 and 11/20/23. There are a total of 11 staff who signed as attending this inservice. Discharge medication orders upon admission 1: Transcribe to POS (Physicians Order Sheet) 2. Notify MD (Physician) 3. Fax to Pharmacy 4. Administer medication at next schedule time. 5. If not delivered from pharmacy, pull from EKit [emergency medication kit]. 6. If not available in Ekit, notify MD and responsible party 7. Document notification of MD and responsible party in nurses note 8. Initial and circle in MAR and note see nurses note on back of MAR. The document stated See Additional Information Attached Best Practice admission of Resident and their Medications reads in part . 2. The orders received prior to admission are to be transcribed to the facility's Physician's Order Sheet by DON/Designee. DON/Designee will notify MD of resident's admission and current physician orders. 3. The physician order sheet is to be copied and faxed to Pharmacy upon arrival of resident to the facility for delivery of current medications. 4. It is the responsibility of the nurse admitting resident and performing medication pass to make sure the resident has the medications that have been ordered by MD. If a medication is due on the following medication pass and the facility has not received the medication, the nurse must pull from the facility's emergency kit. If a medication is due on the following medication pass and the facility has not received the medication, and the medication is not in the facility Ekit, it is the nurses responsibility to notify the physician and the responsible party of the unavailability of medication.

Based on observation, resident interview, staff interview and review of the 2022 Food Code from the United States Public Health Service Food and Drug Administration, the facility failed to ensure chicken was thoroughly cooked the evening of 1/31/24. This affected 5 observed dinner trays, including the tray served to resident #9. The findings include: On 1/31/24 at approximately 6:00 PM, resident #35 requested the survey staff to view the chicken dinner recently served to resident #9. Resident #35 stated that this is the crap food they serve us. An observation of the dinner tray served to resident #9 found a significantly uncooked dark meat chicken quarter. The chicken meat was pink to red and blood was visible. Staff AA, a Certified Nursing Assistant (CNA) was in the room and observed to cover the tray. CNA AA confirmed that the chicken was completely raw and she wouldn't eat it herself. Facility staff became alerted to the undercooked chicken, and began checking and removing affected resident trays. Two additional resident trays with partially eaten food were observed, one was returned to the tray care and the other was placed under a rolling table by the nurse's station on the 100 hall. On both trays, the chicken was visibly undercooked, pink to red in color, and still had some blood on it. (Photographic evidence obtained) On 1/31/24 at approximately 6:22 PM, an interview with the Facility Administrator was conducted. The Administrator stated she did not know how this could've happened. She stated it must have been only one plate with raw chicken. When informed that more than one tray had been spotted by the survey team, the Administrator cut open a small chicken wing to show us it was cooked properly. In the nursing station where the interview was conducted, a dinner tray located at the bottom of a table was spotted. The tray contained an uneaten piece of chicken, but the other food items had been consumed. The surveyor directed the Administrator to the significantly undercooked chicken that was on the plate, and the Administrator stated she did not know how that could have happened. On 1/31/24 at 6:11 PM, an interview was held with Staff FF, a facility cook. When asked what the process is to make sure chicken is cooked all the way, he stated he takes the temperature of all the big pieces. He stated he did not know how this happened, he has received several plates back to cook longer. He also stated that, when something is raw, he shuts down the line and cooks everything longer. When asked who plated that night, he stated he did, but did not see the raw chicken. The surveyor asked [NAME] FF how this could happen if he was checking the temperatures of all the larger chicken pieces? [NAME] FF replied that someone must have grabbed a bag of frozen chicken and added it to the defrosted ones. The surveyor asked, Who could have done that?, and [NAME] FF replied, no one, and that he was the only one that defrosts frozen meats. [NAME] FF confirmed he was the only one plating food that night. The cooked food temperature log from dinner was requested for review. [NAME] FF stated he did not have a temperature log for the chicken. He stated that he tested it as he was plating, but he did not record it anywhere. On 2/1/24 at 9:01 AM, the Facility Administrator provided a food temperature chart. When asked if she had policies and procedures for the kitchen and food preparation, she stated that they did not have policies and procedures related to the kitchen; however, she provided a temperature chart showing the safe cooking temperatures of foods including chicken. When asked for the grievances regarding the raw chicken, she stated her staff had chosen not to file any grievances. A review of the 2022 Food Code, Recommendations of the United States Public Health Service Food and Drug Administration. In the section about Hazard Analysis Critical Control Points (HACCP), the Food Code advises that Salmonella spp. and Campylobacter, as well as spore-formers, such as Bacillus cereus and Clostridium perfringens, are significant biological hazards in chicken. The control measure used to kill pathogens is cooking to the proper temperature. Chicken requires a final internal temperature of 165 degrees Fahrenheit to control the pathogen load for Salmonella spp. Monitoring activities need to be in place to ensure Chicken cooked is to 165 degrees Fahrenheit. Examples of monitoring activities include visual observations and measurements of time and temperature. Monitoring the internal temperature of a select number of chicken pieces immediately following the cook step would be an example of a monitoring activity. Alternatively, the temperature of an oven or fryer and the time required to reach an internal temperature of 165 degrees Fahrenheit could also be monitored.

