**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Record review for Resident #71 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. The resident had diagnoses that included: Encephalopathy, Parkinson's Disease, and Need for Assistance with Personal Care. Review of the Minimum Data Set for Resident #71 dated 02/18/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 14 indicating a cognitive response. Review of the Physician's orders for Resident #71 revealed an order dated 01/13/24 for enablers which are used for bed mobility and safe transfers as tolerated every shift On 05/06/24 at 10:05 AM an observation was made of Resident #71 sitting up in bed with a staff member in the room (Later identified as Staff A, Certified Nursing Assistant (CNA). The resident's call bell was wrapped around the enabler bar located on right side, near the top of the bed. Staff A left the room. The resident was unable to reach for the call light. During an interview conducted on 05/06/24 at 10:10 AM with Resident #71, who was asked if she had any concerns about her care, she said, I can't call for help sometimes because I don't know where the call bell is. During an interview conducted on 05/06/24 10:13 AM with Staff A, who stated she has worked per diem (as needed) at the facility since 2017. When asked about the call bell wrapped around the enabler bar on the side of Resident #71's bed, she said they probably put it there when the breakfast was served to her in bed this morning. During an interview conducted on 05/09/24 at 11:40 AM with Staff B, Registered Nurse (RN) who stated she has worked at the facility for about a year. When asked about call bells, she stated when she first comes on to work, she always makes sure the call bells are in the bed for the resident to use for safe and effective communication. She stated one call can save a life. When asked if the call bell can be wrapped around the bed rail, she said no, it is placed on the bed. An interview was conducted on 05/09/24 at 12:00 PM with Staff C, Licensed Practical Nurse (LPN) who stated she has worked at the facility for 21 years. When asked about call bells, she stated the call bells are kept on the bed in reach of the resident. When asked if they can be wrapped around the bed rail, she said no we are not supposed to wrap anything around the bed rails. Based on observation, interview, policy and record review, the facility failed to ensure accessibility of call lights for 3 of 4 sampled residents reviewed for accommodation of needs (Resident #56, #101, and #71). The finding included: The facility's policy titled, Call System, Resident dated September, 2022 revealed Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. The resident call system remains functional at all times. 1) Resident # 56 was admitted to the facility on [DATE] with diagnoses that included Obstructive and Reflux Uropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract symptoms, and Abdominal Aortic Aneurysm. The Brief Interview for Mental Status (BIMS) score for the resident on the quarterly Minimum Data Set with an assessment reference date of 03/24/24 was 9. This indicated the resident had mild cognitive impairment. On 05/06/24 at 11:43 AM, an interview was conducted with Resident #56 with his son present. The resident was observed in a wheelchair next to his bed with his call light on the bed. The resident was asked if he could reach his call light and he stated he could not. Further observation of the call light revealed it was not plugged into the wall. The resident's son stated that he visits his father daily and half of the week the call light cord is tied around the side rail and not within reach of his father. 2) Resident #101 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, Urinary Tract Infection, and Diabetes Mellitus. The resident currently has Cellulitis of the Right Arm. Cellulitis is a bacterial skin infection that causes swelling, pain, warmth and redness of the affected area. The resident had a Brief Interview for Mental Status (BIMS) score of 14 on the quarterly Minimum Data Set with an assessment reference date of 04/24/24. This indicated the resident was cognitively intact. On 05/06/24 at 10:00 AM, an observation and interview was conducted of Resident #101. The resident was observed in bed with his call light on the floor next to the right side of the bed. The resident was asked if he could reach his call light. The resident stated his right arm was so painful he could not move it and he has not been getting out of bed. He stated he was not able to reach the call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure medications were being administered timely for 1 of 1 sampled resident (Resident #71). The findings included: Review of the facility's policy titled, Medication Administration - General Guidelines dated May 2022 included in part: B. Administration 2) Medications are administered in accordance with written orders of the prescriber. 