**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure wheelchair mobility was provided for one (#7) of eight residents sampled. Finding Included: During multiple observations made on 09/08/2024, 09/09/2024, 09/10/2024 and 9/11/2024 at multiple times 10:00 a.m., 3:00 p.m., and 5:00 p.m., Resident #7 was observed lying down in bed with her call light within reach Review of an admission record showed Resident #7 was admitted to the facility with diagnoses which included but not limited to dysphagia following cerebral infarction, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance. Review of a Minimum Data Set, (MDS) dated [DATE] showed a Brief Interview for Mental Status, BIMS score of 00, which indicated interview was not able to be conducted. Further review of the MDS section GG- showed Resident # 7 used a wheelchair for mobility. Review of a care plan focus for Activity of Daily Living (ADL) initiated on 09/10/2024, showed Resident #7 had an ADL self- care deficit related to ADL needs and participation vary, chronic medical conditions, dementia, limited mobility. Review of the care plan goals showed Resident #7 would not have a decline in ADL functioning through next review date. Initiated on 09/10/2024. Review of the care plan intervention for transfer showed, The resident is dependent and is unable to assist with a transfer and will need assistance x 2 staff. Initiated on 9/10/2024. During an interview on 09/10/2024 at 3:00 p.m. with Staff Z Certified Nursing Assistant (CNA), she stated she had worked at the facility for three years. She was familiar with Resident #7 because she was assigned to her often. She gave the resident a bed bath and checked on her every 2 hours to see if she needed to be changed. She did not get Resident #7 out the bed because she did not have a wheelchair. She stated she had never seen Resident #7 out the bed. During an interview on 09/11/2024 at 10:27 a.m. with Staff W, Registered Nurse (RN), he stated he was assigned to Resident #7 and was familiar with her care. He stated Resident #7 did not get out the bed because she did not have a wheelchair. During an interview on 09/11/2024 at 1:00 p.m. with Staff AA, CNA, She stated she was assigned to Resident #7 and she did not get her out the bed. She stated she was provided with a list of residents that were assigned to get up and Resident # 7 was not on the assigned list to get out the bed. During an interview on 09/11/2024 at 11:16 a.m. with Staff BB, License Practical Nurse/Unit Manger (LPN/ Unit Manager), she stated Resident #7 was a dependent resident with limited mobility and could not walk. Therapy was working with her by providing her with bed exercise. She did not have upper extremity control. She said she had not seen the Resident #7 out the bed. The resident did not have access to a wheelchair because she needed a reclining wheelchair. During an interview on 09/11/2024 at 1:00 p.m. with the Rehab Director, she stated Resident #7 was picked up today, 09/11/2024, for therapy services. She was referred to therapy by nursing. The therapy process was that they screened all residents admitted to the facility for a mobility device. She could not answer why Resident #7 did not have a wheelchair but said they would address the issues so the resident had a wheelchair moving forward. Review of a policy titled, Standards and Guidelines: ADL Care and Services Revised dated 1/2024 showed Standards: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Gudelines: Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. Including appropriate support and assistance with: b. Mobility ( Transfer and ambulation, including walking).

Based on observation, staff interview, and record review, the facility failed to provide two (#76 and #82) of forty-six sampled residents with privacy during two of four days observed. Findings included: 1. On 9/8/2024 at 10:00 a.m., the 100 hall was toured and observed. The 100/200 hall was a very high trafficked hall where staff, residents and visitors pass through. The hall was busy with housekeeping staff, direct care staff, residents ambulating/self propelling, nurses and other departmental staff. Upon reaching Resident #76's room, it was observed her room door was all the way open and she was noted lying flat in bed, on top of the bed linen and with her head over bed approximately twenty-five degrees. Further observations revealed she was wearing a hospital gown. Resident #76's hospital gown was observed pulled up all the way to her waste and she was observed totally nude. There did not appear to be any clothing on the floor, bed, nor was there any evidence of any pull up briefs at or around the bed. Resident #76 resided in the (door) bed and both the door and the privacy curtain were opened all the way. Further observations revealed a male resident seated in a wheelchair, just across from Resident #76's door and was facing her. The resident was not interviewable, but he was positioned in such a way where he could see Resident #76. Also, various staff were observed walking by the Resident's room and none stopped to either close the door or assist her with re gowning or dressing. Resident #76 was observed from the hallway totally naked from the waste down from at least 10:00 a.m. through to 10:11 a.m. with no staff intervention. On 9/8/2024 at 10:12 a.m., Resident #76's room was again approached. She moved in bed in such a manner that when she turned and the gown dropped down and covered her genitals. The resident could not respond with specific answers. She was asked if she needed or wanted any privacy and she did not answer. She was asked if staff provide her privacy when in need and she did not answer. On 9/9/2024 at 8:30 a.m., Resident #76 was again noted in her room and lying upright in bed and lying on top of the bed linen. She was observed wearing a hospital gown and the gown was pulled up to her waste. Further observations revealed she was wearing an adult brief and could be observed from the hallway. The room door and the privacy curtain were both opened all the way. The resident was asked about her day and if she needed any staff to help her. She started to sing aloud in phrases that were not understandable. The hallway was observed with high traffic from staff and visitors as the resident could be seen unrobed from the hallway. The resident was observed from the hallway in this position from 8:30 a.m. through to 8:42 a.m. with no staff intervention. An unidentified staff member walked by the resident's room and went inside to pull the resident's gown down, so she was no longer exposed. On 9/11/2024 an interview with the Resident's assigned Certified Nursing Assistant (CNA) Staff H revealed Resident #76 had cognitive impairment and though she could answer some yes and no questions, she was not able to speak to her care and services. Staff H revealed if the resident was found or seen disrobed, staff should immediately provide her with privacy by either assisting to redress, or close the door so people passing the room could not see her. Staff H revealed the resident was usually assisted with dressing right at the beginning of 7-3 shift, or she might be assisted with dressing from staff on the previous shift. Review of Resident #76's medical record, diagnosis sheet, showed she had diagnoses to include but not limited to: Cerebral Infarction, Dementia, Epilepsy, Major Depression, Schizophrenia, and Heart Failure. Review of the medical record to include nurse progress notes dated 6/25/2024 a. 6/26/2024 15:59 Summary skilled - Resident alert and confused. Review of the nurse progress notes dated from 6/25/2024 through to 9/11/2024 did not have any documented evidence of Resident #76 disrobing or having a history of disrobing. Review of the current care plans with next review date 12/4/2024 revealed the following: 1. Risk for decreased safety and independence related to cognitive communication deficit secondary to CVA, with interventions in place 2. History of exhibiting the following behaviors: Chronic/frequent refusals of care and or services, Non compliant with medications. Can be physically aggressive to staff, refuses, weight at times, with interventions in place. Note: This care plan problem area did not indicate resident has a history of removing adult briefs. 3. Resident has impaired cognitive function/impaired thought process r/t diagnosis of dementia, disease process, with interventions in place 2. On 9/9/2024 at 6:50 a.m., Resident #82 was observed seated in her wheelchair at the nurses station. She was noted dressed for the day and well groomed. She had a blanket over her lap, legs, and pulled up to her neckline. She was pleasant to speak with and had a staff member next to her and was chatting with her. On 9/9/2024 at 7:11 a.m., Resident #82 was observed seated in her wheelchair positioned in the doorway halfway in her room and halfway in the hallway. All of a sudden the resident pulled up her top and removed it all the way by pulling it up and off her head. Resident #82 was completely nude from her waste up and could be seen by all staff and visitors that walked by this area. Residents entire chest was bare and exposed. Further observations in the room revealed a Personal Care Attendant (PCA) Staff C talking with Resident #82's roommate. Staff C was observed to see Resident #82 removing her shirt and she did not say anything to her at first. At 7:14 a.m.,' Staff C called out the resident's name and said; you need to put your shirt on. However, Resident #82 did not attempt to redress. At 7:16 a.m. instead of assisting Resident #82 back in the room and closing the door, she stood at the doorway and put Resident #82's shirt back on. During the time of 7:11 a.m. and 7:16 a.m. over ten various staff and residents had passed by the area when Resident #82 was exposed. Review of Resident #82's medical record, diagnosis sheet, revealed she was admitted to the facility with diagnoses to include but not limited to: Dementia, Major Depression, Anxiety, Insomnia. Review of the current Minimum Data Set (MDS) admission assessment, dated 6/12/2024 revealed a Cognition/Brief Interview Mental Status or BIMS score 9 of 15 which indicated moderately impaired cognition ; Behavior - documented as none exhibited; Mood - None documented as exhibited Review of the nurse progress notes dated from 6/5/2024 through to 9/11/2024 did not show any documentation to support Resident #82 had a history of removing articles of clothing. On 9/10/2024 at 12:20 p.m. an interview with Resident #82's responsible party, confirmed the resident had never exhibited behaviors of removing her clothing. She would hope that staff would respond quickly to redress her if that happened. On 9/11/2024 at 9:35 a.m. an interview with the 100/200 Unit Manager Staff G revealed she did hall rounds throughout the day and if she were to see a resident nude, disrobed or unclothed, she would respond immediately and provide the resident his/her privacy by pulling closed the privacy curtain, closing the door, and attempt to redress the resident. Staff G confirmed this should be an expectation from all staff in the building. Staff G revealed she knew of both Resident #76 and #82 and neither had a history of behaviors of taking off their clothes and disrobing. She revealed she would need to speak with the assigned care aides to see if this was that happened frequently. On 9/11/2024 at 12:10 p.m., the Nursing Home Administrator revealed they did not have a specific Privacy policy and procedure, but had a Resident Rights policy they follow related to resident privacy. The policy provided revealed; Resident Rights, with a last revision date of 1/2024. The policy stated; A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. The guideline section of the policy revealed; Employees shall treat all residents with kindness, respect and dignity. The procedure section of the policy revealed; 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified existence; b. Be treated with respect, kindness, and dignity.

Based on record review and interview, the facility failed to provide Abuse/Neglect training to one (Staff X) of 10 employees reviewed. Findings Included: During an interview on 09/10/2024 4:30 p.m. the Director of Nursing (DON) stated Resident #100 had a lower BIMS score, and frequently wandered around the building. He stated on 03/14/2024 his Assistant Director or Nursing (ADON) and the Unit Manager (Staff G, Licensed Practical Nurse [LPN]), came and let him know that Resident #100's Resident Representative (RR) was reporting an allegation of neglect. The DON stated he went to Resident #100's room to speak with the family. He stated the family reported to him when they came in to visit Resident #100 on 03/13/2024 during the night, they found the resident in two briefs, the resident had a hospital gown on top of her clothes and was tucked in underneath her, the resident's hands were bound behind her, and that the resident's TV was not working. The DON stated once he spoke with the family, he went and notified the Nursing Home Administrator (NHA) and their regional. He stated when the Adult Protective Investigator (API) came in, they showed him pictures with a curtain with a call light and stated, There were no patient identifiers so this could have been any resident's room. He stated the API worker then showed him a picture of a brief and another brief being used as a chuck pad, and then a picture of Resident #100 with the sheets up to her arm pits and her arms outside of the sheet. The DON stated he provided a written copy of his statement to the NHA. During an interview on 09/11/2024 at 12:39 p.m. the Nursing Home Administrator (NHA) stated on 03/13/2024 Resident #100's Resident Representative (RR) came in to visit the resident around 11:45 p.m., with a female companion. During this visit, staff stated the RR was not his usual self and smelt like alcohol. He stated the RR questioned Staff X, Certified Nursing Assistant (CNA) about why the call light was clipped to the curtain and why the TV was not working. He stated the Staff X, CNA went and got Staff Y, Licensed Practical Nurse (LPN), to let her know the RR was there and that he was not acting like his usual self. Staff Y, LPN, then went to the resident's room and noticed two people in Resident #100's room, she was told by the RR that the TV was not working. Staff Y tried to fix the tv, and the RR told her he would come back the next day. He stated on 03/14/2024, the Director of Nursing (DON) was approached by the Assistant Director of Nursing (ADON) and Staff G, LPN, notifying him the RR reported that when they came to see Resident #100 on 03/13/2024 her call light was out of reach, she was wearing two briefs, and she had a hospital gown tucked around her, where she could not move. He stated after the DON spoke with the RR; the DON reported the allegation to him (NHA). He stated, he then reported the allegation of neglect for double briefing and the call light being out of reach, he then had his staff call the abuse hotline, who accepted the case, and the Police who did not proceed. He then suspended the CNA pending investigation. They evaluated the resident by completing skin sweeps, a pain evaluation, psychosocial evaluation and reported the allegation of neglect to the physician. Resident #100 was found to be in no pain, had no skin impairments and remained at her baseline. He stated they did education on Abuse, Restraints, Call Lights, and double briefing. He stated they completed education on restraints because they wanted to rule out any type of restraint, since it was reported Resident #100 was dressed in a gown that was tucked underneath her, and they wanted to do a comprehensive education. During an interview on 09/10/2024 at 3:15 p.m., Staff X, CNA stated Resident #100 was a resident under her care. She stated on 03/13/2024 she worked a double shift, and Resident #100 was known to always be talking and moving about, she stated she never sits still. She stated one night, Resident #100's Resident Representative (RR) came in and was upset that the floor was dirty, and Resident #100 was soiled. She stated she went to change Resident #100, and the RR and his family member asked if they could stay in the room while she performed the care. She stated she agreed and began providing care for the resident. She stated she moved the call bell out of the way and placed it on the curtain. She stated as she began to change the resident, the RR's noticed the liner in the resident's brief and started accusing her of double briefing Resident #100. She stated the resident liked to dig her hands in her vagina, so she added a liner to the resident's brief to keep her from getting her hands in her pants. She stated the RR began shouting at her asking her why the floor was dirty and why the TV was also turned off. She stated she went and got a towel and cleaned up the floor right away. She stated she told the RR she was not sure why the TV was not working, but she would let maintenance know first thing in the morning. She stated the RR was not willing to hear her out, so she went and got the Unit Manger. She stated the RR left after speaking with the Unit Manager. She stated the next day the RR came in and reported Resident #100 was double briefed, and she (Staff X) had touched the resident inappropriately. She stated she was immediately suspended. She stated she spoke with the State's Adult Protective Agency and the police. She stated she was suspended for three days, and she had not completed any training before returning to work and has not received any retraining or education on abuse/neglect since returning to work in mid to late March of 2024. Review of the inservice education dated 03/14/2024, revealed staff was educated on abuse allegations and reporting timely, forms of abuse can include physical restraints, residents are not to be double briefed, and call lights are to be placed with in reach, the sign in sheet did not include Staff X, CNA. Review of the facility's abuse, neglect, exploitation, misappropriation, mistreatment, and injury of unknown origin (ANEMMI) Policy dated 08/2022 revealed: Training Policy: The center will train all new and existing nursing home staff through orientation and ongoing end services in ANEMMI prevention and response. Nursing home staff includes employees, consultants, contractors, volunteers and other caregivers who provide care and services to residents on behalf of the facility. Procedure: In service training will include at a minimum: A. Regulatory requirements regarding freedom from abuse neglect and exploitation. C. What constitutes abuse neglect exploitation misappropriation mistreatment and injury of unknown origin. D. Reporting policies and procedures established by the center. E. Appropriate interventions to deal with aggressive behaviors. F. How to recognize signs of burnout frustration and stress and both residents and staff that might lead to abuse neglect exploitation misappropriation and mistreatment and how to effectively intervene. Prevention Policy: The center will provide supervision and staff support services designed to reduce the likelihood of abusive behaviors. This center will provide ongoing oversight and supervision of staff in order to assure that policies are implemented as written. Procedure only authorized staff directly involved in providing care and services for a resident should be present when care is provided unless the resident consents to other individuals being present during the delivery of care. All supervisory staff will identify inappropriate behaviors, including but not limited to the use of derogatory language; rough handling; ignoring residents while giving care; directing residents who need assistance with toileting to urinate or defecate in their beds; and will take immediate steps to correct such behaviors. Supervisors will be especially sensitive to signs and symptoms of acute frustration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure all alleged violations of abuse to include physical restraints were reported to the State Survey Agency for 1 (#100) out of 23 residents sampled. Findings included: Review of Resident #100's admission Record revealed she was originally admitted to the facility in 2020 with medical diagnoses of Alzheimer's disease, diabetes mellitus, non-Alzheimer's dementia, delusional disorders, chronic kidney disease, peripheral vascular disease, and depressive episodes. Review of Resident #100's Quarterly Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 showing Resident #100 was cognitively impaired. Functional Abilities and Goals, Section GG revealed Resident #100 required Partial/moderate assistance for Toileting hygiene, and Shower/bathe care, personal hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. According to the Self-Care Coding for Partial/Moderate assistance means helper does less than half the effort. A helper lifts or holds trunk or limbs and provides less than half the effort. During a phone interview on 09/10/2024 at 8:59 a.m. the Resident Representative (RR), stated he came in to see Resident #100 on 03/13/2024 around 1:00 a.m., he stated the resident was in bed with a hospital gown and sheet tucked around her. He stated his family member (FM), who was with him, removed the sheet from Resident #100 and saw that her hands were tied behind her back with a towel. He stated his FM untied Resident #100 before he was able to get a picture. He stated he and his FM removed the sheet and hospital gown from Resident #100 and saw she was double briefed and wet. He stated the call bell was also clipped to the curtain in her room and the TV was turned off. He stated he went and got Staff X, Certified Nursing Assistant (CNA) and asked her why Resident #100 was tied up in bed and in a wet brief, he stated Staff X, CNA had no explanation and exited the room and started talking to another staff member in the hallway in another language. He stated he stayed until around 3 a.m., to make sure Resident #100 was taken out of bed, given a bath and changed. He stated he came in the next morning spoke with the Director of Nursing (DON) and told him when he came in to see Resident #100, he found her in her room with a hospital gown and sheet tucked underneath her, with her hands tied behind