Based on resident interview, staff interview, review of Treatment Administration records (TAR), clinical record review, and review of staff training from November 2023, the facility failed to ensure accurate medical record documentation (TAR) for 2 of 21 residents sampled for Medication Administration Records (#9 and #211). The findings include: Resident #211 On 1/31/24 at approximately 2:00 PM, a review of the Treatment Administration Record (TAR) for Resident #211 for the month of January 2024 was conducted. There were multiple treatments not signed on the TAR, and no explanation recorded in the medical record to explain the missed treatments. Resident #211 had a physician order to cleanse the sacral wound with normal saline, pat dry, apply skin prep to peri wound then apply wet to dry dressing to wound bed cover with dry dressing on 7PM-7AM shift daily and as needed. The TAR was not signed off that this had been done on 1/11, 1/23, 1/14, 1/18, 1/21, 1/24, 1/25, 1/27, 1/28, or 1/29/24. Resident #211 had a physician order to check dressing to sacrum every shift for soilage and dislodgement on both shifts. The TAR was not signed that this had been done on 1/11 7PM-7AM, 1/12 neither shift, 1/14 7PM-7AM, 1/15 7AM-7PM, 1/17 neither shift, 1/18 neither shift, 1/20 7AM-7PM, 1/21 7PM-7AM, 1/22 7AM-7PM,1/23 7AM-7PM, 1/24 neither shift, 1/25 neither shift, 1/26 7AM-7PM, 1/27 7AM-7PM, or 1/28/24 7AM-7PM. Resident #211 had a physician order to apply skin prep to the left heel every shift and as needed on 7PM-7AM shift. The TAR was not signed off indicating it was done on 1/11, 1/12, 1/14, 1/18, 1/21, 1/24, 1/25, 1/26, 1/27, 1/28, or 1/29/24. Resident #211 had a physician order to cleanse wound right heel with normal saline pat dry apply calcium alginate to wound bed apply skin prep to peri wound cover with dry dressing daily and as needed on 7PM-7AM shift. The TAR was not signed off indicating that it was done on. 1/11, 1/12, 1/14, 1/18, 1/21, 1/24, 1/25, 1/26, 1/27, 1/28, nor 1/29/24. Resident #211 had a physician order to check dressing to the right heel every shift for soilage and dislodgement on both shifts. The TAR was not signed that this had been done on 1/10 7PM-7AM, 1/11 neither shift, 1/12 neither shift, 1/14 7PM-7AM, 1/15 7AM-7PM, 1/17 7AM-7PM , 1/18 neither shift, 1/20 7AM-7PM, 1/21 7PM-7AM, 1/22 7AM-7PM,1/23 7AM-7PM, 1/24 neither shift, 1/25 neither shift, 1/26 neither shift, 1/27 neither shift, 1/28 neither shift, or 1/29/24 7PM-7AM shift. Resident #211 had a physician order to check gastrostomy tube for placement every shift after administering feeding and as needed. The MAR was not signed off on 1/10/24 on either shift, 1/11 on either shift and 1/12 on 7PM-7AM shift, 1/15 on 7AM-7PM , 1/17 on & AM -7PM, 1/21 7PM-7AM, 1/22 &PM-7 AM, or 1/27/24 on 7PM-7AM shift. Resident #9 On 1/31/24 at approximately 2:00 PM a review of the Treatment Administration Record (TAR for Resident #9 for the month of January 2024 was conducted. There were multiple treatments not signed on the TAR and no explanation recorded in the medical record to explain the missed treatments. On 1/30/24 at approximately 4:00 PM an interview was conducted with Resident #9. He indicated that receiving staff assistance takes a long time. He said everything does not always get done as it should. The resident indicated that he does not always get all prescribed treatments or assistance with getting up out of bed. He explained that the staff will say that he is asleep and refuses but that is not the case. Resident #9 had a physician order to receive nystatin powder1000 under bilateral breast and abdominal folds twice daily as needed antifungal topical preventative. The Treatment Record (TAR) was not signed off on 1/1, 7PM-7AM shift, 1/2 7PM-7AM shift, 1/4 7 PM-7 AM shift, 1/6 7AM-7PM shift, 1/8 both shifts, 1/9 7PM-7AM shift, 1/11 7PM-7AM shift, 1/12 7AM-7PM shift, 1/14 7PM-7AM shift, 1/15 7 AM-7PM shift, 1/17 7 AM-7 PM shift, 1/18 either shift, 1/20 7 AM-7PM, 1/21 7PM-7AM shift, 1/22 7 AM-7 PM shift, 1/23 7 AM-7 PM, 1/24 neither shift, 1/24 neither shift, 1/26 7 AM-7 PM, 1/27 neither shift, 1/17 neither shift, 1/28 neither shift, and 1/29/24 7 PM-7 AM. Resident #9 had a physician order to receive nystatin powder1000 under bilateral knee folds every shift as needed. The TAR was not signed off on 1/1, 7 PM-7AM shift, 1/2 7PM-7AM shift, 1/6 7AM-7PM shift, 1/8 neither shift, 1/9 7PM-7AM, 1/11 7PM-7AM shift, 1/12 7AM-7PM, 1/14 7PM-7AM shift, 1/15 7 AM-7PM shift, 1/17 7 AM-7 PM shift, 1/18 either shift, 1/20 7 AM-7PM, 1/21 7PM-7AM shift, 