12) Medications are administered within (60 minutes) of scheduled time, except before, with or after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. Record review for Resident #71 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. The resident had diagnoses that included: Encephalopathy, Parkinson's Disease, and Need for Assistance with Personal Care. Review of the Minimum Data Set assessment for Resident #71 dated 02/18/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 14, indicating a cognitive response. Review of the Physician's Orders for Resident #71 revealed an order dated 01/13/24 for Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa); Give 1 tablet by mouth three times a day related to Parkinson's Disease. Review of the Physician's Orders for Resident #71 revealed an order dated 01/14/24 for Droxidopa Oral Capsule 200 MG (Droxidopa); Give 1 capsule by mouth three times a day for Orthostatic Hypotension; Monitor blood pressure supine before administration. Review of the Medication Administration Record for Resident #71 for 05/01/24 to 05/07/24 documented the medications to include, Carbidopa-Levodopa 25-100 mg and Droxidopa 200 mg had been signed off as given three times a day (9:00 AM, 1:00 PM, and 5:00 PM) Review of the Medication Administration History Report (Showing Actual Time Medication Given) for Resident #71 from 05/01/24 to 05/07/24 for the medication Carbidopa-Levodopa 25-100 mg revealed for 7 out of 21 opportunities the medication had been given outside of the 60 minutes before/60 minutes after medication scheduled time. On 05/02/24 the 9:00 AM dose was administered at 11:36 AM and the 1:00 PM dose was administered at 1:33 PM indicating the doses were administered less than 2 hours apart. On 05/02/24 the 9:00 AM dose was administered at 11:10 AM and the 1:00 PM dose was administered at 1:58 PM indicating the doses were administered less than 3 hours apart. On 05/07/24 the 9:00 AM dose was administered at 11:47 AM and the 1:00 PM dose was administered at 1:23 PM indicating the doses were administered less than 2 hours apart. Review of the Medication Administration History Report (Showing Actual Time Medication Given) for Resident #71 for 05/01/24 to 05/07/24 for the medication Droxidopa 200 mg revealed for 9 out of 21 opportunities the medication had been given outside of the 60 minutes before/60 minutes after medication scheduled time. On 05/02/24 the 5:00 PM dose was administered at 9:03 PM and on 05/03/24 the 5:00 PM dose was administered at 10:08 PM indicating twice the medication was administered at bedtime. During an interview conducted on 05/06/24 at 10:10 AM with Resident #71 who stated she would like to get her Parkinson's medication a little earlier otherwise she does not eat until noon time. During a telephone interview conducted on 05/07/24 at 8:43 AM with the daughter of Resident #71, the daughter said she thinks the Parkinson's medication is supposed to be given 1 hour before meals, but they are usually about 1 hour late giving the Parkinson's medication. The daughter said the medications makes it so her mother can feed herself. An interview was conducted on 05/08/24 at 10:15 AM with the Consultant Pharmacist (CP) who has been working with this facility since 2011, and on and continuous since 2018. The CP stated that in this facility, a medication ordered for three times a day has a default to be given at 9:00 AM, 1:00 PM, and 5:00 PM. Additionally she said the nurse has an hour before and an hour after the scheduled time to administer the medication. The CP stated the Carbidopa-Levodopa does not need to be every so many hours, as this may be what the resident is used to in the community and if the resident is stable, it would not be an issue. When asked about Resident #71 specifically about the medication Carbidopa-Levodopa 25-100 mg ordered three times a day to be given at 9:00 AM, 1:00 PM, and 5:00 PM, the CP stated when she looked at the Medication Administration in May for this medication for Resident #71, she verified it was given as ordered. When the CP was shown the report for the Carbidopa-Levodopa 25-100 mg for Resident #71 with the actual time documented given in the month of May 2024, the CP said she was unaware of this report and acknowledged the medication was given too close at times. The CP said it should have at least 3 to 4 hours between administration times. If it is given to close, it may cause agitation. When asked if the medication could be given 1 hour before meals per a family/resident request, the CP said it most likely would not make a difference in the resident's movement but may decrease the appetite, she also added the medication can be taken with or without food. The CP stated if the family wanted to have the medications scheduled to be given an hour before meals, they would work with the family. When asked about Resident #71 specifically about the medication Droxidopa 200 mg ordered three times a day to be given at 9:00 AM, 1:00 PM, and 5:00 PM, the CP said if the medication is generally given closer at times during the day but not close to bedtime, because if given too close to the bedtime, it may cause orthostatic hypotension. The CP said ideally, the Droxidopa should be given 3 hour before