her back, and her call light attached to the curtain. He stated after reporting the allegation to the facility no one has contacted him. During an interview on 09/10/2024 at 3:15 p.m., Staff X, CNA stated Resident #100 was a resident under her care. She stated the resident is known to always be talking and moving about, she stated she never sits still. She stated one night the resident's family came in and was upset that the floor was dirty, and Resident #100 was soiled. She stated she went to change Resident #100, and the RR and his FM asked if they could stay in the room while she performed the care. She stated she agreed and began providing care for the resident. She stated she moved the call bell out of the way and placed it on the curtain. She stated as she began to change the resident the RR's FM noticed the liner in the resident's brief and started accusing her of double briefing Resident #100. She stated the resident likes to dig her hands in her vagina so she added a liner to the resident's brief to keep her from getting her hands in her pants. She stated the RR began shouting at her asking her why the floor was dirty and why the TV was also turned off. She stated she went and got a towel and cleaned up the floor right away. She stated she told the RR she was not sure why the TV was not working but she would let maintenance know first thing in the morning. She stated RR was not willing to hear her out, so she went and got the Night Nurse assigned to Resident #100 (Staff Y, Licensed Practical Nurse [LPN]). She stated the RR left after speaking with the Staff Y, LPN. She stated the next day the RR came in and reported Resident #100 was double briefed, and she touched the resident inappropriately. She stated she was immediately suspended. She stated she spoke with the state's Adult Protective Agency and the police. She stated she was suspended for 3 days, and she had not completed any training before returning to work. During an interview on 09/10/2024 4:30 p.m. the DON stated Resident #100 had a lower BIMS score, and frequently wandered around the building. He stated on 03/14/2024 his Assistant Director or Nursing (ADON) and the Unit Manager (Staff G, Licensed Practical Nurse [LPN]), came and let him know that Resident #100's RR was reporting an allegation of neglect. He stated he went to Resident #100's room to speak with the family. He stated the family reported to him when they came in to visit Resident #100 on 03/13/2024 during the night and they found the resident in two briefs, the resident had a hospital gown on top of her clothes and was tucked in underneath her, the resident's hands were bound behind her, and that the resident's TV was not working. He stated once he spoke with the family he went and notified the Nursing Home Administrator (NHA) and their regional. He stated when the Adult Protective Investigator (API) came in, they showed him pictures with a curtain with a call light and stated, There were no patient identifiers so this could have been any resident's room. He stated the API worker then showed him a picture of a brief and another brief being used as a chuck pad, and then a picture of Resident #100 with the sheets up to her arm pits and her arms outside of the sheet. He stated he provided a written copy of his statement to the NHA. Review of the DON's statement dated 3/14/24 included the allegation of the resident in bed wrapped in a hospital gown with her clothes on under the gown so she could not move, and the residents hands being tied behind her back. A review of the federal immediate report submitted to the state agency on 3/14/24 at 4:15 PM and the federal 5 day report submitted by the facility on 3/19/24 at 1:46 PM revealed no information related to the resident being restrained with her hands bound behind her and either a hospital gown or sheets positioned in a way that could possibly restrict her movement. During an interview on 09/11/2024 at 12:39 p.m., the NHA, stated he believed this was the resident who had an allegation of being hog tied, he stated he was trying to locate the reportable because this was about the time the systems changed on where to report to and did not want to speak to anything that did not happen. He then stated on 03/13/2024 Resident #100's RR came in to see the resident around 11:45 p.m., with a female companion (the individual referred to as FM). During this visit, staff stated the RR was not his usual self and smelt like alcohol. He stated the RR questioned the CNA on why the call light was clipped to the curtain, and why the TV was not working. He stated the CNA went and got Staff Y, LPN, to let her know the RR was there and that he was not acting like his usual self. Staff Y, LPN, then went to the resident's room and noticed two people in Resident #100's room. Staff Y, LPN was told by the RR that the TV was not working. Staff Y, LPN tried to fix the TV, and the RR told her he would come back the next day. The NHA said on 03/14/2024, the DON was approached by the ADON and Staff G, LPN, notifying him that the RR reported when they came to see Resident #100 on 03/13/2024 her call light was out of reach, she was wearing two briefs, and she had a hospital gown tucked around her, where she could not move. He stated after the DON spoke with the RR; the DON reported the allegation to him. He stated, he then reported the allegation to the state agency through the online Report System, had his staff call the abuse hotline, who accepted the case, and the police who did not proceed. He then suspended the CNA pending investigation. They evaluated the resident by completing skin sweeps, a pain evaluation, psychosocial evaluation and reported the allegation of neglect to the physician. Resident #100 was found to be in no pain, had no skin impairments and remained at her baseline. He stated they did education on abuse, restraints, call lights, and double briefing. He stated they completed education on restraints because they wanted to rule out any type of restraint, since it was reported Resident #100 was dressed in a gown that was tucked underneath her, and they wanted to do a comprehensive education. He stated that he has the report now and would like to review it so that he does not speak to anything he is unsure of. He reviewed the report and stated, The resident's family did not report the restraint, it was never brought up until after the investigation. He then stated the allegation of the restraint was not added to the federal reportable because there was no skin breakdown. He then stated, We took what appeared to be coherent to us and put it in the report. He stated for allegation of abuse he has 2 hours to report it and, I would report every allegation of abuse or neglect. He stated the facility did not substantiate the complaint and when he tried to reach out to the RR he did not answer the phone or return his calls. Review of the facility's Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin (ANEMMI) Policy, dated 08/2022, and revised on 01/2024, revealed: The center will seek and accept concerns complaints or grievances from residents, resident families and staff without reprisal the right to report a concern or incident is not limited to a formal written grievance process but includes any verbalized complaint to any facility staff member, prompt efforts will be made to resolve concerns complaints or grievances Definitions: Physical Abuse Includes controlling behavior through corporal punishment or physical or chemical restraints. Reporting and Response Policy: All allegations of possible ANEMMI will be immediately reported to the abuse hotline by the administrator or designee and will be evaluated to determine the direction of the investigation Procedure: Any and all staff observing or hearing about such events must report the event immediately to the administrator immediate supervisor and one of the following directors of nursing ANEMMI prevention coordinator or risk manager so that appropriate reporting and investigation procedures take place immediately it will also be reported to other officials in accordance with state and federal regulations A. Immediate Report in accordance with CFR 483.12 (1)(C) with response to allegations of abuse neglect exploitation or mistreatment the facility must 1. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately but no later than two hours after the allegation is made if the events that caused the allegation involve abuse or result in serious bodily injury. The ANEMMI prevention coordinator will also submit to the Agency for Healthcare Administration federal immediate/5 day report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure timely and accurate Pre-admission Screening and Resident Review (PASRR) for one (#73) of 23 sampled residents. Findings Included: 2. Review of the admission Record for Resident #73 showed the resident was initially admitted to the facility on [DATE] with a re-entry admission date of 03/04/2024. Admitting diagnoses included schizoaffective disorder bipolar type, major depressive disorder, dementia, mood disorder due to known physiological condition with depressive features. Review of Level I PASRR for Resident #73 dated 03/16/2022, revealed an incomplete PASRR with the qualifying diagnoses of depression, mood disorder and dementia not indicated. During an interview on 09/11/2024 at 9:45 a.m. with Staff S, Registered Nurse (RN) Minimum Data Set (MDS) Director, she said the facility's process for identifying a resident with a possible MD, ID or related condition prior to admission to the facility would start with the Admissions Department. Admissions got the referrals and the referral for the possible resident admission was given to either the Director of Nursing (DON) or Assistant Director of Nursing (ADON) to look at the clinicals to see if there were any reasons to deny the admission. Based on the clinicals, they gave a decision to admit the resident or not. She said the facility identified residents with newly evident or possible serious MD, ID or a related condition after admission to the facility usually after identifying behaviors. If a behavior was identified a psychiatric consult was done and the resident was seen by psychiatric services within seven days. If any new diagnoses were indicated psychiatric services would add them into the electronic medical record. She said when she was made aware of the new diagnoses, she would update the PASRR at that point. She said she also updated the admission PASRR if it was incorrect. She was responsible for making the referral to the appropriate state-designated authority when a resident was identified as having an evident or possible MD, ID or related condition. She said it would automatically trigger the PASRR so she would do that as well. Upon viewing the PASRR for Resident #73, she agreed it was not correct and missing qualifying diagnoses. The facility has no PASRR policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop a care plan for one (#45) of six residents sampled for skin conditions and failed to develop and implement an Activities of Daily Living care plan for two ( #44 and #51) of five residents sampled. Finding Included: 1 During an observation made on 09/08/24 at 02:20 p.m., Resident # 45 was observed lying down in bed dressed in a hospital grown from the morning until late in the afternoon. The resident was trying to say something but was not able to communicate. On 09/09/2024 at 11:00 a.m., Resident # 45 was observed lying down in bed dressed in his hospital grown. Resident #45's legs was observed with scabs leaking with yellow fluid on his right and left legs. Review of an admission Record showed Resident # 45 was admitted to the facility with diagnoses to include but not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, psoriasis vulgaria, lymphedema, not elsewhere classified. Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status, (BIMS) score of 00, which indicated the resident had cognitive deficits. Review of a care plan focus showing Resident #45 had a rash related to Psoriasis and stasis dermatitis, initiated and revised on 9/10/2024. Review of the care plan goals showed Resident #45 will have no complications from rash through the review date, initiated on 9/10/2024. Review of the care plan intervention showed administer medication as ordered by the Medical Doctor (MD). Initiated on 9/10/2024. During an interview on 09/10/2024 at 4:00 p.m. with the Director of Minimum Data Set (MDS), she stated it was her responsibility to create the residents comprehensive care plan. She stated the Regional MDS nurse created Resident #45's skin care plan on 9/10/2024 after the surveyor asked to see his care plan related to his skin condition. She stated she should have created the skin care plan when she first identified the resident had a skin condition. 2. An interview was conducted on 09/08/2024 at 09:50 a.m. with Resident #44, she was observed to be in bed, with a hospital gown on, hair was disheveled and unkempt. Resident #44 said she did not know when the last time she got a shower was, but she wanted a shower to wash her hands. Her fingernails were observed to extend past her fingertips with a dark brown, black substances under her bilateral nails. The resident said she had not had her fingernails cut and she did not like them long. Her right hand was observed to be curled into her palm and the resident pulled her fingers out and there was a red indented mark on her palm where her nail was resting in her palm. On 09/09/2024 at 10:01 a.m., Resident #44 was observed to be in her bed, hair disheveled, her bilateral fingernails were observed to extended past her fingertips. On 09/10/2024 at 9:45 a.m., Resident #44 was observed to be in her bed, hair combed. Her bilateral fingernails were observed to be extended past her fingertips. On 09/10/2024 at 5:08 p.m., the Director of Nursing (DON) observed Resident #44 eating her dinner in the dining room. The DON verified Resident #44 had long nails. The DON agreed it was a pattern of fingernails not being trimmed. The DON stated the resident's nails should be observed during care by the aide and reported to the nurse. The aide or the activities person would do the resident's nails. The DON stated if we had someone on light duty, they would do nails also. The DON stated if a resident was a diabetic, the podiatrist would do their toenails. Resident #44 was observed to have food all over the front of her clothes. She was not being assisted by any staff members at the time, even though staff members were observed in the dining room. Resident #44 did not have a clothes protector on. The DON stated that the aides were to fill out shower sheets when they gave residents a shower. The shower sheet was to be reviewed by the nurse if the resident refused, the nurse was to go speak with the resident to encourage a shower. If the resident still refused, the nurse was to document. A review of the admission record for Resident #44 showed the diagnoses included but were not limited to dementia, senile degeneration of the brain, convulsions, recurrent depressive disorder, anxiety, sarcopenia, hydronephrosis, chronic pain, overactive bladder, cancer of the brain, and a history of falling. Review of the quarterly Minimum Data Set, dated [DATE] showed a Brief Mental Interview Status (BIMS) score of 07 which indicated severe impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, substantial/maximal assistance for bathing, showering, and personal hygiene. Review of the care plans showed Resident #44 had an ADL (activities of daily living) self-care deficit related to chronic medical conditions, dementia, ADL needs and participation varies revised on 09/09/2024. Interventions included but were not limited to the resident may need dependent assistance of 1 or 2 for ADL care as of 09/09/2024. This may fluctuate with weakness, fatigue, and weight bearing status. The resident needed limited to extensive assistance of 1-2 based on fatigue, weightbearing, weakness as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and / or liquid once the meal is placed before the resident as of 05/23/2024. Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. as of 04/29/2024. Review of the type of bathing provided to Resident #44 showed no showers from 08/13/2024 to 09/10/2024. Full bed baths were provided on 08/13/2024, 08/16/2024, 08/20/2024, 08/23/2024, 08/30/2024, 09/03/2024, 09/06/2024, 09/10/2024. A sponge bath was provided on 08/27/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: 08/13/2024, skin clear, does not need toenails cut, no signature by nursing 08/16/2024, refused shower, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, needs toenails cut, no signature by nursing 08/23/2024, refused shower, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, needs toenails cut, no signature by nursing 08/30/2024, skin clear, needs toenails cut, no signature by nursing 09/03/2024, refused shower, does not need toenails cut, no signature by nursing 09/06/2024, full bed bath, does not need toenails cut, no signature by nursing During an interview on 09/11/2024 at 10:33 a.m. the DON reviewed the Skin Monitoring: Comprehensive CNA Shower Review sheets. The DON verified they showed the resident had refused showers on 08/16/2024, 08/23/2024 and 09/03/2024 and a full bed bath on 09/06/2024. The DON verified that the 08/20/2024, 8/27/2024, 08/30/2024 notes showed the resident needed her toenails cut. The DON stated the need for toenails to be cut would be subjective to the individual giving the bath. If the resident was diabetic, the aide was not expected to cut the toenails. The DON stated the nurse was to sign off on the shower sheet if the resident refused to take a shower. The DON verified the resident refused to shower based on documentation on 08/16/2024, 08/23/2024, 09/03/2024 and the nurse had not signed off on the shower sheet as had reviewed. The DON stated the aide should have taken the shower sheet to the nurse for review. The DON stated the aides needed more education. The DON stated that Resident #44 should have been offered a clothing protector during dining. The DON stated that she was in the dining room for more assistance, as needed. The DON reviewed the care plans and stated that the ADL care plan showed Resident #44 was to have supervision and cuing assistance for eating. The DON stated the ADL care plan showed to provide choice for care provisions, shower twice a week. The DON stated the care plan showed the resident was resistive to care, non-compliant with showers (which was added on 09/11/2024 during survey). 3. An observation was conducted on 09/08/2024 at 09:31 a.m. Resident #51 was observed in bed. She was observed to have a flowered shirt on and she said she had been wearing the shirt for three days. She was also observed to have bilateral fingernails which extended past her fingertips with a black substance under them. An observation was conducted on 09/09/2024 at 10:05 a.m. Resident #51 was observed in bed, wearing a blue shirt. Her nails were long on her bilateral hands with brown and black substances under them. Resident #51 said they did not clean or clip her nails and held her hands up. On 09/10/2024 at 12:25 p.m., Resident #51 was observed in bed, wearing a blue shirt with white flowers. She stated it was a clean shirt. Her fingernails were long on her bilateral hands. She was eating her lunch. She was eating her sandwich but observed to be having some difficulty. It appeared her nails were cutting into the bun of the sandwich. She had spilled her fluids in her sippy cup onto her tray. During and observation and interview conducted on 09/10/2024 at 5:00 p.m. with the DON. Resident #51 was observed eating her dinner of chili with beans, rice, carrots and turnips, and a cup of ice cream. The resident was in her room attempting to feed herself. Resident #51's fingernails were observed to be extended past her fingers on both hands. The resident told the DON her nails were too long, and she wanted them trimmed. The resident was observed putting her fingers and nails into her cup of vanilla ice cream. The DON stated the long nails in her food including her ice cream was not acceptable and was an infection control issue. He stated his expectation was for the resident's fingernails to be cut by the nurse. After observing Resident #51 eating, the DON stated she needed more assistance with dining, more than just set-up. The DON stated he would check Resident #51's therapy evaluations. The DON stated even though the evaluations showed her weight loss was unavoidable due to Resident #51's medical conditions, they (the staff) could do better with assisting the resident to eat. Resident #51 was admitted with diagnoses included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, seizures, recurrent depressive disorder, vascular dementia, severe protein-calorie malnutrition, anxiety, CVA with dysarthria, aphasia, and dysphagia, contracture of the right hand, muscle weakness, and acute pain due to trauma. Review of the quarterly MDS dated [DATE] showed a BIMS score of 03 which indicated severe cognitive impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, dependent assistance for bathing and showering, and personal hygiene. Review of the care plans showed Resident #51 had an ADL (activities of daily living) self-care deficit related to ADL needs and participation vary, chronic medical conditions, confusion, impaired balance, limited mobility. The care plan was updated on 09/10/2024 (after start of survey). Interventions included but were not limited to the resident was dependent on staff for bathing needs, including transfer into and out of shower as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident as of 05/23/2024. Observe resident for changes in ADL capabilities. Notify nurse, therapy, and/or MD as indicated as of 05/23/2024. Review of the type of bathing provided to Resident #51 showed from 08/15/2024 to 09/09/2024 one shower on 08/29/2024. Full bed baths were provided on 08/15/2024, 08/19/2024, 08/22/2024, 09/02/2024, 09/05/2024. A shower refusal on 09/09/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: 08/13/2024, skin clear, does need toenails cut, no signature by nursing 08/15/2024, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, does not need toenails cut, no signature by nursing 08/22/2024, skin clear, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, does not need toenails cut, no signature by nursing 08/29/2024, skin clear, does not need toenails cut, no signature by nursing 09/02/2024, skin clear, does not need toenails cut, no signature by nursing 09/05/2024, skin clear, does not need toenails cut, no signature by nursing 09/09/2024, does not need toenails cut, no signature by nursing During an interview on 09/11/2024 at 10:47 a.m. the DON reviewed the shower sheets. The DON verified the medical record showed only one shower in 30 days on 08/29/2024. The DON stated the shower sheets did not indicate if the resident had a shower or bed bath consistently. The DON reviewed the shower sheets and confirmed they did not match the documentation in the medical record. The DON verified shower sheets existed for 08/20/2024, 08/27/2024 and 08/29/2024 and there was no documentation in the medical record. The DON reviewed the care plans for Resident #51. The DON stated he spoke with the resident's Occupational Therapist (OT) and the resident was on case load for Speech Therapy currently. The OT stated she was working with the resident but not related to eating or the need for assistance. The DON stated OT was picking the resident up today (09/11/2024). The DON stated he reviewed the resident's weight and it was actually up from admission. The DON stated the resident's weight had been fluctuating and staying steady. The DON stated the resident could use some assistance (with eating). The DON stated the aide and the floor nurse should be observing the resident's eating first and the need for eating assistance. The DON stated the resident was resistive to assistance. The DON stated the resident used to be out of her room more, but was refusing to come out of her room. During interview on 09/11/24 at 10:33 a.m. the DON stated the facility followed the RAI (Resident Assessment Instrument) for a care plan policy. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 October 2023, showed 1.1 Overview: The purpose of this manual is to offer clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care. Providing care to residents with post-hospital and long-term care needs is complex and challenging work. Clinical competence, observational, interviewing and critical thinking skills, and assessment expertise from all disciplines are required to develop individualized care plans. As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident's unique path toward achieving or maintaining their highest practical level of well-being. The RAI helps nursing home staff look at residents holistically-as individuals for whom quality of life and quality of care are mutually significant and necessary. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life. Chapter 4: Care Area Assessment (CAA) Process and Care Planning 4.1 Background and Rationale: Regulations require facilities to complete a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas. The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive plan of care. 4.2 Overview of the Resident Assessment Instrument (RAI) and Care Area Assessments (CAAs) The RAI-related processes help staff identify key information about residents as a basis for identifying resident-specific issues and objectives. In accordance with 42 CFR 483.21(b) the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment. 4.3 What are the Care Area Assessments (CAAs)? The completed MDS must be analyzed and combined with other relevant information to develop an individualized care plan. 4.4 What Does the CAA Process Involve? Facilities use the findings from the comprehensive assessment to develop an individualized care plan to meet each resident's needs (42 CFR 483.20(d)).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADLs) for dependent residents which included performing fingernail care and showers for two (#44 and #51) of 46 sampled residents. Findings included: 1. An interview was conducted on 09/08/2024 at 09:50 a.m. with Resident #44. She was observed to be in bed, with a hospital gown on, hair was disheveled and unkempt. Resident #44 said she did not know when the last time she got a shower was, but she wanted a shower to wash her hands. Her fingernails were observed to extend past her fingertips with a dark brown, black substances under her bilateral nails. The resident said she had not had her fingernails cut and she does not like them long. Her right hand was observed to be curled into her palm and the resident pulled her fingers out and there was a red indented mark on her palm where her nail was resting in her palm. On 09/09/2024 at 10:01 a.m. Resident #44 was observed in her bed, hair disheveled, her bilateral fingernails were observed to extended past her fingertips. On 09/10/2024 at 9:45 a.m. Resident #44 was observed in her bed, hair combed. Her bilateral fingernails were observed to be extended past her fingertips. On 09/10/2024 at 5:08 p.m. the Director of Nursing (DON) observed Resident #44 eating her dinner of chili with beans, rice, carrots and turnips, and a cup of ice cream in the dining room. The DON verified Resident #44 had long nails. The DON stated the resident's nails should be observed during care by the aide and reported to the nurse. The aide or the activities person would do the resident's nails. The DON stated if we had someone on light duty, they would do nails also. The DON stated if a resident was a diabetic, the podiatrist would do their toenails. Resident #44 was observed to have food all over the front of her clothes. She was not being assisted by any staff members at the time, even though staff members were observed in the dining room. Resident #44 did not have a clothes protector on. The DON stated that the aides were to fill out shower sheets when they give residents a shower. The shower sheet was to be reviewed by the nurse if the resident refused, the nurse was to go speak with the resident to encourage a shower. If the resident still refused, the nurse was to document. Resident #44 was admitted to the facility with diagnoses that included but were not limited to dementia, senile degeneration of the brain, convulsions, recurrent depressive disorder, anxiety, sarcopenia, chronic pain, and cancer of the brain. Review of the quarterly Minimum Data Set, dated [DATE] showed a Brief Interview Mental Status (BIMS) score of 07 which indicated severe cognitive impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, substantial/maximal assistance for bathing, showering, and personal hygiene. Review of the type of bathing provided to Resident #44 showed no showers from 08/13/2024 to 09/10/2024. Full bed baths were provided on 08/13/2024, 08/16/2024, 08/20/2024, 08/23/2024, 08/30/2024, 09/03/2024, 09/06/2024, 09/10/2024. A sponge bath was provided on 08/27/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: 08/13/2024, skin clear, does not need toenails cut, no signature by nursing 08/16/2024, refused shower, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, needs toenails cut, no signature by nursing 08/23/2024, refused shower, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, needs toenails cut, no signature by nursing 08/30/2024, skin clear, needs toenails cut, no signature by nursing 09/03/2024, refused shower, does not need toenails cut, no signature by nursing 09/06/2024, full bed bath, does not need toenails cut, no signature by nursing Review of the care plans showed Resident #44 had an ADL (activities of daily living) self-care deficit related to chronic medical conditions, dementia, ADL needs and participation varies revised on 09/09/2024. Interventions included but were not limited to the resident may need dependent assistance of 1 or 2 for ADL care as of 09/09/2024. This may fluctuate with weakness, fatigue, and weight bearing status. The resident needed limited to extensive assistance of 1-2 based on fatigue, weight bearing, weakness as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and / or liquid once the meal is placed before the resident as of 05/23/2024. Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. as of 04/29/2024. During an interview on 09/11/2024 at 10:33 a.m. the DON reviewed the Skin Monitoring: Comprehensive CNA Shower Review sheets. The DON verified they showed the resident had refused showers on 08/16/2024, 08/23/2024 and 09/03/2024 and a full bed bath on 09/06/2024. The DON verified that the 08/20/2024, 8/27/2024, 08/30/2024 notes showed the resident needed her toenails cut. The DON stated the need for toenails to be cut would be subjective to the individual giving the bath. If the resident was diabetic, the aide was not expected to cut the toenails. The DON stated the nurse was to sign off on the shower sheet if the resident refused to take a shower. The DON verified the resident refused to shower based on documentation on 08/16/2024, 08/23/2024, 09/03/2024 and the nurse had not signed off on the shower sheet as had reviewed. The DON stated the aide should have taken the shower sheet to the nurse for review. The DON stated the aides needed more education. The DON stated that Resident #44 should have been offered a clothing protector during dining. The DON stated that she was in the dining room for more assistance, as needed. The DON reviewed the care plans and stated that the ADL care plan showed Resident #44 was to have supervision and cuing assistance for eating. The DON stated the ADL care plan showed to provide choice for care provisions, shower twice a week. The DON stated the care plan showed the resident was resistive to care, non-compliant with showers, which was added on 09/11/2024 during survey. 2. During an observation conducted on 09/08/2024 at 09:31 a.m., Resident #51 was observed in bed. She was observed to have a flowered shirt on and she said she had been wearing the shirt for three days. She was also observed to have bilateral fingernails which extended past her fingertips with a black substance under them. During an observation conducted on 09/09/2024 at 10:05 a.m., Resident #51 was observed in bed, wearing a blue shirt. Her nails were long on her bilateral hands with brown and black substances under them. Resident #51 said they did not clean or clip her nails and held her hands up. On 09/10/2024 at 12:25 p.m. Resident #51 was observed in bed, wearing a blue shirt with white flowers. She stated it was a clean shirt. Her fingernails were long on her bilateral hands. She was eating her lunch, barbeque sandwich, baked beans, and cauliflower. She was eating her sandwich but observed to be having some difficulty. It appeared her nails were cutting into the bun of the sandwich. She had spilled her fluids in her sippy cup onto her tray. During and observation and interview conducted on 09/10/2024 at 5:00 p.m. with the DON, Resident #51 was observed eating her dinner of chili with beans, rice, carrots and turnips, and a cup of ice cream. The resident was in her room attempting to feed herself. Resident #51's fingernails were observed to be extended past her fingers on both hands. The resident told the DON her nails were too long, and she wanted them trimmed. The resident was observed putting her fingers and nails into her cup of vanilla ice cream. The DON stated the long nails in her food including her ice cream was not acceptable and was an infection control issue. He stated his expectation was for the resident's fingernails to be cut by the nurse. After observing Resident #51 eating, the DON stated she needed more assistance with dining, more than just set-up. The DON stated he would check Resident #51's therapy evaluations. The DON stated even though the evaluations showed her weight loss was unavoidable due to Resident #51's medical conditions, they (the staff) could do better with assisting the resident to eat. Resident #51 was admitted to the facility with diagnoses that included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, seizures, recurrent depressive disorder, vascular dementia, severe protein-calorie malnutrition, anxiety, CVA with dysarthria, aphasia, and dysphagia, contracture of the right hand, muscle weakness, and acute pain. Review of the quarterly MDS dated [DATE] showed a BIMS score of 03 which indicated severe cognitive impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, dependent assistance for bathing and showering, personal hygiene. Review of the type of bathing provided to Resident #51 showed from 08/15/2024 to 09/09/2024 one shower on 08/29/2024. Full bed baths were provided on 08/15/2024, 08/19/2024, 08/22/2024, 09/02/2024, 09/05/2024. A shower refusal on 09/09/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: 08/13/2024, skin clear, does need toenails cut, no signature by nursing 08/15/2024, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, does not need toenails cut, no signature by nursing 08/22/2024, skin clear, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, does not need toenails cut, no signature by nursing 08/29/2024, skin clear, does not need toenails cut, no signature by nursing 09/02/2024, skin clear, does not need toenails cut, no signature by nursing 09/05/2024, skin clear, does not need toenails cut, no signature by nursing 09/09/2024, does not need toenails cut, no signature by nursing Review of the care plans showed Resident #51 had an ADL (activities of daily living) self-care deficit related to ADL needs and participation vary, chronic medical conditions, confusion, impaired balance, limited mobility. The care plan was updated on 09/10/2024 (after start of survey). Interventions included but were not limited to the resident was dependent on staff for bathing needs, including transfer into and out of shower as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident as of 05/23/2024. Observe resident for changes in ADL capabilities. Notify nurse, therapy, and/or MD as indicated as of 05/23/2024. During an interview on 09/11/2024 at 10:47 a.m. the DON reviewed the shower sheets. The DON verified the medical record showed only one shower in 30 days on 08/29/2024. The DON stated the shower sheets did indicate if the resident had a shower or bed bath consistently. The DON reviewed the shower sheets and confirmed they did not match the documentation in the medical record. The DON verified shower sheets existed for 08/20/2024, 08/27/2024 and 08/29/2024 and there was no documentation in the medical record. The DON reviewed the care plans for Resident #51. The DON stated he spoke with the resident's Occupational Therapist (OT) and the resident was on case load for Speech Therapy currently. The OT stated she was working with the resident but not related to eating or the need for assistance. The DON stated OT was picking the resident up today, 09/11/2024. The DON stated he reviewed the resident's weight and it was actually up from admission. The DON stated the resident's weight had been fluctuating and staying steady. The DON stated even though, the resident could use some assistance (with eating). The DON stated the aide and the floor nurse should be observing the resident's eating first and the need for eating assistance. The DON stated the resident was resistive to assistance. The DON stated the resident used to be out of her room more, but was refusing to come out of her room. Review of the facility's policy, ADL Care and Services, revised 01/2024 showed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 2. The existence of a clinical diagnosis or condition does not alone justify at decline in a resident's ability to perform ADL's. 4. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident in accordance with the plan of care, including some appropriate support and assistance with: a. hygiene parentheses bathing, dressing, grooming, nail care and oral care parentheses; d. Dining (meals, hydration, and snacks). 6. To improve or minimize a resonance functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident has the right to refuse any and all ADL care. The refusal of care will be documented in the resident's medical record with appropriate notification including the physician and resident representative. 8. The resident's response to interventions will be monitored, evaluated, and revised as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide quality care and services according to standards of practice related to medication administration and skin care treatment for one (#45) of three residents reviewed for wound care. Finding included: During an observation made on 09/08/24 at 02:20 p.m., Resident #45 was observed lying down in bed dressed in a hospital grown from the morning until the late in the afternoon. Resident was trying to say something but was not able to communication. During an observation made on 09/09/2024 at 11:00 a.m., Resident #45 was observed lying down in bed dressed in his hospital grown. Resident #45 legs was observed with scabs leaking with yellow fluid on his right and left legs. During an interview on 09/10/2024 at 1:00 pm with Resident #45's representative, he stated [the resident] had been at the facility for a year. He was being seen by a vascular surgeon because the facility thought he could have cancer in his legs. He said the facility never followed back up on what was going on during the time he was seen by the surgeon. He stated the facility did not follow up with him regarding the resident's care. He was supposed to have an appointment with dermatology, but the facility did not make it right. He stated when [name of office] dermatology finally called him back, they told him they had to cancel his appointment and then they rescheduled the appointment for next year. He stated he did not know why [the resident] had to wait so long to been seen. He said [the resident] really needed to be seen by a skin doctor because his skin on his legs was really bad. Review of an admission Record showed Resident #45 was admitted to the facility with diagnoses to include but not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, psoriasis vulgaria, lymphedema, not elsewhere classified. Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status, (BIMS) score of 00, which indicated the resident had severe cognitive impairment. Review of a care plan focus showed Resident #45 had a rash related to Psoriasis and stasis dermatitis, initiated and revised on 9/10/2024. Review of the care plan goals showed Resident #45 would have no complications from rash through the review date, initiated on 9/10/2024. Review of the care plan intervention showed administer medication as ordered by the Medical Doctor ( MD), initiated on 9/10/2024. Review of the Order summary showed an order for Otezla Oral Tablet Therapy pack 10 & 20 & 30 MG, give 1 tablet by mouth one time of day for psoriasis Follow started pack instruction. Further review of the EMAR (Electronic Medication Administration Record] showed on September 2nd, 4th, 5th 6th and 8th Otezla Oral tablet was code on 12 to indicate Medication on order from pharmacy. On September 9th the EMAR showed Staff V, Registered Nurse (RN) marked medication was administered to Resident #45 when it was verified not in stock. Review of the Treatment Administration Record ( TAR ) schedule for September showed an order for Fluocinolone Acetonide External Cream 0.01% (Fluocinolone Acetonide). Apply to Bilateral legs topically every day shift for stasis dermatitis. Further review of the EMAR showed Staff V signed off that she provided treatment on September 5th, 6th, and the 9th During an interview on 09/10/2024 at 2:00 pm. with Staff V, she stated she was not Resident 45's regular assigned nurse so she was not familiar with the resident's plan of care. She stated Resident #45 was not administered his oral medication Otezla today because it was not in stock. She reached out to pharmacy to have the resident's medication reordered. He was supposed to receive this medication for his legs. He was seen by the wound care nurse today, 09/10/2024, for treatments on his legs. Staff V stated when she observed the resident's legs today, she saw he had some drainage coming from his scabs on his legs but that was normal for what he had going on with his legs. She stated the wound care nurse was responsible for doing the resident's treatment. She stated that she signed off on the resident treatments and medication records even if she was not the person doing the resident treatments. She said she did it because she assumed the treatments were being done and they were not allowed to leave holes on the medication or treatment records. During an interview on 9/10/2024 at 2:30 p.m. with Staff EE, License Practical Nurse/Wound Care Nurse, she stated Resident #45 received Fluocinolone Acetonide External Cream applied on his legs by the floor nurses once a day. She reviewed the resident's treatment record and said that it showed Resident #45 was receiving his treatment once a day. She said Resident #45 was followed by wound care for his legs in the beginning of the year, but he was no longer seen by wound care. His wounds were closed at this time, and he was getting daily treatments done by his assigned nurse on day shift. During an interview on 09/10/2024 at 2:45 pm. with the Assistant Director of Nursing (ADON), she stated she heard that Staff V said she did not give Resident #45 his medication and that she signed off on his treatments even though she was not doing the treatments. She said, when it came to treatments, the nurse knew they were responsible for their own treatments on their residents. The wound care nurse was only responsible for wounds that were being followed by the wound care team. She said she would have to discuss this situation with the Director of Nurses. During an interview on 09/10/24 at 4:45 p.m., with The Director of Nurses (DON), he stated this morning when the nurse was doing her med pass, she was not able to find the Otezla for Psoriasis - A medication for Resident #45's skin condition. He said she needed to inform the physician and then contact the pharmacy. He said he could not answer why the resident's medication was not available. Normally when a medication was missing, they contacted the pharmacy and reorder. The resident was moved from one hall to another, and the resident's medication might not have