1/22 7 AM-7 PM shift, 1/23 7 AM-7 PM, 1/24 neither shift, 1/24 neither shift, 1/26 7 AM-7 PM, 1/27 neither shift, 1/28 neither shift, and 1/29/24 7 PM-7 AM. Resident #9 had a physician order to cleanse the area to right buttock and under abdominal fold with normal saline pat dry cover with dry dressing at bedtime. Diagnosis open area. The TAR was not signed off on 1/1, 1/2,1/3, 1/4, 1/8, 1/9, 1/11, 1/12, 1/14, 1/18, 1/21, 1/24,1/25,1/27,1/28, and 1/29/24. Resident #9 had a physician order to receive weekly skin audits during Friday shift on 7PM- 7AM shift was not signed off on the TAR on 1/12/24. On 1/31/24 at approximately 3:30 PM an interview was conducted with Nurse N, Registered Nurse (RN) who was also the Unit Manager and facility Infection Preventionist. She was shown the MAR and TARs for resident #211 and #9. RN N explained that the doses should have been addressed and signed by the nurses responsible for giving the medications and treatments or an explanation given on the back of the MAR/TAR. On 1/31/24 a review of the Medication Administration Policy dated 8/7/2023 was conducted. The policy directs nurses to document necessary medication administration /treatment information when the medications/treatments are given. Review of the Flash Inservice for Administering Medications Upon admission for LPNs and RNs provided 11/15, 11/16, 11/17, 11/18, 11/19 and 11/20/23. There are a total of 11 staff who signed as attending this inservice. Discharge medication orders upon admission 1: Transcribe to POS (Physicians Order Sheet) 2. Notify MD (Physician) 3. Fax to Pharmacy 4. Administer medication at next schedule time. 5. If not delivered from pharmacy, pull from EKit [emergency medication kit]. 6. If not available in Ekit, notify MD and responsible party 7. Document notification of MD and responsible party in nurses note 8. Initial and circle in MAR and note see nurses note on back of MAR. The document stated See Additional Information Attached Best Practice admission of Resident and their Medications reads in part . 2. The orders received prior to admission are to be transcribed to the facility's Physician's Order Sheet by DON/Designee. DON/Designee will notify MD of resident's admission and current physician orders. 3. The physician order sheet is to be copied and faxed to Pharmacy upon arrival of resident to the facility for delivery of current medications. 4. It is the responsibility of the nurse admitting resident and performing medication pass to make sure the resident has the medications that have been ordered by MD. If a medication is due on the following medication pass and the facility has not received the medication, the nurse must pull from the facility's emergency kit. If a medication is due on the following medication pass and the facility has not received the medication, and the medication is not in the facility Ekit, it is the nurses responsibility to notify the physician and the responsible party of the unavailability of medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, family interviews, staff interviews, room check documentation and the housekeeping job description, the facility failed to maintain a sanitary and orderly interior, and clean linens that were in good condition. The facility failed to provide adequate housekeeping services to ensure the daily cleaning of resident rooms throughout the facility. The lack of housekeeping services affected 13 of 26 sampled residents (#1, 2, 9, 10, 16, 19, 23, 30, 40, 45, 47, 54, and #211) plus 8 additional resident rooms (341, 343, 345, 347, 349, 351, 353, and 355), the shower rooms in the 100 and 200 hallways and the baseboards in the 300 hallway. This failure had the potential to affect all 68 residents at the time of the survey. For additional laundry related concerns, please cross reference F835, F867, F880, F908 and F945. The findings include: On 1/29/24 beginning at 11:15 AM, an initial tour of the facility was conducted. The following environmental concerns were observed in resident rooms: In Resident #2's room, the overhead table had rough edges and had sticky stains on the surface, the bed's footboard was torn and the head board was separated from the bed. In Resident #45's room, the ceiling suspended privacy curtain had red colored stains, the bed mattress had no sheets, the window blind had slats missing, the blinds cord did not work, the overhead table surface had stains, and 2 of 4 light bulbs of the overhead lamp were not working. In Resident #54's room, the cover of the resident's pillow was shredded and