bedtime and not like to see given past 6:00 PM or 7:00 PM. When shown the report for the Droxidopa 200 mg for Resident #71 with the actual time documented given in the month of May 2024, the CP acknowledged the Droxidopa was given too close to bedtime on some days. The CP stated it may be better if the facility staff signing off on the medication would put in a code indicating to see a nurses note and describe in the note why the medication was not given within the 1 hour before or 1 hour after the medication scheduled time. During an interview conducted on 05/08/24 at 11:30 AM with the Director of Nursing (DON), who was asked about Resident #71 and the actual medication administration times for the medications Carbidopa-Levodopa and Droxidopa, she acknowledged she just became aware of the medications not being administered as ordered and will start educating staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to safely store medications for 1 of 1 sampled resident (Resident #54). The findings included: Review of the facility's policy titled, Bedside Medication Storage dated May 2022 included in part: Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. Procedures C. For residents who self-administer medications the following conditions are met for bedside storage to occur: 1) The manner of storage prevents access by other resident. Lockable drawers or cabinets are required only if unlocked storage is deemed inappropriate. Facility management should have a copy of the key in addition to the resident. Record review for Resident #54 revealed the resident was admitted to the facility on [DATE] with diagnosis of Heart Failure, Vitamin Deficiency, Dry Eye Syndrome, Candidal Stomatitis, and Personal History of Urinary (Tract) Infections. Review of the Minimum Data Set (MDS) assessment for Resident #54 dated 02/04/24 documented in Section C a Brief Interview of Mental Status score of 15, indicating a cognitive response. Review of Resident #54's records revealed no assessment for self-administration of medications. Review of the Physician's orders for Resident #54 revealed no order to self-administer any medications. On 05/06/24 at 10:58 AM, an observation was made in the semi-private room of Resident #54 of a nightstand between the 2 beds with the top drawer open, and inside the drawer was 3 bottles of Systane lubricant eye drops, a bottle of probiotics, a bottle of organic cranberry 500 mg, and a bottle of urinary harmony supplement capsules. Further observations revealed on top of the nightstand was the Fluorouracil topical cream 5%. Resident #54 was not in the room, but the roommate (Resident #31) was in the room lying in the bed (Photographic Evidence Obtained). On 05/08/24 at 3:00 PM, an observation was made of Resident #54 sitting in her wheelchair with her laptop in front of her on an overbed table. On the overbed table next to the laptop was Fluorouracil topical cream 5%. During an interview conducted on 05/06/24 at 11:54 AM with Resident #54, who was in the day room, and was asked about the medications in and on her nightstand in her room, she said the prescription cream she puts on herself and the staff keep it at the nursing station. She said some nurses are a bit skittish to put it on because it goes in the [ ]. She said last night the head nurse came to her to tell her she did not have the cream, she said maybe I forgot to give it back to them. When asked about the supplements, she said those may be hers because sometimes she takes them. When asked about the eye drops, she said those are hers as well and were prescribed by the ophthalmologist for her and she uses them several times a day. During an interview conducted on 05/08/24 at 3:05 PM, when Resident #54 was asked about the Fluorouracil topical cream 5%, she said that is her dermatological cream she uses on her face, she said her doctor prescribed it for her. When asked if she still has supplements and eye drops in the nightstand, she said yes. During an interview conducted on 05/08/24 at 3:30 PM with the Director of Nursing (DON) who was asked if Residents can have meds at the bedside, she said no, they can be assessed for self-administration, but the nurse will hold the medication locked in the med cart. When the DON was shown the photographic evidence of the medications at the bedside for Resident #54, the DON acknowledged the residents are not supposed to have the medications in the room at the bedside. The DON said she would address the matter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure timely personal care and assist with feeding for 3 of 3 sampled residents (Resident #26 #79, and #59), reviewed for Activities of Daily Living(ADL's). Specifically, eating and incontinent care. The findings included: 1) During an interview on 02/13/23 with the daughter of Resident #26, she expressed concern about the resident not receiving assistance to eat her meals. During the interview, the daughter indicated she can communicate with her mom through her mom's gestors and hand movements. Review of the record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #26 has diagnosis