followed him over. The expectation was that the nurse should have reordered the resident's medications before the medication was out. Staff V told him she placed the order to the pharmacy and notified the physician. When it came to the facility treatment process, treatments were done by the floor nurses. The floor nurses were responsible for signing off on their own treatments. The wound care nurse had a list of residents that she saw. The wound care nurse took care of the resident's wound dressing and not the treatments. Review of the facility policy titled, Standards and Guidelines: Physician Orders, Revised date 01/2024 showed Guidelines: Orders and administration of medication and treatment will be consistent with principles of safe and effective order writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview on 09/08/2024 at 9:10 a.m., Resident #13 was observed lying in bed dressed in a hospital gown. A catheter bag was observed on the floor underneath the bed. The resident was leaning to the right of the bed hanging onto the railing of the bed. She stated when she first came to the facility, she was getting therapy to help her with her mobility but most recently she has not been going to therapy anymore and would like to start going to therapy again so she can become more independent. During an observation and interview with Resident #13 on 09/10/2024 at 1:00 p.m., she was observed lying in bed dressed in a gown and clean in appearance, there was a catheter bag located on the floor with the privacy side up. She stated she no longer had concerns about therapy because she was transferring to another facility at the end of the week so she would be closer to her family. She stated she would worry about therapy when she got to the new facility. Review of Resident #13's admission Record showed Resident #13 was admitted to the facility with diagnoses of anxiety disorder, major depressive disorder, dementia, and neuromuscular dysfunction of bladder. Review of Resident #13's care plan dated 05/24/2024 showed, the resident has a risk for injury/infection presence of indwelling catheter secondary to a diagnosis of neurogenic bladder, start date 05/24/2024. With a goal of the resident will be free of complications catheter use through next review. With a focus of Position catheter bag and tubing so that it promotes dignity and drainage, Privacy bag/cover in place, provide catheter care per orders, Urology consult and follow up as indicated/ordered. During an interview on 09/11/2024 at 9:00 a.m., with Staff K,CNA, she stated Resident #13 was a total care resident who chose to stay in bed. She stated the resident would occasionally go to the dining room for food. She stated the resident was a 2 person [mechanical]Hoyer lift. Staff K stated she provided the resident with Peri Care, and emptied the catheter bag every shift, she stated the bag should always be placed with the privacy side out, and hanging below the bladder, she stated there was a hook on the bed they normally clipped it to. During an interview on 09/11/2024 at 9:11 a.m., with Staff L, LPN, she stated residents with catheters received perineal care to include cleaning the area. She stated residents who are mobile received a [urine collection] bag that attached to their leg, and they made sure it was covered by their clothing. She stated for residents who were in bed the catheter bag should be placed at the bottom of the bed below the bladder. She stated the catheter bags should never be placed on the floor. Review of the facilities Catheter Care, dated 10/2020, revealed Standard: The facility will maintain infection control guidelines related to catheter use and catheter care to minimize catheter associated infections. Guideline: The clinical staff will receive education and training related to providing catheter care to minimize catheter associated infections. 1. Use standard precautions when handling or manipulating the drainage system, catheter tubing, or drainage bag .3. Ensure the drainage spigot is not touching the floor, the tubing is free of kinks, the catheter is capped at an appropriate level to promote urine flow, and dignity is maintained. Catheter coverings are not required when drainage bags are out of sight from the public or per the residence preference. Based on observation, interview and record review, the facility failed to provide indwelling urinary catheter care and services to prevent leakage and breaks in tubing for two (#82 and #13) of ten sampled residents during two of two days observed (9/8/2024 and 9/9/2024). Findings included: 1. On 9/8/2024 at 10:45 a.m., Resident #82 was observed seated in her wheelchair and was slowly self propelling down the hall from her room. An attempt to interview the resident revealed she had cognition deficits and was only able to answer some simple yes and no questions. She kept saying, I just want to go back to my room, I want to go to bed. Passing staff told her, ok, in a minute, but we have lunch soon. Further observations revealed when the resident was self propelling in her wheelchair down the hallway, she was noted with an indwelling urinary catheter. The catheter bag was observed appropriately hanging under the seat of the wheelchair. However, the tubing from the bag to the resident was observed in excess slack, dragging on the floor with approximately six to seven inches on the floor. Further, as the rear wheelchair tires were rolling, the tubing was observed either very close to being ran over, or was touching the tire as the resident and wheelchair was moving. She remained parked near the unit station and room [ROOM NUMBER] for a period of time with staff continually passing her and saying hello. However, staff did not address the catheter on the floor. Photographic evidence was obtained. On 9/8/2024 at 10:56 a.m., Staff D, Certified Nursing Assistant (CNA) was observed to walk by the resident as the resident shouted, I just want to go get into my bed. Staff D accommodated her while pushing her back to her room, while she was in her wheelchair. While Staff D was pushing her down the hallway the catheter tubing was still observed dragging on the floor under the resident and touching the rear wheelchair tires. Staff D brought her into her room and then left as the tubing was still on the floor. On 9/8/2024 at 11:30 a.m., Resident #82 was observed in the main dining room seated in her wheelchair and positioned at a table. She had just received her lunch meal tray. Further observations revealed her indwelling catheter tubing was again dragging on the floor near her rear tire. Staff F, Registered Nurse (RN) and Staff E, RN had just repositioned the catheter up off the floor not even seven minutes prior to this observation. She remained in the main dining room until 12:13 p.m. when an unidentified staff member assisted the resident back to her room by pushing her while in her wheelchair with the tubing dragging the floor. On 9/9/2024 at 6:50 a.m., Resident #82 was observed seated in her wheelchair at the 100/200 nurse station. She was dressed for the day and well groomed. She had a blanket over her lap, legs, and pulled up to her neckline. At 6:59 a.m., she was noted to leave the area and self propelled herself down the hall, towards her room. Both of her feet were on the wheelchair foot pedals and she was using both of her hands to turn the tires to move forward. She was observed with her indwelling urinary catheter tubing dragging on the floor beneath her with approximately six inches of tubing on the floor. The rear wheelchair tire was observed brushing up against the tubing as she was moving forward. During the time she was moving towards her room, there were many staff who passed by her. Some stopped to say hello and moved on. No staff was observed to identify the tubing on the ground. Therefore, it was not reported to nursing to be readjusted. On 9/10/2024 at 12:20 p.m. an interview with Resident #82's responsible party revealed she was aware [the resident] was utilizing a urinary catheter and was made aware yesterday, 9/9/2024, of the catheter removal. The responsible party said there had been times when she had come in to visit and had seen [the resident] while in her wheelchair and with the catheter bag and tubing dragging on the floor. She said she had not thought anything about it until now during the interview. An interview with Resident #82 could not be obtained as she had cognitive deficits and could not speak specifically to her catheter care and other medical care/services. Review of Resident #82's medical record,diagnosis sheet, showed diagnoses which included but were not limited to Dementia, Neuromuscular Dysfunction of Bladder, and Presence of Urogenital Implants. Review of the current Minimum Data Set (MDS) admission assessment, dated 6/12/2024, revealed Cognition/Brief Interview Mental Status or BIMS score 9 of 15, which indicated the resident had moderate cognitive impairments; Activities of Daily Living ADL - Toileting = Dependent, Dressing = Substantial/Maximal assistance, Personal Hygiene = Dependent; Bowel and Bladder - Checked for use of Indwelling catheter and always incontinent of bowel. Review of the current Physician's Order Sheet for month 9/2024, and reviewed at 12:00 p.m. on 9/9/2024 revealed the following orders: 1. Indwelling Urinary Catheter change catheter bag and tubing every night shift staring on 18th; 2. Indwelling Urinary Catheter monitor every shift and notify the physician of changes in urinary appearance and or urinary output; 3. Indwelling Urinary Catheter change 16fr 10 ml catheter tubing, and collection bag as need when medically necessary; 4. Indwelling Urinary Catheter Encourage and assist resident to use/apply leg bag when out of bed and/or as tolerated/requested A new order on 9/9/2024 revealed to remove Foley Catheter for voiding trial one time only on 9/9/2024. On 9/11/2024 at 9:25 a.m., an interview with Staff G, 100/200 Unit Manager revealed she knew Resident #82 well and she had spoken with her responsible party at times when she visited the resident. Staff G said she usually rounded the unit multiple times a shift and looked out for resident care needs, staff delivery of care, and general resident safety. She confirmed Resident #82 utilized a urinary catheter up to the afternoon of 9/9/2024. Staff G revealed that herself, along with other nurses on the floor would observe the catheter for placement, patency, safety and infection risks. Staff G said if any resident's catheter bag and/or tubing was observed on the floor while either in bed or while in a wheelchair, the tubing and bag should be positioned safely and off the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure trauma informed care was provided for one (#39) of one resident with post-traumatic stress disorder (PTSD). The facility did not ensure PTSD triggers were on Resident #39's care plan. The facility did not ensure staff was trained annually on trauma informed care as the facility policy indicated. Findings Included: Review of admission Record showed Resident #39 was initially admitted to the facility diagnoses which included major depressive disorder, schizoaffective disorder, unspecified psychosis, post-traumatic stress disorder, other specified persistent mood disorders, anxiety disorder, dementia. Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE], Section C-Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Review of Resident #39's Care Plan dated revealed the following: A focus area initiated on 7/24/24 showed, the resident had experienced a traumatic event which had impacted their emotional health as evidenced by (AEB) PTSD nightmares. The goal showed, frequency or severity of the trauma-related symptoms would not increase. The interventions showed, Alert MD/designee of any significant changes in behavior. Provide a quiet, non-threatening environment as indicated. Respect resident's space and privacy. Encourage and assist the resident to have contact with family/friends as able. On 09/09/2024 at 11:50 a.m., Resident #39 was observed lying in his bed and speaking with Staff O, Licensed Practical Nurse (LPN). Resident #39 told Staff O he did not want a particular person in his room because that person tried to kill his girlfriend. The name of the person mentioned by Resident #39 was unintelligible. Resident #39 repeated his statement that he did not want a particular person in his room because that person tried to kill his girlfriend. Staff O, LPN, did not respond to the resident or acknowledge the resident's statement. An interview was conducted with Staff O, Licensed Practical Nurse (LPN) on 09/09/2024 at 11:50 a.m. Staff O said he was not aware of the care plan for Resident #39. He said he did not look at the care plans he only gave medications to the resident. Staff O, LPN said he was not aware of any psychiatric issues Resident #39 might have. An interview was conducted with The ADON (Assistant Director of Nursing) on 09/10/2024 at 10:30 a.m. The ADON she said nurses could check the care plans to see if there was anything new or different with the resident. She said they could also check the care plan if there were any new behaviors or behavior triggers on the care plan. She said the care plan was the big key for care. The nurse might put any new issues they encountered with a resident on the report/care sheet during their shift. An interview was conducted with Staff I, LPN, on 09/11/2024 at 9:54 a.m. Staff I, who was taking care of Resident #39 on this day, stated she definitely had one resident on her assignment who was diagnosed with PTSD. She stated the name of the resident whom she said has the PTSD diagnosis, however, it was not Resident #39. The resident Staff I indicated did not have a PTSD diagnosis. An interview was conducted with the DON (Director of Nursing) on 09/11/2024 at 10:15 a.m. He said the nurses on the floor should be familiar with the resident care plans. The nurses also had the task listings available for review on their assigned resident's electronic medical records. He said the staff also needed to check the [a system for organizing patient information that nursing staff use to create care plans] as well as the care plan. The DON said he believed the underlying cause of the Resident #39's PTSD was related to nightmares, but he was not sure. He said care plan interventions were monitored through feedback from the resident, social service visits, daily care and community visits. He said the facility could ensure care was consistent with the care plan through education. He said the education portion was done during the orientation process and there was no continuing education done. Changes in condition were reported to the MD and to the family. He said the care for the resident with PTSD was based on listing out the medical diagnoses and identify to see if there was PTSD and trauma. The care plan should be based on the history of trauma and the triggers. Changes in the care plan and resident's condition were communicated to the staff after care plan meetings through unit managers and MDS (Minimum Data Set) Assessments. An interview was conducted with Staff R, RN MDS Coordinator on 09/11/2024 at 2:00 p.m. He said his role in the care plan process was related to nursing. During review of the resident's care plan, he said the Focus section regarding the type of trauma the resident experienced would be based on the psychiatric evaluation. If the psychiatric evaluation did not have the specific PTSD trauma it would not be listed. He said this is the same case for the interventions, if the psychiatric evaluation does not list specific triggers they would not be listed on the care plan. Review of Resident #39's current physician's orders revealed the resident is currently taking the following medications: -Celexa oral tablet 20 MG (Citalopram Hydrobromide)/Give 1 tablet by mouth one time a day related to major depressive disorder -Trazodone HCI oral tablet 100 MG (Trazodone HCI)/Give 1 tablet by mouth in the evening for insomnia related to major depressive order -Ativan Injection Solution 2MG/ML (Lorazepam)/Inject 0.25 ml intramuscularly every 24 hours as needed for seizures Review of Resident #39's Subsequent Psychiatric Evaluation dated 05/15/2022 revealed the resident had a PTSD diagnosis related to nightmares. Review of the policy - Trauma Informed Care Issued 04/2019 and revised 01/2024 showed The facility will ensure each resident receives care and services to attain and maintain the highest practicable psycho-social well-being. The procedure included: 1. Residents will be assessed for a history of PTSD upon admission and as needed. 2. When Trauma has been identified the Social Services Director or Designee will inform the resident's attending physician and request both Psychiatry and Psychology Services for the resident. 3. Through resident interview and Psych Services, a Comprehensive Plan of Care will be developed with the interdisciplinary Team to reduce the risk of re-traumatization. 4. Residents who are trauma survivors will receive culturally competent, trauma-informed care, in accordance with professional standards of practice and accounting for residents' experiences and preferences, in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. 5. Staff will be educated on Trauma Informed Care upon hire and annually.

Based on observation, interview, and record review, the facility failed to provide residents and visitors with up to date and correct daily staffing posting information. It was determined the facility had not updated this sheet for a total of three days. Findings included: On 9/8/2024 at 8:33 a.m., an observation was made of the facility's entrance lobby. A desk in the lobby area was observed with a stand up clear plastic document holder. The holder had encased a Daily Staffing Projection sheet. The sheet had information with the date, how many nurses and how many Certified Nursing Assistants (CNAs) were working for each of the three shifts, and the resident census. The sheet showed a date of 9/5/2024, which was three days prior to the current date reviewed, 9/8/2024. The sheet had not been updated to reflect the current date, the current staffing numbers per each of the three shifts, or the current resident census. The sheet reflected a resident census of 104. An interview with the Front Desk receptionist revealed she was aware of the form because it was at her desk area. However, she was not able to explain who updated the form. An interview with the weekend supervisor, who was also the Certified Dietary Manager, revealed the current resident census was 111. At 9:02 a.m. an interview with the Nursing Home Administrator (NHA) revealed the Daily Staffing Projection sheet was updated every day and it was the Staffing Coordinator's responsibility to update and replace the sheet daily. He confirmed the front lobby desk area was the only place they posted this sheet. The NHA revealed on weekends, the assigned weekend supervisor would update and replace this sheet. He reviewed the current sheet and confirmed it had not been updated for three days. He confirmed that today, Sunday 9/8/2024, the Certified Dietary Manager was responsible for updating and posting the current day's Daily Staffing Projection sheet. On 9/9/2024 at 6:10 a.m. the building was entered. The Staffing Coordinator Staff B was met with and revealed what the Daily Staffing Projection sheet expectations were. She was observed updating the sheet as the building was entered. Staff B was asked who was responsible for changing and updating that form. She said it was her responsibility to change and update the form on a daily basis Monday through Friday. She said she was not at the facility on the weekends and it was the responsibility of the weekend supervisor to change and update it on Saturday and Sunday. Staff B was made aware from the NHA that the sheet had not been updated and changed since 9/5/2024. She said she was off on 9/6/2024 and did not know why it was not changed. On 9/11/2024 at 10:00 a.m., the Nursing Home Administrator said the facility did not have a specific policy with regards to the daily nursing assignment posting. He did say it was their standard to update and have the current nursing assignment posting available for residents and visitors to see.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure the medication error rate was less than 5% for three (#14, #93, #498) of four sampled residents who were administered medications. This resulted in seven errors from 35 medication administration opportunities for a medication error rate of 20.00%. Findings included: 1. On 09/10/2024 at 9:55 a.m., Resident #498 was observed sitting in her room. Staff U, Licensed Practical Nurse (LPN) was observed passing medications. Verified a total of 9 medications were in the medication cup The following medications were observed as administered to Resident #498: Aspirin delayed release 81 mg (milligrams) daily for DVT prophylaxis (deep vein thrombosis) Cefuroxime Axetil 500 mg two times a day for pneumonia for 2 days Ventolin HFA inhalation Aerosol Solution 108 mcg/ACT (microgram/actuation) 1 puff three times a day for COPD (Chronic Obstructive Pulmonary Disease) Glimepiride 1 mg by mouth in the morning for Diabetes Iron 325 mg daily for supplement Lasix 40 mg give daily for CHF (Congestive Heart Failure) MiraLax 17 GM (gram)/scoop daily for constipation mix in 4-8-ounce water Duloxetine HCL delayed release 30 mg twice a day for major depression Gabapentin 300 mg give two times a day for nerve pain Pro-Stat oral liquid give 30 ml by mouth twice a day for supplement Topiramate 200 mg give 2 tablets twice a day for migraine headaches Review of the physician orders and Medication Administration Review (MAR) for September showed Azithromycin 500 mg daily for pneumonia for 2 days, not observed administered, but documented as given Flonase allergy relief Nasal Suspension 50 mcg/act (Fluticasone Propionate Nasal) 1 spray both nostrils in the morning for allergies, not observed administered, but documented as given Fluticasone-Salmeterol 250-50 mcg/act aerosol powder, 1 puff twice a day for chronic resp. failure with hypoxia Rinse mouth after use, not observed administered, but documented as given Resident #498 was admitted on [DATE] and readmitted on [DATE]. Review of admission record showed diagnoses included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, heart failure, chronic respiratory failure with hypoxia, COPD, and asthma. Review of the care plans showed Resident #498 had a care plan for antibiotic therapy related to infection as of 09/09/2024. Interventions included but not limited to administer antibiotic medications as ordered by physician. The resident was at risk for altered respiratory status/difficulty breathing related to episodes of shortness of breath, pneumonia, COPD/asthma. Interventions included but not limited to administer medication/inhalers/nebulizers as ordered as of 09/09/2024. 