had no pillow case. About 6 feet of the 300 hallway baseboard was detached from the wall In Resident #19's room, the base of the overbed table was stained. In Resident #16's room, the bed linens were dirty with grainy like matter, there was no pillowcase for the pillow, a ceiling tile was dislodged, and the bathroom's mirror was splashed with a dried substance. In Resident #30's room, the floor was dirty with a sticky brown substance, the ceiling suspended privacy curtain had red stains, the pillow did not have a pillowcase, and the bathroom mirror was splashed with a dried substance. On 1/30/24 at 9:30 AM, the 300 hallway's baseboard remained detached from wall. On 2/01/24 at 9:24 AM, two days after the initial tour, the following observations were made: In Resident #2's room, the overbed table still had rough edges and the base remained stained, the footboard edges remained torn, the head board remained separated, the ceiling-suspended privacy curtain remained stained with a red-colored stain, and pillows were placed on top of a wheelchair without a pillowcase. In Resident #54's room, the overhead table's base remained stained and the shredded pillow was visible under the pillowcase. In Resident #45's room, the overbed table and base were dirty. The 300 Hallway's baseboard had orange-colored tape temporarily attaching the 6 foot loose area to the wall. In Resident #19's room, the overbed table remained dirty with a sticky substance. In Resident #16's room, the pillows had no pillowcases, the overbed table was dirty with a sticky substance, the bathroom mirror remained stained, and the ceiling-suspended privacy curtain still had red-colored stains. In Resident #30's room, the ceiling-suspended privacy curtain still had red stains. (Photographic evidence was obtained) On 2/1/24 at 10:16 AM, an interview was conducted with Staff CC, housekeeping personnel (HK). He stated the ceiling-suspended privacy curtains inside residential rooms were checked every day and changed as needed by housekeeping staff. Staff CC further stated there were extra curtains available at the clean linen closet located in the 300 hallway. On 2/1/24 at 10:20 AM, a tour of the clean linen storage room was conducted with Staff CC. There was one clean privacy curtain on a shelf. Staff CC stated, if he needed more curtains, he would get them at the laundry room. A tour of the laundry room was conducted and there were a total of 6 clean privacy curtains on a shelf. On 2/1/24 at 11:15 AM, an interview was conducted with the Environmental Services Supervisor who is also the Housekeeping Supervisor. She stated housekeeping staff check the ceiling-suspended privacy curtains and change them as needed as part of their daily tasks. She further stated housekeeping staff used a check list form. A blank check list form was provided. Upon requesting completed check lists from the last 2 weeks for all rooms and hallways, the Environmental Services Supervisor stated staff had not been filling them out. She further stated she had been very busy trying to keep up with the laundry. On 2/1/24 at 1:00 PM, the Environmental Services Supervisor provided a check list dated 1/30/24, conducted by herself, that indicated ceiling-suspended privacy curtains had been checked. On 1/29/24 beginning at approximately 11:30 AM during the initial facility tour, it was noted that many bathroom faucets had a thick white and green powdery build-up. The bathroom ceiling vents were covered with a thick build-up of a brown substance. This was observed in patient rooms 341, 343, 345, 347, 349, 351, 353, and 355. A review of the Daily Quality Assurance Check Sheets for Light Housekeeping, dated 1/28/24 and 1/29/24, was conducted. The check sheets indicated daily cleaning of sinks and floors was checked as being done in rooms 341, 343, 345, 347, 349, 351, 353, and 355. On 1/29/24 at approximately 11:30 AM, Resident #10 was observed seated in a wheelchair that had a build-up of dust and grime on the seat, the legs, and attachments of the chair. The resident was asked about her wheelchair and indicated she would like her chair washed. The resident added that she saw the large kind of roaches in her room last night. The bathroom sink faucet of her room was observed to have a thick build-up of a greenish white powdery substance and the vent in the bathroom had brown build up on it. On 1/29/24 at approximately 11:50 AM, Resident #9 was observed wearing a hospital style gown, and had no sheets on his/her bed. Resident #211 was wearing a hospital style gown, and had no