to include Parkinson's Disease and Rheumatoid Arthritis. The resident was admitted to hospice services on 11/24/22. On 02/14/23 at 8:55 AM the resident was observed in her wheelchair beside her bed with her breakfast tray. The resident was attempting to eat however she was not able to get the food onto her spoon. On 02/14/23 at 9:00 AM Staff J, a Licensed Practical Nurse (LPN) arrived in the room and questioned Resident #26 why she wasn't eating. The resident motioned with her spoon from the food to her mouth. The surveyor asked Resident #26 if this meant she needed help to eat her breakfast. The resident gave a thumbs up to indicate she needed help. On 02/16/23 at approximately 9:10 AM Resident was sitting in her wheelchair beside her bed. The breakfast tray was positioned in front of her and she was attempting to eat with her spoon and was unable to get any food on her spoon. No one was in the room to assist Resident #26 with eating. The plan of care was reviewed for Resident #26. The plan of care for ADL's (Activities of Daily Living) revealed the resident requires extensive assist by one staff to eat. Review of the Minimum Data Set (MDS) assessment dated [DATE], documented Resident #26 has a Brief Interview for Mental Status (BIMS) score of 12 on a 0 to 15 scale, which indicates the resident was moderately impaired. The MDS also documented the resident needs extensive assistance by one staff to eat. On 02/16/23 at 8:30 AM, an interview was conducted with the Director of Nursing who stated they want the resident to do as much as she can for herself, and they will cue her to eat on her own. Review of the Plan of Care and the MDS reveal the resident is extensive assist by one staff for eating. 2) On 02/13/23, an interview was conducted with Resident #79. She stated she gets her diaper changed at 5:00 AM and they never change it until 2:00 PM or 2:30 PM. She stated this is the reason I have UTI's (urinary tract infection). She stated the facility is very understaffed. They need more help. On 02/15/22 at 9:00 AM, an interview was conducted with Resident #79 who stated she called for help last night from 2:00 AM until 5:00 AM. She stated no one answered the call bell. She stated she then used the phone to try to reach someone at the desk for help. She stated the phone rang busy for 1 hour and after an hour it just kept ringing. She stated she needed help repositioning her arm and she needed her diaper changed. She stated she had spoken to the night nurse about her concerns for her incontinent care. She stated she doesn't know anyone's name because they come into your room and never introduce themselves. She stated they usually only change her diaper every 8 hours and that is not enough. She stated no one has spoken to her about her concerns for her incontinent care. Record review revealed Resident #79 was admitted to the facility on [DATE] with diagnosis to include Hemiplegia and Hemiparesis following cerebral infarct affecting left non dominant side, pain and muscles spasms. The personal history of UTI's diagnosis was added on 12/22. Review of the current MDS assessment dated [DATE] documented Resident #79 had a BIMS of 15, indicating she was alert and oriented and cognitively intact for decision making. The MDS also documents the resident is extensive assist with bed mobility and toileting. Review of the Plan of Care for Resident #79 revealed the resident requires extensive assist by 1 staff to turn and reposition in bed. The plan of care indicates the resident has bowel and bladder incontinence and the resident is to be checked every two hours for assistance with toileting. 3) An interview was conducted with Resident #59 on 02/13/23 at 9:39 AM. The resident stated the facility does not care. She stated it takes 4-5 hours on overnight shift to get her diaper changed. She stated the employees have told her they do not have enough staff to get to her diaper change at night. On 02/15/23 at 8:22 AM, the resident was interviewed. She stated she had waited 5 ½ hours last night for anyone to come in and change her diaper. She stated they finally changed her at 6:00 AM. She stated she could not locate her call button and no one checked on her to see if she needed her diaper changed. On 02/16/23 at 9:50 AM, the resident stated she had needed her diaper changed from 1:00 AM and they finally checked on her at 6:30 AM. She stated at night she is unable to locate her call button. Resident stated that she had shared her concerns for her incontinent care with the night nurse however nothing has changed Record review revealed Resident #59 was admitted to the facility 03/11/22 with a diagnosis of Parkinson's Disease. Review of the MDS dated [DATE] documented Resident #59 has a BIMS score of 15, which indicates the resident was alert and oriented and cognitively intact for decision making. The MDS also documented the resident needs extensive assist of one person for toileting, personal hygiene and dressing. The plan of care for Resident #59 documents the resident is incontinent of bowel and bladder and to check and change disposable brief as required. On 