2. On 09/10/2024 at 10:25 a.m. Resident #93 was observed sitting in her room. Staff V, Registered Nurse (RN) was observed passing medications. The following medications were observed as administered to Resident #93: Aspirin 81 mg daily for DVT prophylaxis Clopidogrel Bisulfate 75 mg daily for blood clot prevention Metoprolol Succinate ER Extended Release 24 hour 50 mg in the morning for CHF, hold for heart rate less than 60 Metformin HCL 500 mg twice a day for diabetes Midodrine HCL 5 mg three times a day, please hold for systolic over 120 Review of the physician orders and Medication Administration Review (MAR) for September showed MiraLax 17 gm give by mouth for constipation for 5 days, mix with 4-6 oz of liquid, not observed administered, but documented as given Ranolazine ER 12-hour 500 mg for chronic chest pain, not observed administered, but documented as given Sennosides 8.6 mg give 2 tablets twice a day for constipation for 5 days, not observed administered, but documented as given Review of progress notes showed on 09/10/2024 at 9:35 a.m. the Nurse Practitioner was notified that a.m. meds may be administered late this a.m. Nurse Practitioner gave ok to give meds by noon. Resident #93 was admitted on [DATE]. Review of the admission record showed diagnoses included but not limited to COVID-19, diabetes, atherosclerotic heart disease, hypertension, pneumonia, history of falling, Transient Ischemic attack, muscle weakness, and reduced mobility. Review of the care plans showed Resident #93 had a care plan for altered cardiovascular status related to hyperlipidemia, hypertension as of 08/16/2024. Interventions included but not limited to administer medications per MD order. Care plan for resident was at risk for bowel irregularity related to decreased mobility, disease process as of 08/16/2024. Interventions included but not limited to administer medications as per MD orders. 3. On 09/10/2024 at 10:32 a.m. Resident #14 was observed sitting in her room. Staff W, Registered Nurse (RN) was observed passing medications The following medications were observed as administered to Resident #14 Eldertonic oral liquid give 15 ml daily for supplements House liquid protein 30 ml by mouth 100% Miralax 17 gm/scoop in the morning for constipation mix with 8 oz. of water Xeljanz XR ER 24-hour 11 mg daily for RA do not crush Advair diskus Aerosol Powder Breath Activated 250-50 mcg/dose 1 puff orally two times a day for asthma rinse mouth after use Calcium 500 mg twice a day for supplement Docusate Sodium 100 mg twice a day for constipation Eliquis 2.5 mg twice a day for blood clots prevention Ferrous Sulfate 325 mg twice a day for supplementation Senna 8.6 mg give 2 tablets twice a day for GI motility, hold for loose stool Review of the physician orders and Medication Administration Review (MAR) for September showed Calcium 600 mg twice a day for supplement was ordered on 03/11/2024 Resident #14 was admitted on [DATE]. Review of the admission record showed diagnoses included but not limited to rheumatoid arthritis, disorder of lung, severe protein-calorie malnutrition, and hypertension. Review of the care plans showed Resident #14 had a care plan for at risk for alteration in nutritional status related to BMI under 18, history of significant weight loss, history of malnutrition, dependency for meals, need for nutritional supplements and diagnoses / history including: rheumatoid arthritis, history of dysphagia and hypertension. Interventions included but not limited to encourage intake of supplements and / or snacks provided. Provide supplement as ordered. Review of progress notes showed on 09/10/2024 at 10:26 a.m. the Nurse Practitioner was notified that a.m. meds may be administered late this a.m. Nurse Practitioner gave ok to give meds by noon. Assistant DON During an interview on 09/11/2024 at 10:57 a.m. the Director of Nursing (DON) reviewed the MARs for Resident's #498, #93 and #14 for medications administered. The DON stated all the medications should have been given as per orders. The DON stated the nurses should not have documented medications had been administered when they had not been administered. The DON said the missed medications were considered medication errors. The DON verified Resident #93's medical provider had been notified at 9:35 a.m., 1 hour before the resident's medication administration was given. The DON stated the notification of the nurse practitioner was a blanket statement letting them know the medications were going to be late due to scheduling. The DON stated they had schedule changes that morning due to call offs. Resident #93 was given Midodrine at 10:30 a.m. per the DON and the next dose was scheduled for 1:00 p.m. or 2 ½ hours later. The DON verified Resident #93's Midodrine was given at 2:00 p.m. The DON verified the Calcium order for Resident #14 was for 600 mg not 500 mg as was administered. During an interview on 09/11/2024 at 12:19 p.m. the Medical Provider / APRN (Advanced Practice Registered Nurse) stated all medications should be given as ordered. The APRN stated if medications are not given, it should be documented and reported to the provider. The APRN said if the medications are given late, the provider should also be notified. She stated if a medication that was ordered three times a day was given late, the provider should be called for input into a possible order change / time change. The APRN stated it was not good for a nurse to document what had not been given. Review of the facility's policy, Medication Administration, revised 01/2024 showed medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services supervises and directs all personnel who administer medications and / or have related functions 3. Medications are administered in accordance with prescriber orders, including any required time limit. 4. Medication administration times are determined by resident need, preference, and benefit, not staff convenience. 5. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 6. Medications are administered within one hour before or after their prescribed time, unless otherwise specified. 9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rationale in the residence medical record and notify the physician and responsible party if indicated. 17. As required or indicated for a a medication, the individual administering the medication records in the residence medical record: a. the date and time the medication was administered; B. The dosage; C. The route of administration; F. Any results achieved and when those results were observed if applicable, and G. The signature and title of the person administering the drug.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1. the medical record contained accurate and complete documentation for three (#498, #93, #14) of 46 sampled residents related to bathing and for one (#51) of four sampled residents related to medication administration. Findings included: 1. On 09/10/2024 at 9:55 a.m. ,Resident #498 was observed sitting in her room. Staff U, Licensed Practical Nurse (LPN) was observed passing medications. Verified a total of 9 medications in the medication cup The following medications were observed as administered to Resident #498: Aspirin delayed release 81 mg (milligrams) daily for DVT prophylaxis (deep vein thrombosis) Cefuroxime Axetil 500 mg two times a day for pneumonia for 2 days Ventolin HFA inhalation Aerosol Solution 108 mcg/ACT (microgram/actuation) 1 puff three times a day for COPD (Chronic Obstructive Pulmonary Disease) Glimepiride 1 mg by mouth in the morning for Diabetes Iron 325 mg daily for supplement Lasix 40 mg give daily for CHF (Congestive Heart Failure) MiraLax 17 GM (gram)/scoop daily for constipation mix in 4-8-ounce water Duloxetine HCL delayed release 30 mg twice a day for major depression Gabapentin 300 mg give two times a day for nerve pain Pro-Stat oral liquid give 30 ml by mouth twice a day for supplement Topiramate 200 mg give 2 tablets twice a day for migraine headaches Review of the physician orders and Medication Administration Review (MAR) for September showed Azithromycin 500 mg daily for pneumonia for 2 days, not observed administered, but documented as given Flonase allergy relief Nasal Suspension 50 mcg/act (Fluticasone Propionate Nasal) 1 spray both nostrils in the morning for allergies, not observed administered, but documented as given Fluticasone-Salmeterol 250-50 mcg/act aerosol powder, 1 puff twice a day for chronic resp. failure with hypoxia Rinse mouth after use, not observed administered, but documented as given Resident #498 was admitted on [DATE] and readmitted on [DATE]. Review of admission record showed diagnoses included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, heart failure, chronic respiratory failure with hypoxia, COPD, and asthma. 2. On 09/10/2024 at 10:25 a.m., Resident #93 was observed sitting in her room. Staff V, Registered Nurse (RN) was observed passing medications. The following medications were observed as administered to Resident #93: Aspirin 81 mg daily for DVT prophylaxis Clopidogrel Bisulfate 75 mg daily for blood clot prevention Metoprolol Succinate ER Extended Release 24 hour 50 mg in the morning for CHF, hold for heart rate less than 60 Metformin HCL 500 mg twice a day for diabetes Midodrine HCL 5 mg three times a day, please hold for systolic over 120 Review of the physician orders and Medication Administration Review (MAR) for September showed MiraLax 17 gm give by mouth for constipation for 5 days, mix with 4-6 oz of liquid, not observed administered, but documented as given Ranolazine ER 12-hour 500 mg for chronic chest pain, not observed administered, but documented as given Sennosides 8.6 mg give 2 tablets twice a day for constipation for 5 days, not observed administered, but documented as given Resident #93 was admitted on [DATE]. Review of the admission record showed diagnoses included but not limited to COVID-19, diabetes, atherosclerotic heart disease, hypertension, pneumonia, history of falling, Transient Ischemic attack, muscle weakness, and reduced mobility. 3. On 09/10/2024 at 10:32 a.m. Resident #14 was observed sitting in her room. Staff W, Registered Nurse (RN) was observed passing medications The following medications were observed as administered to Resident #14 Eldertonic oral liquid give 15 ml daily for supplements House liquid protein 30 ml by mouth 100% Miralax 17 gm/scoop in the morning for constipation mix with 8 oz. of water Xeljanz XR ER 24-hour 11 mg daily for RA do not crush Advair diskus Aerosol Powder Breath Activated 250-50 mcg/dose 1 puff orally two times a day for asthma rinse mouth after use Calcium 500 mg twice a day for supplement Docusate Sodium 100 mg twice a day for constipation Eliquis 2.5 mg twice a day for blood clots prevention Ferrous Sulfate 325 mg twice a day for supplementation Senna 8.6 mg give 2 tablets twice a day for GI motility, hold for loose stool Review of the physician orders and Medication Administration Review (MAR) for September showed House Supplement 60 ml 100% consumed, not observed administered, but documented as given Calcium 600 mg twice a day for supplement was ordered on 03/11/2024 Resident #14 was admitted on [DATE]. Review of the admission record showed diagnoses included but not limited to rheumatoid arthritis, disorder of lung, severe protein-calorie malnutrition, and hypertension. During an interview on 09/11/2024 at 10:57 a.m. the Director of Nursing (DON) reviewed the MARs for Resident's #498, #93 and #14 for medications administered. The DON stated the nurses should not have documented medications had been administered when they had not been administered. The DON said the missed medications were considered medication errors. During an interview on 09/11/2024 at 12:19 p.m. the Medical Provider / APRN (Advanced Practice Registered Nurse) stated all medications should be given as ordered. The APRN stated if medications are not given, it should be documented and reported to the provider. The APRN said if the medications are given late, the provider should also be notified. She stated if a medication that was ordered three times a day was given late, the provider should be called for input into a possible order change / time change. The APRN stated it was not good for a nurse to document what had not been given. 2. An observation was conducted on 09/08/2024 at 09:31 a.m. Resident #51 was observed to be in bed. She was observed to have a flowered shirt on and she said she had been wearing the shirt for three days. She was also observed to have bilateral fingernails which extended past her fingertips with a black substance under them. An observation was conducted on 09/09/2024 at 10:05 AM Resident #51 was observed to be in bed, wearing a blue shirt. Her nails were long on her bilateral hands with brown and black substances under them. Resident #51 said they did not clean or clip her nails and held her hands up. On 09/10/2024 at 12:25 p.m. Resident #51 was observed to be in bed, wearing a blue shirt with white flowers. She stated it was a clean shirt. Her fingernails were long on her bilateral hands. She was eating her lunch, barbeque sandwich, baked beans, and cauliflower. She was eating her sandwich but observed to be having some difficulty. It appeared her nails were cutting into the bun of the sandwich. She had spilled her fluids in her sippy cup onto her tray. Resident #51 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed the diagnoses included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, seizures, recurrent depressive disorder, vascular dementia, severe protein-calorie malnutrition, anxiety, CVA with dysarthria, aphasia, and dysphagia, contracture of the right hand, muscle weakness, acute pain due to trauma, history of falling, age related OP, and hypertension. Review of the quarterly MDS dated [DATE] showed a BIMS score of 03 (severe impairment). Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, dependent assistance for bathing and showering, personal hygiene. Review of the type of bathing provided to Resident #51 showed from 08/15/2024 to 09/09/2024 one shower on 08/29/2024. Full bed baths were provided on 08/15/2024, 08/19/2024, 08/22/2024, 09/02/2024, 09/05/2024. A shower refusal on 09/09/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: 08/13/2024, skin clear, does need toenails cut, no signature by nursing 08/15/2024, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, does not need toenails cut, no signature by nursing 08/22/2024, skin clear, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, does not need toenails cut, no signature by nursing 08/29/2024, skin clear, does not need toenails cut, no signature by nursing 09/02/2024, skin clear, does not need toenails cut, no signature by nursing 09/05/2024, skin clear, does not need toenails cut, no signature by nursing 09/09/2024, does not need toenails cut, no signature by nursing During an interview on 09/11/2024 at 10:47 a.m. the DON reviewed the shower sheets. The DON verified the medical record showed only one shower in 30 days on 08/29/2024. The DON stated the shower sheets do not indicate if the resident had a shower or bed bath consistently. The DON reviewed the shower sheets and confirmed they did not match the documentation in the medical record. The DON verified shower sheets existed for 08/20/2024, 08/27/2024 and 08/29/2024 and there was no documentation in the medical record. Review of the facility's policy, Medication Administration, revised 01/2024 showed medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 3. Medications are administered in accordance with prescriber orders, including any required time limit. 4. Medication administration times are determined by resident need, preference, and benefit, not staff convenience. 5. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rationale in the residence medical record and notify the physician and responsible party if indicated. 17. As required or indicated for a medication, the individual administering the medication records in the residence medical record: a. the date and time the medication was administered; B. The dosage; C. The route of administration; F. Any results achieved and when those results were observed if applicable, and G. The signature and title of the person administering the drug.

Based on observation and interview, the facility failed to ensure two of two community shower rooms were cleaned and maintained. Findings included: On 09/08/2024 at 8:55 a.m. an observation was made of the community shower room at the end of the hall between the 100-200 rooms hallway. Entry into the shower room revealed the door to the shower room was not locked. Upon entry into the shower room an observation was made of spots of a brown substance on the floor in front of the sink vanity. Observation was made of spots of the same brown substance in the middle of the floor of the shower room and in the doorway which led into the stall with the toilet. A yellow dirty linen bin was observed inside of the shower room to the left of the door. The lid to the dirty linen bin was on the floor beside the bin. In the stall with the toilet a cabinet was observed on the wall and inside of the cabinet was a spray bottle with a label indicating it was a bottle filled with a cleaning solution. The cabinet had a lock on it, but the cabinet was not locked and a key for the cabinet was not observed. Two shower chairs were observed inside one of the three shower stalls. One of the shower chairs was observed to have a comb with hair in it laying on top of the chair seat. On the same chair there was a yellowish-brown substance on top of the chair seat to the right of the opening in the chair. Another shower chair was observed with a brown substance on top of the seat of the chair towards the back right side of the opening of the chair. An observation was made of the drain in one of the shower stalls showing hair in the drain and gauze with two pieces of tape attached. (Photographic Evidence Obtained) On 09/09/2024 at 8:20 a.m. an observation was made of the community shower room at the end of the hall between the 100-200 rooms hallway. Upon entry into the shower room an observation was made of spots of a brown substance in the middle of the floor of the shower room. An observation was made of the drain in one of the shower stalls showing hair in the drain. A shower chair was observed with a brown substance on top of the seat of the chair towards the back right side of the opening of the chair. An observation was made underneath the mat on top of the shower bed revealing spots of a reddish-brown substance on the mesh. (Photographic Evidence Obtained) On 09/09/2024 at 8:35 a.m. an observation was made of the community shower room located on the 400 rooms hallway. An observation was made underneath the mat on top of the shower bed revealing spots of a thick, odoriferous, brown-black substance on the mesh. (Photographic Evidence Obtained) During an interview on 09/10/2024 at 10:12 a.m. with Staff P, Housekeeper, she said the Certified Nursing Assistants (CNA) were supposed to clean up the shower area after they gave resident showers. Housekeeping was responsible for cleaning floors, disinfecting, and cleaning the shower area on their usual cleaning rounds. The CNA's were responsible for cleaning in between routine housekeeping cleanings. An interview was conducted with Staff M, Housekeeping Supervisor and Staff N, Environmental Services Director on 09/10/2024 at 12:06 p.m. Staff M said the housekeeping responsibilities of the shower rooms included disinfecting, general clean-up, spraying down the showers/walls/doors/handles/mirrors and vanities with the disinfectant and wiping the areas down. Staff M said the CNA's were responsible for disinfecting the entire shower room and the equipment after each resident shower. A spray disinfectant was supposed to be located in a locked cabinet in the toilet stall in each shower room. Staff N said housekeepers and the floor technicians deep cleaned all shower room equipment weekly which included pressure washing. The equipment should be cleaned and disinfected everyday by housekeeping. Staff N said the facility has four housekeepers working in the facility every day, including weekends, from 7:00 a.m. until 3:00 p.m. One of the four housekeepers worked from 8:00 a.m. until 4:30 p.m. Staff N said if the shower rooms got really dirty and the CNA's were really busy, staff could request housekeeping to return to the shower room to clean it again. Staff N said he was not aware the cabinet in the shower room on the 100-200 hall was not locked and did not have a key attached to it. Review of the policy titled Standards and Guidelines: Shower Room issued 10/2018 and revised 01/2024 showed: The facility will ensure that the shower rooms are cleaned and regularly maintained for the safe environment for residents and staff. The implementation portion of the policy included the following: 2. Remove Debris and Waste: Clear the shower room of any visible debris such as hair, soap scum and personal items. Empty trash bins and replace liners. Remove used towels, washcloths and bath mats for laundering. 3. Surface Cleaning: Shower Walls and Floors: Use a disinfectant cleaner to wipe down the shower walls, floor, and any seating areas. 5. Mopping the Floor: Sweep the floor to remove any loose dirt or debris. Mop the floor with a disinfectant solution, starting from the farthest point in the room and moving towards the door. 7. Inspection: Inspect the shower room for cleanliness. Report any issues to maintenance through the electronic maintenance request system.