pillowcases on his pillows or sheets on his bed. His bed was visibly soiled with a grayish buildup that appeared to be old skin and dirt, and adhered to the surface of the mattress. The tube feeding pump, pole and surrounding floor was covered with a dried splattered white substance. The bathroom sink faucet of the room had a thick buildup of a greenish white powdery substance and the vent in the bathroom had brown build up on it. During the observation, a resident in the hallway could be heard asking staff if today was the day that he could wash his clothes. A staff member was heard asking another staff member if they would go check in the outside storage area to bring in more sheets. On 1/29/24 at approximately 12:10 PM, soiled wet towels were observed left on the floor in the shower room in the 100 hall. The shower room was not in use at the time. On 1/29/24 at approximately 12:42 PM, an interview was conducted with the Maintenance Supervisor who stated that facility textiles and resident laundry was being processed at a local laundromat [by facility employees]. He stated this has been going on for a long time, at least 3 months. He stated that he has been helping with processing laundry on the weekends. He stated, It is disgusting but has to be done. The Maintenance Supervisor indicated that they had been waiting for an ordered part to arrive for about 9 months for a washer. When the second machine went out, the facility was left with no operating washing machine since about November of 2023. The surveyor asked how he ensured that the laundry is properly cleaned. The Maintenance Supervisor explained that the laundry gets washed. He did not express any knowledge of chemical detergents or water temperature requirements for properly laundering of resident clothing and linens. On 1/29/24 at approximately 1:00 PM, an interview was conducted with Resident #40. He complained of seeing bugs in his room all the time. He indicated that someone comes out to spray. The man who comes out to spray never comes into the rooms when he is here. On 01/29/24 at 1:00 PM, a telephone interview was conducted with the daughter of Resident #311. She stated her father was admitted to the facility on [DATE] from the hospital following a stroke. She stated that she brought him home the very next day on 11/15/23 because her father called her screaming Get me out of here. She stated the food was terrible, the dishes were not clean, there were roaches in her father's room, and the room was so filthy she felt she had to clean it upon her father's admission. On 1/29/24 at approximately 2:50 PM, an interview was conducted with Resident #9. The surveyor noted that he had a blanket under him instead of a sheet and that he was wearing a hospital style gown. His mattress was visibly soiled with buildup. There were yellow stains on a blanket below his mattress and his room smelled of urine. He was asked if he preferred to have a blanket under him instead of a sheet. The resident indicated that his back hurts and the facility often runs out of sheets. He said the church gave him sheets to use but the facility does not keep up with laundry. He indicated that he does not like wearing the gown and wanted staff to assist him to change into his clothes and get out of bed. The bathroom sink faucet of the room had a thick build up of a greenish white powdery substance and the vent in the bathroom had brown build up on it. (Photographic evidence obtained) On 1/30/24 at approximately 10:00 AM, Residents #1, #9, and #211 were again observed wearing hospital gowns. Residents #9 preferred to wear their own clothing, but his personal clothes had not been returned from the laundry. On 1/31/24 at approximately 11:00 AM, an interview was conducted with a direct care staff member who wished to remain anonymous. The employee indicated that she did not want her name to be revealed due to fear of retaliation. She indicated that the linen supplies at the facility have been inadequate for a long time. Frequently, there are piles of soiled linens waiting to be washed and left-over wet linens waiting to be dried. She indicated that laundry is not processed after 6:00 PM. The facility often runs out of linen on a daily basis and it has been a problem for months. On 01/31/24 at approximately 2:30 PM, an interview was conducted with the significant other of Resident #211. She was asked if the resident preferred to wear a patient gown. She indicated that he prefers to wear his own clothing. The surveyor inquired about the pillows without pillowcases and mattress