02/16/23 at 2:45 PM, an interview was conducted with Staff K, a Certified Nursing Assistant (CNA) she stated she turns, and positions residents every 2 hours. She stated she changes the residents diapers every 3 hours. On 02/16/23 at 3:00 PM, an interview was conducted with Staff G, a CNA concerning resident care. She stated she turns, positions and changes the residents every 2 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure padded bed side rails were provided & properly used for 2 of 4 sampled residents reviewed for accidents, both of whom had a history of seizures (Residents #10 and #15). The findings included: 1) Review of the record revealed Resident #10 was admitted to the facility on [DATE]. Review of the current care plan initiated on 11/04/20 revealed Resident #10 was at risk for seizure related injuries related to conversion disorder with seizures or convulsions. An intervention dated 02/09/22 revealed the use of bilateral upper half padded side rails for safety. An order dated 10/16/17 documented the use of two padded side rails for safety. The current Minimum Data Set (MDS) assessment dated [DATE] confirmed the diagnosis of seizures. During an observation on 02/13/23 at 10:26 AM, Staff A, Certified Nursing Assistant (CNA), had just finished providing personal care for Resident #10, and left the room, leaving the resident in the bed. A half side rail, located along the middle portion of the resident's left side, was raised and a blue padded mat was noted hooked to the side rail by a Velcro strap, and hanging down from the rail along the outer aspect of the bed and to the floor (Photographic Evidence Obtained). At this time the right side rail was positioned up as a quarter rail at the head of the bed, and lacked any type of pad. A supplemental observation on 02/13/23 at 12:27 PM revealed Resident #10 still in bed with the side rail padding still improperly placed on the left side, and none on the right. An observation on 02/14/23 at 9:11 AM revealed Resident #10 in bed with the left side rail pad hooked in the same manner as the previous day, but more was on the floor as the bed was slightly lower than the day before. The right side rail remained without any pad. An observation on 02/15/23 at 10:24 AM revealed Resident #10 in bed. Both side rails lacked any padding (Photographic Evidence Obtained). During an interview on 02/16/23 at 10:52 AM, when asked about the blue pads in the room of Resident #10, Staff A, CNA, stated she put the pads on the side rails when the resident was in bed. When the surveyor informed the CNA, who had worked with Resident #10 throughout the survey, of the observations as noted above, the CNA had no response. During an interview on 02/16/23 at 10:57 AM, Staff B, agency Registered Nurse (RN), confirmed the order for the bilateral padded side rails. When notified of the surveyor's observations as noted above, the RN agreed the pads should have been utilized and placed properly on the side rails for resident safety. 2) Review of the record revealed Resident #15 was admitted to the facility on [DATE]. Review of the current care plan initiated on 09/27/22 and corresponding orders, documented the use of padded quarter side rails for safety, for a diagnosis of seizures. Review of the current MDS dated [DATE] confirmed the diagnosis of a seizure disorder. A Quarterly Device/Enabler/Restraint evaluation dated 12/29/22 also documented seizure precautions with the use of padded quarter side rails while in bed for safety, related to the diagnosis of seizures. An observation on 02/13/23 at 11:34 AM revealed Resident #15 in bed with both upper side rails raise, and without padding. Two side rail pads were noted on edge, leaning against the wall (Photographic Evidence Obtained). A supplemental observation on 02/13/23 at 3:39 PM revealed the resident in bed, side rails raised, and the pads in the same location against wall. On 02/14/23 at 10:02 AM and on 02/15/23 at 10:20 AM, Resident #15 was in bed with the side rails raised and the side rail pads in the same location against the wall. During the continued interview on 02/16/23 beginning at 10:57 AM, Staff B, agency Registered Nurse (RN), confirmed the order for the bilateral padded side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement a new order for increased water flushes via enteral (tube feeding) means, for 1 of 2 sampled residents, who was ordered the increase related to an electrolyte imbalance (Resident #1). The findings included: Review of the record revealed Resident #1 was admitted to the facility on [DATE]. Further review of the record revealed the resident received all food and fluids via a tube. A physician progress note dated 02/13/23 revealed an elevated sodium level with a plan that increased the water flushes with the PEG feeding (percutaneous endoscopic gastrostomy/surgical placement of a feeding tube). The tube feeding water flushes had recently been increased to 150 ml (milliliters) every 4 hours. A Registered Dietician's (RD) progress note dated 02/14/23 documented to increase the tube feeding water flushes to 200 ml every 4 