Based on a review of the Food Committee meeting minutes and the facility policy on Grievances/Complaints, Filing; interview with the Dietary Manager, and interview and observation of eight residents (#157, #160, #159, #158, #38, #15, #30, #72) at meals, the facility failed to resolve a concern related to receiving condiments at meals voiced at the Food Committee meeting. Findings included: An interview was conducted with Resident #157 on 08/29/2022 beginning at 10:30 a.m. He reported that the breakfast meal was always great with the lunch and dinner meal so-so. He said he was never given salt and pepper and was told he had to ask the aides for it when they brought his tray. He said he sometimes would remember to ask before they brought the tray, but if he forgot they often forgot also. He said he liked sandwiches at lunch, not the hot meal, but usually it didn't come with mayonnaise or mustard. He said sometimes he waited for someone to being him the condiment and sometimes he went without. A second visit with Resident #157 on 08/30/2022 at 12:30 p.m., during lunch, confirmed that salt and pepper were not delivered on the trays and only salad dressing for his salads was consistently provided. He said other kinds of condiments, such as ketchup or mayonnaise were not provided. On 09/01/2022 from 8:20 a.m. until 9:00 a.m., visits were made to seven residents who confirmed the meal trays never had salt and pepper. Resident #160 reported that there was no salt or pepper and usually no other condiment, like jelly at breakfast. The resident said there was only one margarine served as well. Resident # 159 reported that there was never any salt and pepper and even if you asked someone to bring you some, they usually forgot. Resident #158 reported that there wasn't any salt or pepper served but he confirmed he didn't really miss it either. Resident # 38 confirmed that she couldn't have the salt but there never was any pepper, so she did without. A small jar of mayonnaise was observed on her table and she smiled and confirmed that she liked her mayonnaise. Resident # 15 confirmed there never was any salt and pepper but commented that he ate everything this morning anyway. A small plastic cup of condiments was noted on his side table. Resident # 38 confirmed that there was never any salt and pepper or sugar. He confirmed he usually got his salad dressing for his side salads. He reported that if the meal was a sandwich there was never any mayonnaise or mustard to use on the sandwich. Resident # 72 reported that he received many additional items to his main meal, but never any salt and pepper or any other kind of condiment. A review was made of the Food Committee meeting minutes from March 2022 until August 2022. The 07/05/2022 meeting minutes included under New Meeting Information: Not enough condiments and Sugar in tea. The 07/19/2022 meeting listed a new concern (too many cold meals on menu) under Past Meeting Information/Follow up rather than the voiced concerns from the 07/05/2022 meeting. On 09/01/2022 at 1:30 p.m. the Dietary Manager was asked about the resolution to the two voiced concerns. She reported she spoke to her dietary aides during tray line to remind them to put condiments that were appropriate to the meal on the trays. She didn't think she had documented the discussion with the staff. When asked about the sugar in the tea, she reported that the sweet iced tea concern was specific to one resident and they had solved the concern for that one resident by ensuring she always got several sugar packets at meals to add to her tea. When asked what nursing said or did to assist in resolving the issue, she said she hadn't shared it with nursing. She confirmed that salt and pepper and sugar are on the top of the cart that delivers the meal trays to the units. A review of the facility policy, Grievances/Complaints, Filing revealed the Policy Statement indicated residents and their representatives have the right to file grievances . and the Administrator and staff will make prompt efforts to resolve the grievances to the satisfaction of the resident and/or representative. Point #3 under Policy Interpretation and Implementation read: All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to implement their Weight Assessment and Intervention Policy by developing a care plan relevant to weight loss and failed to implement the care plan that had been developed on 02/19/2021 and revised on 04/09/2021 and 03/14/2022, for one (Resident #20 ) of 48 sampled residents related to weight loss. Findings included: Resident #20 was re-admitted to the facility on [DATE] with multiple diagnoses that included Multiple Sclerosis, heart disease, and depression. A review of the resident's monthly weights revealed weight loss from 179 lbs (pounds) on 01/06/2022 to 159 lbs on 08/03/2022. In six months, from 02/02/2022 when the resident was weighed at 175.5 lbs, until 08/03/2022, the resident sustained a weight loss of 16.5 lbs or 9%. Resident #20 weighed 173 lbs on 06/07/2022, 168 lbs on 07/04/2022, and 159 lbs on 08/03/2022. Weight loss for this resident was continuing without changes to the care plan or to the resident's diet order. The change in weight from 07/04/2022 when the resident weighed 168 lbs. to 08/03/2022 when the resident weighed 159 lbs, was a loss of 9 lbs or 5.3% , which is considered significant. Review of the resident's medical record revealed a Weight Warning note dated 08/30/2022 which documented the resident's weight at 159.1 lbs, which was a negative 5% change over 30 days. The note read: weight loss is questionable since resident has a good appetite and consumes more than 75% of most meals. Requested a re-weight from nursing. Diet is regular, thin liquids and tolerated well. Will follow up once re-weight. This weight warning was written 27 days after the weight was taken, which was identified as a negative 5% change in 30 days. A reweigh was documented on 09/01/2022 and indicated continued weight loss with weight documented at 158.6 lbs. A Nutrition Full Assessment was completed on 08/30/2022 . It was identified as a significant change assessment. The assessment documented the resident's diet as regular with thin liquids with an excellent intake . No supplements were in place. Diet history confirmed the resident independently consumed three meals per day with at least 75% intake at most meals. The resident had all his teeth and there were no chewing or swallowing difficulties noted. The resident's height was 72 with an ideal body weight range of 178 lbs +/- 5%. The assessment documented that the resident was at 99% of his ideal body weight. Weight history documented a 5% or more loss in one month. Estimated needs (2400 calories and 96 grams protein) were calculated for maintenance and his intake of his diet, supplement, nourishments, and snacks were noted to meet or exceed 100% of his needs. (The assessment identified that there were no supplements in place.) There were no labs to review and no request was made to order labs to help in determining why there had been significant weight loss. The assessment's Problem Etiology Statement (PES) read: at risk of weight loss due to diagnosis of MS (Multiple Sclerosis). The assessment summary read: Resident remains at nutrition risk r/t (related to ) MS, depression and HTN (hypertension). Resident remains on a regular diet. Tolerating diet. Skin remains intact. Weight loss of 5% in one month seems questionable , po (by mouth) intake of meals is 75% or greater. Asked nursing for re-weight since his po intake is good. The interventions and monitoring from the assessment were continue current plan of care. monitor weights monthly. An annual Minimum Data Set (MDS) Assessment was conducted on 03/02/2022 which identified the resident as having a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. He was able to eat his meals with supervision after being provided with set up assistance. A quarterly MDS was conducted on 06/01/2022 which identified the BIMS score as not having changed but the resident required supervision or encouragement at meals with one staff physically assisting him with his meal. In an interview on 08/31/22 at 9:00 a.m., the resident was observed sitting up in bed, watching television with his breakfast on the over the bed table in front of him. When asked how his breakfast was, he responded that it was good and he confirmed he had eaten most of it. When asked if he thought he had lost weight, as the record showed he had, he was thoughtful but then answered no, he didn't think he had lost weight. He reported that he thought he ate most of his meals. Later in the day on 08/31/22, at 12:35 p.m. the resident was observed sitting up in bed with his lunch in front of him. The resident hadn't eaten anything from the plate and he was just looking at it. Resident #20 said he wasn't hungry yet. The resident's Certified Nursing Assistant , Staff A, approached the doorway and reported that he ate a good breakfast and she would help him if he did not' eat some on his own. The care plan developed for Resident #20 for the Focus area of at risk for/has actual alteration in nutritional status r/t advancing disease process. H/o [history of] MS, weight loss. The Focus area was initiated on 02/19/2021 with a revision date of 04/09/2021. The first Goal of the care plan was for the resident not to exhibit any signs of aspiration (i.e. shortness of breath, fever, coughing, etc.) through next review. The second Goal of the care plan was for the resident to consume 50-75% of at least three meals every day through the next review. Relevant interventions included: document food choices and report changes; evaluate for reversible causes of weight loss, anorexia, or dehydration as appropriate (i.e. medication, pain, nausea, gastrointestinal disturbance, depression, oral pain, etc.); monitor lab work as ordered; Weigh weekly x 4 weeks (or until stable) subsequent to admission and monthly thereafter unless otherwise indicated. (The interventions were initiated on either 02/19/2021 or 04/25/2021.) An interview was conducted with one of two of the facility's Registered Dietitians (Staff E) on 09/01/2022 beginning at 10:57 a.m. She confirmed she had not assessed this resident but after reading the weight warning and the nutrition assessment confirmed that the resident had sustained a significant weight loss. She commented that there was no nutrition recommendation made except for a re-weight and both (the assessment and request for a reweigh) had occurred almost one month after the weight of 159 lbs was documented. A review of the facility policy entitled Weight Assessment and Intervention revealed the Policy Statement read: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The Policy gave direction related to Weight Assessment that included: 3. Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. 5. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss = (usual weight - actual weight )/(usual weight ) x 100: a. 1 month - 5% weight loss is significant; greater than 5% is severe. The policy gave direction for Care Planning which included: 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment. Resident #20's care plan did not include an identified cause of the weight loss, there were no specific goals or benchmarks for improvement and no parameters for monitoring and reassessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) tasks for residents who required assistance to address soiled fingernails for one (Resident #207) of three residents sampled for ADL care. Findings included: Review of Resident #207's record revealed she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 06 which indicated severe cognitive impairment. Review of the admission readmission Nursing Packet dated 08/12/2022, revealed under the ADL Evaluation section the resident was coded as X 1 Staff Total Dependence (Resident Does Not Participate In Activity At All) regarding how much assistance the resident required with personal hygiene. Review of the resident's care plan dated 8/12/22 with a revision on 8/29/22 related to OT (Occupational Therapy) evaluation complete. Resident requires assistance with ADL functions. Review of the Certified Nursing Assistant's (CNA) documentation of the resident's Personal Hygiene Self Performance for the past 30 days revealed this task was completed with mostly Total Dependence. Review of the North Shower Schedule revealed that Resident #207 had showers scheduled for Wed/Sat (Wednesday/Saturday). Observations of Resident #207 on 08/29/22 at 9:25 a.m., revealed the residents' bilateral hands had fingernails that were slightly above the top of the fingers and were noted to be soiled under the nails with a black/brown substance. An observation on 08/31/22 at 3:35 p.m., of Resident #207 revealed the resident was sitting in her room. The residents' nails on her bilateral hands were noted to be soiled with a black/brown substance under the nails. During an interview with Resident #207 at this time, she reported she could not get her nails cut because her hands did not work the same anymore, but the resident said the staff could clean her nails. An observation of Resident #207 on 09/01/22 at 12:21 p.m., revealed the resident was sitting in her room and the fingernails on her bilateral hands were noted to be soiled with a black/brown substance. An interview on 09/01/22 at 12:23 p.m., with Staff F, Registered Nurse (RN) revealed the residents' fingernails were cleaned by the CNA and if the residents' fingernails were dirty, they should be cleaned as needed including on the resident's shower days. An interview on 09/01/22 at 12:25 p.m., with Staff G, CNA revealed CNA's provided nail care, and if a resident's nails were dirty, she would wash the resident's hands, and typically clean their nails on their shower days. During an observation of Resident #207's bilateral hands on 09/01/22 at 12:26 p.m., with Staff F, RN and Staff G, CNA present, Staff F and Staff G confirmed Resident #207's nails were dirty. Review of the facility policy titled Activities of Daily Living (ADLs), Supporting with a revised date of March 2018 revealed the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: A. Hygiene, (bathing, dressing, grooming, nail care and oral care);

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to assess scratches on a resident's shins for one (Resident #9) of two residents sampled for skin conditions. Findings included: Review of Resident #9's record revealed she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. An observation of Resident #9 on 08/29/22 at 9:54 a.m., revealed the resident's bilateral shins were noted with scratches that were dry and red in color. An observation on 08/31/22 at 3:36 p.m., revealed Resident #9 sitting in her wheelchair in her room. The resident was noted to have scratches that were red in color on her bilateral shins. An interview with the resident at that time revealed she did not know how she got the scratches and thought she scratched herself. In an interview on 09/01/22 at 11:01 a.m., the Director of Nursing (DON) said she was not aware the resident had scratches on her bilateral shins. She reported the resident had fragile skin and she would sometimes scratch her skin. The DON said they keep the residents' nails trimmed and manicured to prevent sharp edges and encourage skin moisturizing to address dry itchy skin. In an interview on 09/01/22 at 11:45 a.m., the DON revealed she took a look at Resident #9's shins and confirmed the resident had scratches on her bilateral shins. She reported the resident said she did not know how she got them and she probably scratched herself in her sleep. The DON reported the direct care staff were to document in their tasks document if scratches were observed and should notify the nurse who would assess the skin. She reported this should be done each time the skin was observed. Review of the resident record revealed no documentation that indicated the scratches on the residents' bilateral shins were identified by the facility staff. Review of the Certified Nursing Assistant (CNA) task data for the past 30 days revealed for skin observations the staff consistently documented None of the above observed which included the areas of Scratched, Red Area, Discoloration, Skin Tear, Open Area Review of the facility policy titled Prevention of Skin Impairments, with a revised date of April 2020, revealed under the sub-heading of Skin Assessment the following: 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. Under the sub-heading of Monitoring the following: 1. Evaluate, report and document potential changes in the skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility did not identify the specific behaviors to monitor related to the administration of psychotropic medications for two (Residents #1 and #9) of six residents sampled for unnecessary medications. Findings included: 1. A review of Resident #9's record revealed that she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. Resident #9 had diagnoses that included Major Depressive Disorder, Mood Disorder, and Anxiety Disorder, according to her face sheet. A review of the resident's physician orders revealed current orders for the use of Depakote Tablet Delayed Release 125 MG give 125 mg by mouth in the evening related to UNSPECIFIED MOOD (AFFECTIVE) DISORDER; Escitalopram Oxalate Tablet Give 10 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED; Lorazepam Tablet 0.5 MG Give 0.5 mg by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED Review of the August 2022 Medication Administration Record (MAR) revealed the monitoring of the Depakote, Escitalopram and Lorazepam were combined into one monitoring tool on the MAR. When behaviors were documented, it was noted that there was no way to decipher which behaviors were associated with which medication. Review of the resident's progress notes for the month of August 2022 revealed no entries related to what behaviors exhibited were associated with which of the three medications. An interview on 08/31/22 at 12:54 p.m. with the Director of Nursing (DON) revealed the residents' behaviors were all monitored together and each behavior number referred to the behavior. She reported the behavior was identified by what the medication was prescribed for and was different for every resident. 2. A review of the admission Record for Resident #1 revealed she was admitted on [DATE] with a Re-entry date of 08/08/22. Her diagnoses included Persistent Mood [Affective] Disorder, Major Depressive Disorder Recurrent, and Anxiety Disorder. A review of the physician orders revealed the following: Ziprasidone HCI Capsule 60 mg (milligram). Give 1 capsule by mouth two times a day for mood. Start date: 08/09/22; an order for Citalopram Hydrobromide Tablet 40 mg. Give 1 tablet by mouth one time a day for depression. Start date: 08/02/22; and an order for clonazePAM tablet 0.5 MG. Give 1 tablet by mouth two times a day for anxiety. Review of the electronic Medication Administration Record (eMAR) and the electronic Treatment Administration Record (eTAR) for the month of August included one behavior and side effects monitoring tool for use of psychoactive medication. An interview was conducted on 08/31/22 at 9:01 a.m. with Staff C, Licensed Practical Nurse (LPN), stating there was behavior monitoring in place for medications that cause side effects like antipsychotics, narcotics, and depression. Review of the Subsequent Psychiatric Evaluation dated 07/08/22 for Resident #1 revealed under the subsection titled Additional Recommendations: Monitor her mood, behavior, and appetite. Review of the Psychiatric Progress Note dated 08/25/22 for Resident #1 revealed under the subsection titled Treatment Plan: Monitor for changes in mood or behaviors. An interview was conducted on 08/31/22 at 11:00 a.m. with the Director of Nursing (DON) who stated behavior monitoring was done for anxiety, depression, and psychotropic medication. During the interview, the DON looked through Resident #1's chart for behavior monitoring for depression. The DON pointed to the behavior monitoring indicated use for a psychoactive medication. DON stated the nurses would indicate for example, agitation for anxiety medication on the one behavior monitoring. Resident #1 had orders for depression, anxiety, and psychoactive medications, with one behavior monitoring order in place. An interview was conducted on 08/31/22 at 12:54 p.m. with the DON, stating they used to have behavior monitoring in place for every medication that was in place for residents, but now one monitoring was in place for all medications. She said the nurses would document the behavior and what each behavior was monitored for in the notes. The DON said for Resident #1 she showed agitation with anxiety and the nurse would document it. She noted if agency nurses were not sure about behaviors for residents such as crying, the agency nurse would ask and clarify if it was a normal behavior. At 2:53 p.m. on 09/01/2022, an interview with the Consultant Pharmacist was conducted by phone. The Pharmacist stated the expectation was for the nurses to monitor behavior that was related to the type of medication the residents were taking. For example, for an anxiolytic, nurses would monitor for anxiety or other symptoms related to anxiety. She reported behaviors such as restlessness, repeating the same question, nervousness that the resident was exhibiting could be specifically monitored for anxiety or whatever behaviors the doctor had ordered the drug for. The Pharmacist reported that notes in the healthcare provider software, by facility staff such as the Unit manager might read: this is what we have been seeing,' or the APRN (Advanced Practice Registered Nurse) might make changes and document why the changes were made. The Pharmacist said she would expect the APRN to observe the resident for symptoms and then document and maybe change the medication or dose. It was pointed out that documentation of 'anxiety' was made, but not the actual behavior - such as restlessness. The Pharmacist was reminded that only one set, or area on the eMAR was monitored, and there was no differentiation between symptoms that were documented as having occurred. Review of the policy entitled Behavioral Assessment, Intervention, and Monitoring Revised in March 2019 revealed under subsection titled Management: 10. When medications are prescribed for behavioral symptoms, documentation will include: e. Specific target behaviors and expected outcomes;

Based on observation, interview, and record review, the facility did not ensure the medication error rate was below 5 % for three (Residents #35, #257, and #96) of four sampled residents who were observed during medication administration. This resulted in 8 errors from 31 medication administration opportunities for a medication error rate of 25.81%. Findings Included: 1. On 08/31/2022 at 8:47 a.m., an observation of medication administration with Staff D, Registered Nurse (RN), was conducted with Resident #35. Staff D prepared and administered the following medications: Brimonidine Tartrate 0.2% solution one drop in both eyes, multivitamin with mineral one tablet, Plavix 75 mg one tablet, Lisinopril 40 mg tablet, Duloxetine HCL capsule delayed release 60 mg, Spironolactone 25 mg one tablet, Timolol maleate solution 0.5% one drop into each eye, and Lasix 40 mg tablet one tablet. Staff D stated the resident had an ordered dose of Amitiza capsule 8 mcg give 1 capsule by mouth every 12 hours for constipation dated 07/01/2022, but it was not in the medication cart. The nurse further checked the facility contingency system, and it was not available. Medication reconciliation revealed multivitamin tablet was not ordered with mineral. 2. On 08/31/22 9:57 a.m., a medication administration observation was conducted alongside Staff B Registered Nurse as she prepared the medications for Resident #257. She performed a blood pressure that revealed systolic at 108 diastolic at 55 and pulse 72. The following medications were administered: Amlodipine besylate tablet 5 mg one tablet, Combivent aerosol solution 20-100 mcg/act 2 puffs, Eliquis 2.5 mg one tablet, Lexapro 10 mg one tablet, vitamin C 250 mg one tablet, multi-vite liquid 15 cc, and iron supplement 220/ 5 ml liquid. Reconciliation revealed: Amlodipine besylate tablet 5 mg per gastroesophageal tube (g-tube) one time a day for hypertension hold for Hold for systolic blood pressure (SBP) Less than 100 or diastolic blood pressure (DSP) Less than 60 or pulse less than 60 start date 08/17/2022 thus indicated the Amlodipine should have been held related to the DSP was less than 60. Additionally, orders were to administer Famotidine suspension reconstituted 40 mg/5 ml give 2.5 ml via G-tube two times a day for gastroesophageal disease (GERD) start dated 08/25/2022. The medication was not available to be given. 3. On 08/31/2022 at 10:40 a.m., medications were prepared by Staff C Licensed Practical Nurse for Resident # 96. The following medications were prepared: vitamin C 500 mg one tablet, Ferrous sulfate tablet 325 mg one tablet, Senna 8.6 mg one tablet, multivitamin with mineral one tablet, Pantoprazole 40 mg pak mixed was mixed in applesauce, Losartan potassium 75 mg one tablet, Doxazosin Mesylate 4 mg one tablet, Memantine HCL 5 mg two tablets, Metoprolol Tartrate 25 mg one tablet, Risperidone 1 mg one tablet, Zoloft 25 mg one tablet and Zoloft 100 mg one tablet, and Lorazepam 0.5 mg one tablet. Staff C confirmed she had crushed all medications and that was all that was due at that time. Medication reconciliation revealed order for Ferrous sulfate tablet 325 mg give one time a day for hemoglobin, Swallow whole do not crush, or chew start date 6/11/2022. Folic Acid tablet 1 mg give 1 tablet by mouth one time a day for anemia start date 5/28/2022 was not administered, nor was the Systane solution 0.4-0.3 % instill 1 drop in both eyes two times a day for dry eyes dated 05/28/2022. Further review Lorazepam 0.4 mg order read to Hold if sedated, dated Resident #96 was observed tired and did not respond to verbal stimuli after multiple attempts to open his eyes, and mouth. And would not swallow his medications until water was poured into his mouth. Ativan (Lorazepam), an antianxiety agent. Elderly or debilitated patients may be more susceptible to the sedative effects of Lorazepam. Therefore, these patients should be monitored frequently and have their dosage adjusted carefully according to patient response. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/017794s044lbl.pdf. On 08/31/2022 at 1:51 p.m., an interview was conducted with Staff C as she reviewed the resident medication administration record. She confirmed that she had signed for the administration of Folic acid 1 mg. At that time, the medication cart was searched. Neither a bottle nor blister card was located that contained Folic acid 1 mg. When asked about the ordered Systane eye drops, Staff C indicated she was unaware of any ordered eye drops, yet the MAR indicated it was administered. On 08/31/22 at approximately 2:17 p.m. an interview was conducted with the Director of Nursing who was informed that concerns were identified with the medication administration observation after reconciliation. Errors included not following ordered blood pressure parameters, crushing medications that were indicated not to crush, omitted medications, and the omission of medications due to unavailability. Review of the facility policy titled 1:0 Medication Dispensing System did not contain a date. Policy All medications will be prepared (blister card, vials Artomic box) and administered in a manner consistent with the general requirements outlined in this policy. E. Crushing oral medications REQUIRES a physician's order since some medications are not designated to be crushed. I. If required, obtain vital signs before medication administration.