without a sheet on it. Resident #211's significant other indicated that the facility has seemed to be short on linen since he was admitted (about 3 weeks earlier). On 1/31/24 at approximately 4:50 PM, neither Resident #23 nor Resident #47 had a change of clothes available in their wardrobes. On 2/1/24 at approximately 9:00 AM Resident #23 and #47 were observed wearing the same clothes as the previous day. On 2/1/24 at approximately 10:00 AM during a resident care observation, staff did not have a clean fitted sheet to apply to the bed for Resident #9. The surveyor followed Nurse D, a Licensed Practical Nurse (LPN), to each of the two indoor laundry storage rooms. Each of the 2 indoor clean linen storage areas had very little clean laundry available. The first indoor storage room had about 4 bed pads, three sheets, 3 bed spreads, 15 towels, 1 patient gown and a stack of wash cloths. The other indoor linen storage area had about 5 patient gowns, about 30 towels, three bed spreads, 1 stack of bed pads, and about 15 flat sheets. The shelves were mostly bare and there were no fitted sheets in any of the indoor storage areas to apply to Resident #9's bed. (Photographic evidence obtained) On 2/2/24 at approximately 11:00 AM, an observation of the shower room on the 200 hall was conducted. The shower room contained a functional small capacity household style washer along with 2 large bins of soiled linen. The Environmental Services Manager was unable to provide specific information regarding what types of textiles were being washed in the machine. On 2/1/23 at approximately 3:00 PM, an interview was completed with the Infection Preventionist nurse (IP). She was asked if she does infection prevention rounds around the facility to ensure compliance with infection control processes. The IP explained that she does not do rounds. She explained that the Director of Nursing (DON) normally does infection control rounds. The DON has been out from work for about 2 weeks on extended leave. She mentioned the environmental services manager is in charge of ensuring infection control processes are followed when it comes to handling and laundering linen. The IP was asked how the small functional washing machine in the shower room was being utilized. The IP was unable to provide specific information regarding its use. The housekeeper job description, undated, was reviewed. The section Purpose of Your Job Position documented that the primary purpose of your job position is to perform the day-to-day activities of the housekeeping department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, as may be directed by the Administrator and or the Director of Housekeeping, to assure that our facilities are maintained in a clean safe and comfortable manner. Under Housekeeping Services the document included: -Perform day-to-day housekeeping functions -Clean/polish furnishings, fixtures, ledges, room heating/cooling units etc., in resident rooms, recreational areas etc. daily as instructed. -Clean, wash, sanitize, and/or polish bathroom fixtures. Ensure that watermarks are removed from fixtures. -Clean windows/mirrors in resident rooms, recreational areas, bathrooms, and entrance/exit ways. -Clean floors to include sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting etc. -Clean walls and ceilings by washing, wiping, dusting, spot cleaning, disinfecting deodorizing, etc. -Remove dirt, dust, grease, film etc., from surfaces using proper cleaning/disinfecting solutions. -Clean hallways and stairways.

Based on staff interviews and record review of the payroll-based journal (PBJ) Staffing Data Reports for Quarter 3 and Quarter 4 2023, the facility failed to accurately submit staffing information to CMS (Centers for Medicare and Medicaid). The findings include: A review of the fiscal year PBJ Staffing Data Report, form 1705D, for the 4th Quarter in 2023 (July 1 - September 30, 2023) found low weekend staffing, no Registered Nurse (RN) hours, and a failure to have Licensed Nursing coverage 24 hours a day. On 1/29/24 at 4:11 PM, an interview was conducted with the Administrator. She stated the PBJ was not submitted appropriately. She further stated that it was not possible that the facility did not have an RN or Licensed Nursing coverage from 7/1/23 until 9/16/23. On 2/02/24 at 2:49 PM, a follow up interview was conducted with the Administrator. She stated the PBJ was not properly filled out because the previous owner would not provide the data to the new company's corporate office and would disregard corporate requests.