hours due to elevated BUN (Blood urea nitrogen), a lab value related to a person's hydration status, identified with repeat laboratory tests. This note also documented the RD was to monitor hydration status, tube feed intake, weight trends, and labs. A current order dated 02/14/23 documented the increase of fluids to 200 ml every four hours via the tube feeding route was to begin at of 4 PM that same day. An observation on 02/15/23 at 9:59 AM revealed Resident #1 in bed with the head of the bed elevated. The tube feeding pump was set at 150 ml every four hours for the water flush (Photographic Evidence Obtained). On 02/16/23 at 10:05 AM, Staff C, Registered Nurse (RN), had just finished administering medications via the tube, and started to walk away. When asked the rate of the water flush via the pump, Staff C verified it was set for 150 ml every four hours. The surveyor left and proceeded to the nurse's station, when Staff C arrived and asked her coworker, Staff B, agency RN (who was training the newly hired nurse, Staff C) to verify the water flush order. Staff B verified the current order, that was to be initiated on 02/14/22, was for the increased water flush of 200 ml every four hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) A review of the Resident Council Meeting minutes, on 02/15/23 at 8:10 AM, revealed the following concerns were noted: a. During the Resident Council Meting on 09/26/22: In the section for 'Old Business Not resolved': Dining room is open at 8:00 AM but CNAs not available to start service. In the section for 'New Concerns/Grievances': Residents would like staff to have call bells answered and request resolved in a timely manner. and b. During the Resident Council Meeting on 11/28/22: In the section for 'New Concerns': Sometimes no staff in sitting area Not enough staff on weekends. c. During the Residnet Council Meeting on 12/26/22: In the section for 'Old Business not resolved: Sometimes staffing shortages on weekends. d. During the Resident Council Meeting on 01/23/23: In the section for 'Old Business/concerns not resolved, documented': Sometimes staff shortages on the weekends. During an interview, on 02/15/23 at 2:25 PM, with active members of the Resident Council, including Resident #4, with a Brief Interview for Mental Status (BIMS) score of 10 (moderately impaired), Resident #18, with a BIMS score of 9 (moderately impaired), Resident #35, with a BIMS score of 10(moderately impaired), and Resident #77, with a BIMS score of 15 (cognitively impaired), when asked about staffing concerns documented in the Resident Council Meeting Minutes, all of the 4 attendees agreed that the staffing concerns had not been resolved. Resident #4 stated, Especially on Saturday and Sunday, they should have 4 (referring to CNAs). Resident #4 further stated that residents have had to wait excessive amount of time for staff to respond to the call lights - the other 3 attendees acknowledged and agreed with the statement. Resident #35 stated, I have Parkinson's and sometimes with a bad tremor and I have some of the staff say, 'just try and you will be able to do it. They want me to walk, because they are not very happy to wheel me to lunch and I can't do more than I do. there is a limit to my action. One said to me ' i have asked you so many times and why can't you walk, you just want people to wait on you. Resident #77 stated, I have to use the lift to get out of bed, I had to wait. On the weekends, it is always short, lucky if there are two aids and they tell me that I have to stay in the bed all day because there is only 2 aides. for what I am paying for a partial room, they should be able to hire more aides. Resident #4 added Every Saturday and every Sunday they tell us 'we have 15 people to take care of.' they complaint about how much they are getting paid. Based on interview, observation, record review, policy review, the facility failed to ensure sufficient staffing for 2 (4 North and 4 South) of 5 resident units, affecting the provision of care and services for the residents. The findings included: The facility policy titled LNMR Staffing, Sufficient and Competent Nursing and revised August 2022, documents in part: #6 Staffing numbers and the skill requirement of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment. 1) During an interview on 02/13/23 with the daughter of Resident #26, she expressed concern about the resident not receiving assistance to eat her meals. Review of the record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #26 has diagnosis to include Parkinson's Disease and Rheumatoid Arthritis. The resident was admitted to hospice services on 11/24/22. On 02/14/23 at 8:55 AM the resident was observed in her wheelchair beside her bed with her breakfast tray. The resident was attempting to eat however she was not able to get the food onto her spoon. On 02/14/23 at 9:00 AM Staff J, a Licensed Practical Nurse (LPN) arrived in the room and questioned Resident #26 why she wasn't eating. The resident motioned with her spoon from the food to her mouth. The surveyor asked Resident #26 if this meant she