Based on observation, record review, and interview, the facility failed to provide dental services to one (Resident #35) of three residents sampled for dentures. Findings Included: On 08/29/22 at 11:09 a.m., an interview was conducted with Resident #35 as she was observed edentulous when she opened her mouth. She stated, I had dentures, but it was years ago. She said when she was hospitalized about 4 or 5 years ago, I had to call an ambulance to pick me up. I wish I had taken my dentures with me. Resident #35 stated When I was in the hospital, they threw out everything in my apartment. My dentures and everything I owned. She denied having issues with chewing but if the meat, especially the pork chops, were dry it took a while to chew them. When asked, Resident #34 smiled broadly and stated, I would love dentures. She confirmed she would wear them if she had them. Resident #35 denied the facility had ever asked about obtaining dentures. She said she could not recall the last time a Dentist had performed an oral examination. Medical record review of the admission Record Resident Information form indicated Resident #35 was admitted to the facility three years ago. The diagnosis information listed diabetes mellitus, chronic ischemic heart disease, cerebral vascular disease and dysphagia, oropharyngeal phase. Review of Quarterly /Annual Significant Change Nursing Evaluations-V4 A. Evaluation revealed 2. Teeth: the box was checked that indicated Some natural teeth 3. Wears dentures: was omitted. B. Notify MD for possible Dental Consult was checked no. Further medical review revealed no Dental consult nor Dental examination had been provided in three years. On 09/01/22 11:30 a.m. an interview was conducted with the Social Services Director (SSD). The SSD confirmed she knew the resident well and she talked with her almost daily. The SSD went to Resident #35's room and asked her if she would like dentures. Resident #35 stated I would love dentures. The SSD asked the resident why she never told her. The resident stated, no one has ever asked me. The SSD confirmed she had never asked resident #35 if she wanted dentures. On 09/01/22 at 12:15 p.m., an interview was conducted with the Director of Nursing that confirmed dental needs should be addressed by nursing evaluations that were performed and the evaluations should be accurate. On 09/01/2022 at approximately 12: 36 p.m., the SSD provided a copy of a Dental visit dated 03/09/2022. The SSD said she had called the dental services they use and received a report of a dental visit. The SSD said it was the first time she had seen the report. The report read [name of resident] is eligible to enroll. She is interested in a complete upper and lower denture. Will call power of attorney (POA) to discuss. Review of the policy titled Routine Dental Care dated April 2007. Policy Statement Each resident will receive routine dental care. 3. The Attending Physician will include, as part of his/her initial medical assessment, an assessment of the resident dental needs. 4. Our facility routine dental care includes, but is not limited to: a. An initial evaluation of the dental needs: b. Consultation with the resident, staff, and dental consultant. Preventative care and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that one (Resident #21) of 40 residents sampled for PASRR (Pre-admission Screen and Resident Review) compliance was accurately completed and referred to the appropriate authority for PASRR Level II evaluation and determination. Findings included: Resident record review for Resident # 21 revealed that she was admitted to the facility on [DATE] with diagnoses that included Dementia and Psychosis. The record review revealed that the Level I PASRR was completed on 7/3/19, prior to admission. Further review revealed that the PASRR was inaccurate indicating that Resident #20 did not have a diagnosis of Dementia. The record review of the medical record for Resident #21 revealed that there was no written proof that a completed Level II PASRR had been completed. An interview was conducted with the Social Services Director on 4/14/21 at 1:58 p.m. who confirmed that the PASRR paperwork was not accurate in the chart for Resident #21 and should have been corrected with a Level II screening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure two (Residents #6 and #28) of forty sampled residents received the necessary services to provide grooming and personal hygiene related to showers, nail care, and shaves. Findings included: 1. An observation and interview was conducted on Monday, 4/12/21 at 11:53 a.m., with Resident #6. The resident appeared to have a scruffy appearance and was unshaven. When asked if he choose to be unshaven, he stated he needed to be shaved. The resident stated he would allow staff to shave him if they asked. On Tuesday, 4/13/21 at 8:50 a.m., Resident #6 was observed lying in bed, his facial hair appeared to be unshaven and unclean. On 4/14/21 at 8:47 a.m., Resident #6 was asked if he had the amount of showers he wanted, he stated, I need to have more. Resident #6 stated staff help when they were able and when asked if he wanted to be shaved, the resident nodded head and chuckled. The admission Record for Resident #6 indicated that the resident had an admission date of 9/29/20 following an initial admission date of 6/28/19. The record included diagnoses not limited to unspecified Alzheimer's Disease, bipolar-type schizoaffective disorder, and acquired absence of right and left leg above the knee. The Quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #6's Brief Interview of Mental Status (BIMS) score as 13 out of 15, indicative of an intact cognition. On 2:45 p.m. on 4/13/21, the facility's shower schedule was obtained from the Nursing Home Administrator (NHA). The NHA confirmed that the residents who resided in the A-bed (door) of even numbered rooms received showers on Monday, Wednesday, and Friday during the 7:00 a.m. - 3:00 p.m. shift, B-bed (window) residents in even numbered rooms received showers during the 3:00 p.m. - 11:00 p.m. shift on the same days, residents residing in odd numbered rooms received showers on Tuesday, Thursday, and Saturday following the same schedule for the A and B beds, and per resident preference. The review of the shower schedule indicated that Resident #6 was to obtain a shower three times a week on Monday, Wednesday, and Friday during the 7:00 a.m. - 3:00 p.m. shift. A review of bathing task documentation for the period from 3/15/21 to 4/13/21 indicated that out of the thirteen (13) bathing opportunities, the resident had received a bed bath on 3/15/21 and 4/7/21, refused bathing on 4/5/21 and 4/9/21, was unavailable on 4/2/21, and the task was not applicable on Friday 3/26/21 at 11:33 a.m., Wednesday 3/31/21 at 1:09 p.m., and at 2:49 p.m. on Monday 4/12/21. The Certified Nursing Assistant (CNA) task documentation did not specify an area in which staff would document shaving the residents. Review of Resident #6's progress note did not indicate the nurse had documented that the resident refused any bathing or assistance to be shaved. The Care Plan for Resident #6 identified that the resident had a deficit in Activities of Daily Living (ADL) and required assistance due to (d/t) recent hospitalization, impaired mobility, decreased strength, and endurance. The goal indicated that the resident would complete and/or maintain self-care tasks with assistance through next review and a corresponding intervention was to ensure Resident #6 had a clean neat appearance daily. The Functional Status of Resident #6's MDS indicated that during the assessment's 7-day period, the activity of bathing did not occur, the resident required extensive assist from 2 persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. The annual MDS, dated [DATE], indicated that per the resident it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. The CNA [NAME] instructed staff was to notify physician and activated medical decision maker if non-compliant with preventative care/treatment and did not include that staff were to shave the Resident #6. At 9:38 a.m. on 4/14/21, Staff F, Unit Manager reported that aides (CNAs), nurses, and podiatry clip fingernails. She stated, mostly responsibility of aides and that the aides were to shave residents if they (residents) did not refuse. Staff F confirmed residents were to receive a shower three times a week and if a resident refused, the aides were to chart the refusal then let the nurse know of the refusal. She stated, If it's not charted it was not done. Staff F reviewed Resident #6's bathing task and confirmed that the resident did not get bathed as scheduled and that even if the resident was care planned for refusals it should be documented. Staff F stated that she had seen Resident #6 today and the resident had asked her for a razor. 2. An observation and interview was conducted on 4/12/21 at 9:50 a.m. with Resident #28. The observation revealed that his fingernails on both hands were long, extending approximately 1/4 inch above the tip of the finger, with orange-brown residual under the nails. The resident's hair was long and disheveled, his beard was scruffy with white particles in it, and not combed. As the resident was non-verbal, he was able to answer questions with nodding/shaking head and facial expressions. He indicated that he did not want the beard shaved but when asked if he wanted his fingernails clipped, he looked at them and nodded his head yes. On 4/13/21 at 8:55 a.m., Resident #28 was observed with his hair uncombed and his beard unkempt. At 8:51 a.m. on 4/14/21, Resident #28 was observed with the same long fingernails with orange-brown residual underneath. At 3:02 p.m. on 4/14/21, Resident #28 was asked if he wished he had received more showers, he nodded his head yes. Resident #28 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified cerebral infarction, aphasia, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The Quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition was intact. The review of the facility showering schedule indicated that Resident #28 was to receive a shower/bath on Monday, Wednesday, and Friday during the 7:00 a.m. to 3:00 p.m. shift. A review of the Certified Nursing Assistant (CNA) documentation of the resident's bathing task for the 30 days prior to 4/14/21 indicated that the resident received a bed bath on Wednesday 3/31/21 and Wednesday 4/7/21, refused on 4/9/21, was not available on 4/2/21, and on Wednesday 3/24/21 at 2:59 p.m., Friday 3/26/21 at 2:16 p.m., and Monday 4/5/21 at 2:58 p.m. the task was not applicable. The facility had provided bathing twice and the resident had refused one time in the thirteen opportunities from 3/15/21 to 4/14/21. The CNA care [NAME] indicated the task of bathing and bathing as necessary without describing specifics and indicated that care was to be used when shaving or cutting nails. The Quarterly MDS identified that the resident required extensive assist from one person for bed mobility, dressing, toilet use, and personal hygiene and was totally dependent upon one person for bathing. The Annual MDS, dated [DATE], identified that Resident #28 felt that chooses between a tub bath, shower, bed bath, or sponge bath was somewhat important. The Care Plan for Resident #28 included the following focuses and interventions: - Had self-care performance deficit related bathing/showering/dressing/hygiene/toileting related to (r/t) impaired mobility, impaired strength to right arm (contracture), initiated 4/30/19 and revised 4/9/21. The goals for the resident were last revised on 4/30/19 and did not include a target date that the goal should be achieved. The interventions for Resident #28 instructed staff to assist customer getting in and out of bed, assist with lower body dressing, assist with meal set up, keep oral mucous moist, and to provide oral/hygiene mouth care. The interventions did not include care instructions regarding the assistance that the resident required for bathing/showering. - Had behavioral tendencies r/t refusal of care. Frequently refuses baths. The focus was initiated and revised on 4/9/21. The interventions instructed that staff were to discuss implication of non-compliance with therapeutic regime and to explain risk versus (vs) benefit. The progress notes from 3/13-4/14/21 for Resident #28 indicated that the resident was alert and oriented to place, time, situation and able to make needs known. The progress notes did not include documentation that the resident refused showering/bathing. An agency CNA, Staff E stated, on 4/14/21 at 8:57 a.m., that bathing was documented in the computer as she pointed to the computer monitor on the wall. She stated staff documented the type of bathing done (shower or bed bath) and if the resident was assisted with 1 or 2 people. She stated if a resident refused to bathe, staff document it on the computer and have to tell the nurse. On 4/14/21 at 9:07 a.m., Staff C said during showers, staff did shave the residents and if the residents refused bathing, she would re-offer twice then after the third refusal she would let the nurse and Unit Manager know. On 9:36 a.m. on 4/14/21, Staff G, Registered Nurse (RN), reported that the CNAs did let her know if residents refuse showering/bathing and that they did not have a paper form to fill out for showers, they chart on the kiosks. At 9:52 a.m. on 4/14/21, Staff F, Unit Manager stated that Resident #28 did refuse to be showered and/or shaved. She reviewed the bathing task of Resident #28 and confirmed that the resident had not received bathing as scheduled. When asked if she had seen his fingernails, she stated no and when asked how often staff assisted the resident with hand washing, she stated his hands were washed often as the resident used his hands to eat his pureed diet and refused to allow staff to assist him. This writer and the Unit Manager visited the resident immediately following the interview and the resident confirmed he wanted his fingernails clipped and then showed Staff F his nails on both hands. On 4/14/21 at 11:45 a.m., when asked if CNAs informed him when a resident refused to be showered or bathed Staff I, Licensed Practical Nurse (LPN), stated, Honestly they don't tell me if a resident refuses, mostly agency staff. At 10:38 a.m. on 4/14/21, the Director of Nursing reviewed Resident #28's bathing task and said that the resident often refused. She stated staff were using the not applicable column as refusals and she wanted to get rid of that column. When she reviewed Resident #6's bathing task she stated, Sometimes staff do not chart if the resident refused so they could reapproach the resident and inform the nurse of the refusal. The Nursing Home Administrator (NHA) stated, on 4/14/21 at 12:03 p.m., the facility did not have a policy for Activities of Daily Living or a procedure for showering/bathing. The findings of Resident #6 and #28 was discussed with her and she stated refusals should be documented and that the issue regarding residents not receiving showers/baths as scheduled sounds like a management problem. A Customer Council Summary, dated 1/28/2021, indicated that five (5) customers attended the meeting and that the concern of Shower days was voiced. The Department Response Form indicated that Customers feel shower days not consistent and sometimes missed. The form did not include a response to this concern. A review of a Team Member/ Nursing/ Inservice Education, dated February 2, 2021, provided by the Director of Nursing indicated that CNAs were to ensure you are checking your shower schedule at beginning of shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure an accident free environment for one (Resident #56) of three residents sampled for accidents. Findings included: On 4/12/21 at 12:16 p.m., Resident #56's oxygen tubing was observed on the floor and under the resident's bed. A review of the Resident #56's face sheet revealed that the resident was admitted on [DATE], readmitted on [DATE], and was his own responsible party. A review of Section E (Mood and Behaviors) of Resident #56's Minimum Data Set (MDS) completed on 3/10/21 revealed that the resident had no identified areas of concern for behaviors. Section O (Special Treatments) revealed that the resident received oxygen therapy. A review of Resident #56's event history for the last 120 days revealed an event on 2/8/21 at 3:30 p.m. that stated, [Resident #56] observed lying on the floor in his room [Resident #56] stated 'I trip [sic] on the oxygen cord and fell, I'm ok just get me up.' A review of Resident #56's care plan completed on 3/17/21 revealed a focus area for oxygen dependence that included interventions of monitor changes in vital signs, oxygen at 2 liters per minute (LPM), and promote increased rest periods. A second focus area identified Resident #56 as a fall risk. Interventions included ensure the call bell is always in reach when resident is in room, and when [Resident #56] is in bed to place all necessary items within reach. A review of Resident #56's progress notes revealed a post event follow up note on 2/11/21 at 2:51 p.m. that read as follows, IDT (Interdisciplinary Team) met r/t (related to ) post fall. Intervention in place and effective at this time. [Resident #56] has no complaint of pain/discomfort at this time. This progress note was entered by the Director of Nurses (DON). On 4/13/21 at 8:19 a.m., Resident #56 was observed in a wheelchair at his bedside. The oxygen tubing was on the floor wrapped in a pile under the bed near the wheelchair's wheels. On 4/13/21 at 1:51 p.m., Resident #56 stated that he kicks the tube under the bed, so he doesn't trip on it. On 4/14/21 at 9:07 a.m., an observation revealed that Resident #56's oxygen tube remained on the floor. Photographic evidence obtained. On 4/14/21 at 1:33 p.m., Staff A, Certified Nursing Aide (CNA), stated in regards to residents receiving oxygen therapy, CNAs were responsible to ensure the oxygen was on and flow rate was according to physician's orders, ensure the tubing is not on the floor, and if the tubing is on the floor to notify the nurse to replace it. On 4/14/21 at 2:05 p.m., Staff B, Registered Nurse (RN), stated regarding Resident #56, Staff educates [Resident #56] on oxygen treatment safety, ensure [Resident #56]'s room is free of clutter. If [Resident #56]'s oxygen tubing is found on the floor, then a nurse will replace it. When asked about the sanitation of the oxygen tube being on the floor, Staff B stated, That is definitely a concern. On 4/15/21 at 8:24 a.m., Staff A was observed walking by Resident #56's room and looking in the area of the resident's oxygen tube that was on the floor. Staff A did not stop to assist. On 4/15/21 at 8:50 a.m., the DON stated that after the Resident #56 fell due to the oxygen tubing, therapy evaluated the resident and provided education about the safety of keeping it off the floor. When asked about the intervention that was added to the care plan, the DON stated, That is something that would be in the therapy notes. When asked what her expectation would be for oxygen tubing, she stated her expectation may be different than the policy and that she would provide the policy. Therapy documentation and policies were requested. When showed the progress note about interventions being put in place post event, the DON could not recall what specific intervention was implemented regarding the oxygen tubing. A review of the Occupational Therapy notes for Resident #56 revealed a note that stated Max [verbal cue] needed for safety with [oxygen] hose. Treatment was noted as completed in resident's room with no adverse effect noted. A review of the facility's policies Nasal Cannula and High Pressure Oxygen Cylinders revealed no procedure regarding the maintenance of oxygen tubing being on the floor. A policy regarding the oxygen tubing was requested from the Administrator and DON but was not provided. On 4/15/21 at 10:19 a.m., the DON confirmed that the only intervention included in Resident #56's care plan related to the fall event due to the oxygen tube was Maintain a clutter free environment in customer's room. On 4/15/21 at 10:31 a.m., the DON returned with an updated care plan intervention within the Resident #56's care plan which stated, Ensure oxygen tubing is neatly secured off floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations the facility failed to assess eight (#6, #10, #11, #14, #18, #30, #45, and #73) out of forty sampled residents for the use of bed/side rails prior to their use, to obtain consent for their use from the resident or/and representative prior to their use, failed to obtain a physician order for their use, and to include the use of side rails in the resident's care plan. Findings included: The policy number ROP-44 was obtained from the Director of Nursing (DON), titled: Proper Use of Side Rails, and created 11/17, indicated the facility prohibits the use of side rails as a restraint. The Explanation and Compliance Guidelines of the policy included the following: - 2. An assessment of the resident's symptoms and the reason for using side rails will be conducted prior to use, including their mental status and reason for use of the side rail, and will be documented in the residents record. - 3. The physician will also review and order side rails usage as he deems necessary. - 4. Side rails may only be used in order to assist in mobility and transfer of residents. - 6. The use of side rails as an assistive device will be addressed in the residents' care plan. An interview was conducted, on 4/14/21 at 4:51 p.m., with the Director of Nursing (DON). She stated that she had been working on getting rid of the side rails. The DON stated that therapy screened the residents for the use of rails/enablers and therapy used the rails to assist the resident with positioning and enabling. She reported that the rails/enablers were assessed quarterly, should be care planned and had contacted families regarding the use but did not have signed consents for their use. The DON stated she knows that she had written notes regarding contacting the family. The DON asked to speak with the Minimum Data Set (MDS) Coordinator because she works with it. The DON left the interview and returned with the MDS Coordinator at 4:59 p.m. who stated they considered the rails as facilitators and residents would have a physician order, an assessment, and the siderails/enablers would be care planned. When a discussion regarding observations made of the use of side rails, the DON stated she did assessments of persons needing them when she first arrived at the facility in 2019. 