Based on observation, resident interviews, and employee interviews, the facility failed to ensure an adequate supply of clean bath linens was readily available for resident use and care in 2 out of 2 linen closets currently in use. This failure had the potential to affect all 62 residents residing in the facility at the time of the survey. The findings include: An observation of the clean linen supply closets on the locked unit and front hallway was conducted in the presence of anonymous employee B on 1/31/23 at approximately 11:05 AM. There were no clean sheets, washcloths, or towels observed to be available in the closets. Anonymous employee B indicated these clean linen closets were the areas clean linen was stored for use. (Photographic evidence obtained.) An observation of the laundry room located outside the facility in a separate room was conducted on 1/31/23 at approximately 11:18 AM. A laundry employee was observed stocking a linen cart with approximately 10 washcloths, approximately 15 towels, and stacks of sheets. During this observation, the Environmental Director (ED) was observed in a storage room near the laundry room removing linen out of bags and boxes to include towels, sheets, and washcloths. The ED stated the items were new stock she was putting out for use. She stated the facility had one washing machine not functioning out of two and one dryer not functioning out of three. She stated that the facility had ordered parts for both machines. She stated right now she only had one laundry aid. Further interview was conducted with the ED on 1/31/23 at approximately 11:51 AM. She stated she is usually on duty in the facility from 8:00 AM to 5:00 PM or maybe 6:00 PM and when she leaves the laundry room is locked. Staff have access to a key if the room is locked. She stated the washing machine had not been functional since about the last week of December 2022 and the dryer had not been functional since about November 2022. She stated that she believes the part order for the washing machine was placed about 2 weeks ago and the dryer motor was ordered about the first part of December. She did not know why the parts had not arrived. She confirmed there was no laundry staff in the facility daily from about 6 PM to 8 AM. She had hired an employee to begin the night shift. She stated the facility was keeping up with the linen supply before the washer and dryer quit functioning. However, at the current moment, nursing assistants were hiding the linen and throwing washcloths away. She came in about 7:30 AM that morning and staff had towels, washcloths, and sheets, but they had no washable incontinent under pads. She did not know how long the staff had been without any under pads. She stated about 60 under pads were put out for use around 4:00 PM the previous day. The ED stated the Regional Environmental Services Director authorizes funds for replacement or repairs for the washing and drying machines. An interview was conducted with anonymous employee A on the morning of 1/31/23. The employee stated they do not have adequate supplies to complete daily living care for residents. A couple of days ago, the nursing assistants went to the store to purchase washcloths and towels for resident care with their own funds and they were not reimbursed by the facility. The employee stated that the toilet paper the facility supplies did not clean the residents adequately. An interview was conducted with anonymous employee B on the morning of 1/31/23. The employee stated sometimes the staff do not have adequate supplies to perform daily resident care in the morning. An interview was conducted with anonymous employee C on the morning of 1/31/23. The employee stated they do not usually have adequate linens to complete resident care in the mornings. The employee stated they used to go to the laundry room and try to obtain the supplies but stopped because the laundry staff would tell them not to do so. Anonymous employee C stated in the last 2 weeks they had worked about 10 days and each day did not have adequate linen supply for morning resident care. When the facility does not have adequate linen, they use toilet paper or paper towels to clean residents. Anonymous employee C stated the Director of Nursing (DON) was aware of the staff not having adequate linen for resident care. An interview was conducted with anonymous employee E on the afternoon of 1/31/23. Anonymous employee E stated the facility does not have adequate linen to care for residents. The facility usually does not have an adequate supply of under pads, towels, or washcloths. They must use blankets and pillowcases as under pads and wash cloths at times. They also must use toilet paper or paper towels to clean residents when out of linen. One resident even got her family to bring her linen from home. An interview was conducted with resident #1 on 1/31/23 at approximately 12:49 PM. She stated the facility runs out of clean linen every day. She stated she must hide some linen in her dresser for herself and her roommate just to ensure they have it available. She has reported the shortage to the head of housekeeping. An interview was conducted with resident #2 on 1/31/23 at approximately 12:53 PM. He stated the facility does not have an adequate linen supply. He stated he keeps one towel and reuses it, and that this towel is only replaced about once a month. An interview was conducted with resident #3 on 2/1/23 at approximately 11:44 AM. She stated she keeps extra washcloths and towels in her drawer so when the facility is short on linen she can still bathe. The resident then showed the surveyor the towels and washcloths in her drawer but would not allow the surveyor to obtain a photo of the linen. An interview was conducted with resident #4 on 2/1/23 at approximately 1:44 PM. She stated the facility does not always have adequate linen such as towels and washcloths. This has been an issue for about 2-3 weeks. She had her family purchase her own washcloths because many times the facility did not have any available. An interview was conducted with resident #5 on 2/1/23 at approximately 2:11 PM. She stated the facility did not always have adequate linens for bathing. She is aware they have one washer and one dryer out of service. She has purchased her own washcloths. An interview was conducted with the facility Administrator on 2/1/23 at approximately 3:42 PM. He stated he started working at the facility on 1/9/23. He stated the washer and dryer has been in disrepair and this has slowed down the return of resident clean clothing back to the residents and has impacted the facility's staffing. He stated the laundry staff are working until 6:00 PM. He was made aware of the washer and dryer not functioning on 1/9/23. He ordered parts for repair on the same day and, to his knowledge, staff and residents have adequate linen. An interview was conducted with the DON on 2/1/23 at approximately 4:04 PM. She stated she had been made aware the staff were having trouble obtaining the linen they needed. The facility ordered the parts for repair of the washer and dryer on 1/9/23 and they ordered more linen in December 2022 when the washer went down. She stated the Administrator should have been following up with staff and residents to ensure they had adequate linen. They had been discussing this almost daily in their meetings. A telephone interview was conducted with the Regional Environmental Director on 2/2/23 at approximately 10:47 AM. He stated the facility identified a problem with the washer and dryer about 4 weeks ago. Parts had been ordered. He checked the order status and they are currently on back order with no estimated time of arrival. He stated the machines are about 5-6 years old.

Based on observation, staff interviews, resident interviews, and quality assurance performance improvement plan review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to ensuring an adequate supply of clean bath linens was readily available for resident use and care. This failure had the potential to affect all 62 residents residing in the facility at the time of the survey. Cross reference F584. The findings include: During the survey conducted on 1/31/23 through 2/2/23, observations and multiple interviews with both staff and residents confirmed the facility failed to ensure an adequate supply of clean bath linens was readily available to staff and residents for resident care. (cross reference F584) An interview was conducted with the facility Administrator on 2/1/23 at approximately 3:42 PM. He stated he started working at the facility on 1/9/23. He stated the washer and dryer were in disrepair and this has slowed down the return of resident clean clothing back to the residents and has impacted the facility's staffing. He stated the laundry staff were working until 6:00 PM. He was made aware of the washer and dryer not functioning on 1/9/23 and parts were ordered for repair on the same day. To his knowledge, staff and residents had adequate linen. An interview was conducted with the Director of Nursing (DON) on 2/1/23 at approximately 4:04 PM. She stated she had been made aware the staff were having trouble obtaining the linen they needed. The facility ordered the parts for repair of the washer and dryer on 1/9/23. In addition, they ordered more linen in December 2022 when the washer went down. She stated the Administrator should have been following up with staff and residents to ensure they had adequate linen. They had been discussing this almost daily in their meetings. A telephone interview was conducted with the Regional Environmental Director on 2/2/23 at approximately 10:47 AM. He stated the facility identified a problem with the washer and dryer about 4 weeks ago. Parts had been ordered. He checked the order status and they are currently on back order with no estimated time of arrival. He stated the machines are about 5-6 years old. Further interview was conducted with the facility Administrator on 2/2/23 at approximately 11:04 AM. He stated the facility had changed the delivery times of linen and the number of linens delivered at one time to ensure they had enough linens. They had just hired a new staff member in laundry who works until 11 PM. They had ordered more linens as well. He did not know if any rounds or audits were implemented to ensure adequate linens were available. He stated the facility had not developed a quality assurance performance improvement (QAPI) plan regarding linen because they had adequate supplies to meet the demand. Review of the undated facility QAPI plan reveals the goals, scope, governance and leadership, feedback, data systems and monitoring, guidelines for PIPs (performance improvement plans), systemic analysis and systemic action, and evaluation. Practice areas assessed as needing improvement or change will be addressed in a performance improvement action plan using a SMART (Strategic, Measurable, Achievable, Relevant, Timely) formula for setting the goal of the plan, root cause analysis to find the systemic cause of why the practice area is in need of improvement or change and feed back from all stakeholders to ensure the safety and high quality of all clinical interventions emphasize autonomy and choice in the daily life of residents. The Administrator is accountable for the leadership and coordination of the Quality Assurance Performance Improvement Program. Topics for Performance Improvement Projects will be identified through deficient practices that impact the quality of services delivered to our residents. Our organization will develop projects on an as needed basis or as soon as an area of concern is identified. The project teams will be assembled by the project manager and include at least 3 members from affected and unaffected departments to ensure that an interdisciplinary approach.