1. Resident #6 was observed on 4/14/21 at 3:01 p.m. lying in bed with bilateral quarter side rails raised. On 4/15/21 at 2:22 p.m., the resident was observed lying in bed with bilateral side rails raised while his eyes were closed. The resident was admitted on [DATE] and 9/29/20. The admission Record included diagnoses not limited to Acquired absence of Right and Left leg above knee, unspecified Alzheimer's Disease, and unspecified Cerebral Infarction. The Quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicative of an intact cognition. A review of the clinical record, as of 4/15/21, did not include a physician order for bilateral side rails. A review of Resident #6's current care plan did not include the resident's use of side/bed rails or enablers despite identifying that he had a deficit in his Activities of Daily Living. On 4/15/21 at 2:19 p.m., the DON provided a Bed Rail Evaluation, effective 4/15/21 at 1:27 p.m., for Resident #6. The evaluation indicated appropriate alternatives were attempted which included placing the call bell within reach with reminders to use, and the bed in low position. The evaluation indicated these alternatives were effective and the use of perimeter reminders such as body pillow/cushions or mattress with raised edge were not effective. The evaluation indicated no other alternative was attempted. The bed rail was considered for mobility/transferring assistance and to assist during care. The evaluation questioned can the customer ambulate without assistance to and from the bathroom and can the customer safely exit or enter the bed in which the DON had answered both not applicable. The Interdisciplinary Team Recommendations indicated that Bed Rails were recommended at this time because other and instructed if chosen other to list which the team had documented see below. Section H3 of the evaluation indicated that bed rails were not recommended at this time due to Customer is immobile and makes no attempt to exit or shift in bed. The recommended frequency of use was during care as enabler and the use was discussed with the customer. The care plan initiated 6/29/19 and revised on 10/13/20, for Resident #6 identified that the resident had a deficit in Activities of Daily Living(s) (ADL) and required assistance due to (d/t) recent hospitalization, impaired mobility, decreased strength, and endurance and was at risk for falls related to (r/t) history of (h/o) fall with fracture, impaired mobility and cognitive impairment. The interventions related to these deficits did not include the use of side/bed rails and/or enablers to assist with care. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #6 had a Brief Interview of Mental Status (BIMS) score of 13, indicative of an intact cognition. The care plan indicated that the resident had established advanced directives which included a statement of incapacity with a decision maker. The admission Record identified a family member as the resident representative for decision making. 2. On 4/12/21 at 10:01 a.m., Resident #10 was observed lying in bed with eyes closed. The observation identified that the bed in which the resident was lying had bilateral quarter side rails raised and a trapeze hanging above her head. At 3:04 p.m. on 4/14/21, the resident was observed in bed with the side rails in the raised position. On 4/15/21 at 2:25 p.m., an observation was conducted of Resident #10. The resident was lying in bed with bilateral raised side rails and a visitor sitting beside the bed. Resident #10 was admitted on [DATE] and 9/3/20. The admission Record included diagnoses not limited to fusion of spine at lumbar region, unspecified Chronic Obstructive Pulmonary Disease, and unspecified dementia without behavioral disturbance. A review of the quarterly MDS, dated [DATE], identified Resident #10's BIMS score of 15, cognitive intact. The Functional Status portion of the MDS indicated that the resident required extensive assistance by 2 persons for bed mobility. A review of the clinical record for Resident #10, active as of 4/15/21, did not include a physician order for bilateral side rails and/or enablers. The care plan for the resident did indicate that the resident had a deficit in ADL(s) and required assistance d/t recent hospitalization, impaired mobility, decreased strength, and endurance, initiated 8/23/20 and revised 9/15/20. The interventions included the use of 1/2 side rails to assist with turning and repositioning, initiated 1/17/20 and revised 9/3/20. A request was made to the MDS Coordinator for Resident #10's Bed Rail Evaluation. The evaluation was not provided. 3. An observation was conducted on 4/12/21 at 10:03 a.m. of Resident #11 lying in bed with bilateral quarter side rails in the raised position and bed was at thigh-high level. The resident was holding the right side rail and no staff were observed in the room. At 11:43 a.m. the bilateral side rails continued to be in the raised position with no staff in the room. On 4/14/21 at 3:05 p.m., Resident #11 was observed lying in bed with the bilateral side rails in the raised position. At 2:26 p.m. on 4/15/21, the resident was observed lying in bed with the side rails in raised position with no staff in the room. Resident #11 was admitted on [DATE] and 10/2/20. The admission Record included diagnoses not limited to other seizures, myasthenia gravis without (acute) exacerbation, and unspecified Type 2 Diabetes Mellitus without complications. A review of the clinical record for Resident #11, active as of 4/15/21, did not include a physician order for the use of side rails or enablers. The Quarterly MDS, dated [DATE], indicated a BIMS score of Resident #11 of 10, indicating moderate cognitive impairment. The Functional Status assessment of the resident indicated that she required extensive assist by one-person for bed mobility and transferring only occurred once or twice during the assessment period with one-person assist. The care plan included a focus that identified the resident was at risk for falls secondary to impaired mobility with limitations of her extremities, use of hypnotic medication, a diagnosis of seizure disorder, and declined use of padded side rails, initiated on 7/9/15 and revised on 12/15/17. The goal for this focus was to implement appropriate interventions to minimize the risk of falls through next review, revised on 6/11/18. The interventions related to the resident's risk for falls did not include the use of side rails. The care plan indicated Resident #11 had established advanced directives including a Determination of Incapacity, initiated on 7/9/15 and revised on 3/14/17. The care plan identified that the resident was totally incontinent of bowel and bladder, required total assist with toileting needs, had the potential for constipation related to impaired mobility and the use of multiple pain medications. The intervention, initiated 4/14/21, indicated the resident used a bedside enabler during care. This intervention was initiated two (2) days after the initial observation of Resident #11's raised side rails and the observations did not include staff caring for the resident. The Bed Rail Evaluation, completed by the DON and effective 4/14/21 at 5:34 p.m., indicated that appropriate alternatives were and were not attempted to considering bed rail and the following alternatives were effective: - Call bell easily within reach with visual and verbal reminders to use call bell. - Bed placed in low position. (Multiple observations during the survey period revealed the resident bed in a knee-high or higher level.) The use of perimeter reminders such as body pillow/cushions or mattress with raised edge was not effective. The evaluation indicated that the reason the Bed Rail was being considered was due to mobility/transferring assistance during care. The Mobility and Transfer Evaluation portion of the Bed Rail Evaluation asked if the customer could ambulate without assistance to and from the bathroom and can the customer safely exit or enter the bed, which the DON answered, not applicable. The Interdisciplinary Team Recommendations indicated that Bed Rails were recommended other: see below and that Bed Rails were not recommended at this time due to the customer being immobile and made no attempt to exit or shift in bed. The recommended frequency of use was during care as enabler and use of the bed rail was discussed with the customer. The evaluation did not indicate an informed consent, or a physician order was obtained. 4. Resident #14 was observed 4/14/21 at 3:00 p.m. lying in a low-positioned bed with bilateral raised side rails. The observation did not include staff providing care to the resident. Resident #14 was admitted on [DATE] and 10/8/20. The admission Record included diagnoses of unspecified dementia without behavioral disturbance and unspecified dementia with behavioral disturbance. The Quarterly MDS, dated [DATE], identified the residents' BIMS score of 3 out of 15, indicative of severe cognitive impairment. The Functional Status of the MDS indicated the resident required extensive one-person assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of the clinical record for Resident #14, active as of 4/15/21, did not include a physician order for the use of side rails. The care plan for the resident identified that he had a deficit in ADL(s) and required assistance d/t recent hospitalization, impaired mobility, decreased strength, and endurance, initiated and revised on 3/20/21. The interventions related to the ADL deficit did not include the use of side rails. The facility did not provide the Bed Rail Evaluation for Resident #14 as requested on 4/15/21. 5. An observation was conducted on 4/12/21 at 10:14 a.m. of Resident #18. The resident was lying in a low-positioned bed with one side rail raised. The observation did not identify staff were assisting the resident with care. On 4/14/21 at 3:04 p.m., an observation of Resident #18 revealed the resident was lying in bed and bilateral quarter side rails were in the raised position. The observation did not indicate staff were assisting the resident. On 4/15/21 at 2:25 p.m., an observation identified that Resident #18 was lying in bed with raised bilateral side rails and no staff were in the resident's room. Resident #18 was admitted on [DATE] and 9/1/20. The admission Record included diagnoses not limited to unspecified dementia without behavioral disturbance and unspecified lack of coordination. The Quarterly MDS, dated [DATE], did not include a BIMS score for the resident as she was rarely/never understood. The Functional Status of the MDS indicated that Resident #18 required extensive one-person assist with bed mobility, transfers, and dressing and was total dependent for one-person for eating, toilet use, personal hygiene, and bathing. A review of the clinical record for Resident #18, active as of 4/15/21, did not include a physician order for the use of side rails. Resident #18's Quarterly Therapy Screen, effective 1/28/21, indicated the following areas were impaired-no change: cognitive status, communication, self-feeding, swallowing with the comment of peg tube, Upper Extremity (UE) self-care, Lower Extremity (LE) self-care, bed mobility, transfer, gait, and safety awareness. The screen identified that no skilled therapy was indicated and that the resident utilized side rails. The care plan for Resident #18 indicated she had a deficit in ADL(s) and required assistance d/t impaired mobility, decreased strength, and endurance, initiated 12/30/18 and revised on 9/15/20. The care plan indicated the intervention for side bed enablers during care was initiated on 4/14/21. The care plan identified that the resident had established advanced directives which included an Incapacity statement and a Healthcare Proxy. A Bed Rail Evaluation, effective 4/14/21 at 6:06 p.m. and completed by the Director of Nursing (DON), indicated that appropriate alternatives were and were not attempted to considering bed rail. The effective alternatives attempted included call bell use with visual and verbal reminders and the bed in low position. The evaluation indicated that the reason for the bed rail to be considered was for mobility/transferring assistance during care. The Mobility and Transfer portion of the Bed Rail Evaluation indicated that the questions Can the customer ambulate without assistance to and from the bathroom and Can the customer safely exit or enter the bed were not applicable. The Interdisciplinary Team (IDT) Recommendations identified that bed rails were not recommended at this time due to customer was immobile and makes no attempt to exit or shift in bed. The IDT also identified that bed rails were recommended because other and if chose other, please list: see below. The recommended frequency of use of bed rails was during care and that the bed rail use had been discussed with the customer and that the plan of care had been updated. 6. An observation on 4/12/21 at 10:01 a.m., indicated Resident #30 was lying in bed with bilateral raised side rails. The resident was holding onto the right side rail and staff were not providing care. On 4/14/21 at 3:04 p.m., the resident was observed lying in bed with bilateral raised side rails. Resident #30 was admitted on [DATE] and 12/26/17. The admission Record included diagnoses not limited to unspecified dementia without behavioral disturbance, and history of falling. The Quarterly MDS, dated [DATE], identified Resident #30's BIMS score of 8, indicative of moderate cognitive impairment. The Functional Status of the MDS identified that the resident required extensive one-person assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS revealed that the activity of moving from seated to standing position, walking, and turning around did not occur and that the resident was only able to stabilize self with staff assistance for moving on and off toilet and with surface-to-surface transfer. A request was made on 4/15/21 for Resident #30's Bed Rail Evaluation. The evaluation was not provided. A review of the clinical record for Resident #30, active as of 4/15/21, identified that there was no physician order for the use of bilateral side rails. The care plan for Resident #30 did not identify that the resident utilized bilateral side rails. 7. On 4/12/21 at 10:03 a.m., an observation was made of Resident #45 lying in bed with bilateral raised side rails. At 3:05 p.m. on 4/14/21, the resident was lying in bed with bilateral side rails in the raised position. An observation was conducted at 2:26 p.m. on 4/15/21, of the resident lying in bed with eyes closed and raised bilateral side rails. Resident #45 was admitted on [DATE] and 9/22/20. The admission Record included diagnoses not limited to unspecified dementia without behavioral disturbance and unspecified sequelae of cerebral infarction. The Annual MDS, dated [DATE], identified a BIMS score of 0, indicative of severe cognitive impairment. The Functional Status of the MDS indicated that the resident required extensive one-person assist for bed mobility, dressing, and eating, was totally dependent upon one-person for transfers, toilet use, and personal hygiene. A review of Resident #45's clinical record, active as of 4/15/21, did not include a physician order for the use of side rails. Review of the resident's care plan did not include use of side rails. The facility did not provide Resident #45's Bed Rail Evaluation as requested. 8. An observation on 4/14/21 at 3:03 p.m., indicated Resident #73 in bed with bilateral side rails in the raised position. On 4/15/21 at 2:24 p.m., Resident #73 was observed lying with eyes closed in bed with bilateral raised side rails. The observations did not indicate staff was providing care to the resident. Resident #73 was admitted on [DATE] and 12/25/19. The admission Record included diagnoses not limited to unspecified chronic obstructive pulmonary disease and unspecified single episode major depressive disorder. The Annual MDS, dated [DATE], indicated a BIMS score of 15, indicative of an intact cognition. The Functional Status of the MDS indicated that Resident #73 required extensive assistance from one-person for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A review of the clinical record for Resident #73, active as of 4/15/21, did not include a physician order for the use of side rails. The care plan for Resident #73 indicated that the resident had an alteration in memory/decision making r/t Cerebrovascular Accident, alert with confusion noted, unclear speech, staff continued to redirect/orient as needed (prn) and BIMS 3 (severe cognition impairment). The care plan did not include the utilization of side rails. The facility did not provide a Bed Rail Evaluation for Resident #73 as requested. An interview was conducted on 4/15/21 at 2:18 p.m. with Staff Member C, Certified Nursing Assistant (CNA). The staff member stated when residents were out of bed, the side rails were down and she only pulls the side rails up if the residents were fall risks when they were in bed, so they won't fall. On 4/15/21 at 2:19 p.m. the DON stated she had some assessments (Bed Rail Evaluations) that the facility did but they did not include any of the residents that this writer had spoken to her about on 4/14/21. She stated that the side rails were not restraints. The DON provided three Bed Rail Evaluations for residents that were not sampled and one Bed Rail Evaluation for a resident sampled but not for bed rail concerns.

Based on observations, record reviews, and interviews the facility failed to implement an effective Antibiotic Stewardship program related to the monitoring of antibiotic use of one (Resident #27) of one resident sampled for Transmission-based precautions. Findings included: The Facility Matrix indicated that Resident #27 was on Transmission-based precautions. An observation on 4/13/21 at 4:03 p.m. of the area outside of Resident #27's room, did not indicate that any Personal Protective Equipment was available for staff or any signs were posted with the type of precautions to be observed while caring for the resident. On 4/13/21 at 4:04 p.m., Staff J, Registered Nurse Supervisor, stated there was not anyone on Transmission-based Precautions. When asked about Resident #27, she stated she had spoken to the physician and that the precautions were discontinued as the resident had been on an antibiotic for eight days. A review of the April Medication Administration Record (MAR) for Resident #27 indicated the resident received Linezolid 600 milligrams (mg) by mouth every 12 hours for Vancomycin Resistant Enterococci (VRE) in urine on 4/1 to 4/14/21. The Infection Onset Report for Resident #27, dated 4/1/21, indicated that symptoms of the Urinary Tract [Infection] were observed on 3/28/21. The Criteria indicated that, If the Customer has not had an indwelling catheter in the past 48 hours: at least one response from #1, #2 and #3 must be present. The responses indicated that the resident exhibited symptoms in #2: supra-pubic pain and #3: at least a 100,000 colony count of any organisms in a urine specimen. The criteria did not indicate that the resident exhibited symptoms listed in group #1. During an interview on 4/15/21 at 8:51 a.m., the Infection Control Preventionist (ICP) stated that she looked at all the orders and had only identified the antibiotic ordered for Resident #27 on 3/5 to 3/12/21. She stated the line listing for April was current as of 4/12/21. A review of the April Line Listing did not include Resident #27's antibiotic use. The ICP reviewed the April MAR for Resident #27 and confirmed that the resident had received an antibiotic (Linezolid) from 4/1 to yesterday. When asked why the resident was not included on the line listing, she stated she did not know. She reviewed the line listing for March and it indicated that the resident had been added then crossed off. She stated she thought maybe she started to put it on the list but when the Cipro (order prior to sensitivity) was discontinued and the Linezolid was ordered on 3/31/21, but not started until April, It got missed. The ICP added Resident #27 to end of the April Antibiotic Line Listing. The ICP reviewed the Infection Onset record for Resident #27 and indicated that the infection did not meet McGreer criteria. She stated that the floor nurses filled out the criteria and when an antibiotic was ordered, she would confirm that an Infection Onset report was completed. She would review progress notes to see if the resident had the third criteria, if necessary, and if it did not meet criteria, she would call the Unit Manager and ask that the provider be called to discontinue the antibiotic. She stated that the resident should have been on Transmission-based precautions for the entire course of antibiotics and could not definitely identify if Resident #27 was on isolation at all since the order was missed. The ICP reported that physician orders were not reviewed during the morning meetings and that she was not included in the Change In Condition meetings. On 4/15/21 at 10:31 a.m., the Director of Nursing (DON) stated that the ICP should be notified prior to the discontinuation of precautions but was unsure if the Unit Manager had informed the ICP. At 10:42 a.m., the DON stated the Unit Managers are telling the ICP that precautions are discontinued, the ICP does not tell Unit Manager. On 4/15/21 at 11:27 a.m., the ICP said that the facility did not have a policy regarding Antibiotic Stewardship but provided a Monthly Infection Control Report, revised on 8/29/2017. The report described the Antibiotic Days of Therapy, Adverse Drug events related to (r/t) Antibiotics, Rate of Antibiotic, Prophylactic Antibiotic Therapy, and a short description of the Constitutional Criteria. The ICP provided education regarding the Core Elements for Antibiotic Stewardship in Nursing Homes from the Centers for Disease Control and Prevention, and a power point education titled, Antibiotic Stewardship.