needed help to eat her breakfast. The resident gave a thumbs up to indicate she needed help. On 02/16/23 at approximately 9:10 AM Resident was sitting in her wheelchair beside her bed. The breakfast tray was positioned in front of her and she was attempting to eat with her spoon and was unable to get any food on her spoon. No one was in the room to assist the Resident #26 with her eating. The plan of care was reviewed for Resident #26. The plan of care for ADL's (Activities of Daily Living) revealed the resident requires extensive assist by 1 staff to eat. On 02/16/23 at 8:30 AM an interview was conducted with the Director of Nursing who stated they want the resident to do as much as she can for herself, and they will cue her to eat on her own. Review of the Plan of Care and the MDS revealed the resident is extensive assist by one staff for eating. 2) On 02/13/23 an interview was conducted with Resident #79. She stated she gets her diaper changed at 5:00 AM and they never change it until 2:00 PM or 2:30 PM. She stated this is the reason I have UTI's (urinary tract infection). She stated the facility is very understaffed. They need more help. Review of record revealed Resident #79 was admitted to the facility on [DATE] with diagnosis to include Hemiplegia and Hemiparesis following cerebral infarct affecting left non dominant side, pain and muscles spasms. The personal history of UTI's diagnosis was added on 12/22. Review of the current MDS assessment dated [DATE] documented Resident #79 had a BIMS of 15 indicating she was alert and oriented and cognitively intact for decision making. The MDS also documents the resident is extensive assist with bed mobility and toileting. Review of the Plan of Care for Resident #79 revealed the resident requires extensive assist by 1 staff to turn and reposition in bed. The plan of care indicates the resident has bowel and bladder incontinence and the resident is to be checked every two hours for assistance with toileting. 3) An interview was conducted with Resident #59 on 02/13/23 at 9:39 AM. The resident stated the facility does not care. She stated it take 4-5 hour on overnight shift to get her diaper changed. She stated the employees have told her they do not have enough staff to get to her diaper change at night. On 02/15/23 at 8:22 AM the resident was interviewed. She stated she had waited 5 ½ hours last night for anyone to come in and change her diaper. She stated they finally changed her at 6:00 AM. She stated she could not locate her call button and no one checked on her to see if she needed her diaper changed. On 02/16/23 at 9:50 AM the resident stated she had needed her diaper changed from 1:00 AM and they finally checked on her at 6:30 AM. She stated at night she is unable to locate her call button. Resident stated that she had shared her concerns for her incontinent care with the night nurse however nothing has changed The Resident was admitted to the facility 03/11/22 with a diagnosis of Parkinson's Disease. Review of the MDS 12/15/22 documents Resident #59 has a BIMS score of 15, which indicates the resident was alert and oriented and cognitively intact for decision making. The MDS also documents the resident needs extensive assist of one person for toileting, personal hygiene and dressing. On 02/14/23 at 8:10 AM, an interview was conducted with Staff G, a Certified Nursing Assistant, (CNA) She stated they need more help with the residents. She stated she only works day shift and it is very tiring. Most of her residents are total care. 02/14/23 at 10:30 AM, an interview was conducted with Staff F, a Licensed Practical Nurse (LPN). She stated she is caring for 30 Residents and today she has 4 CNA's however sometimes she only has 2-3 CNA's to assist with care. She stated that Sundays are the hardest because they usually only have 2 CNA's. She stated she works 8 hour shifts and she is unable to complete her work within the 8 hours. On 02/15/23 at 7:30 AM, an interview was conducted with staff H, a CNA. She stated she has worked at the facility for many years. She stated there is never enough time to complete her assignment. She stated she always stays late to finish up her charting. On 02/15/23 at 7:43 AM, an interview was conducted with Staff I, a CNA. She stated they do not have enough staff to meet the needs of the residents in the amount of time they work. On 02/16/23 at 8:30 AM, an interview was conducted with the Director of Nursing (DON). She stated she is attempting to hire additional staff. On 02/16/23 at 2:45 PM, an interview was conducted with Staff K, a Certified Nursing Assistant (CNA) she stated she turns, and positions residents every 2 hours. She stated she changes the residents diapers every 3 hours. On 02/16/23 at 3:00 PM, an interview was conducted with Staff G, a CNA concerning resident care. She stated she turns, positions and changes the residents every 2 hours. The facility provided a document with the list of residents living in the facility who require 2-person assistance. Review of the document revealed the census of the facility is 108 and 40 of the residents are 2 person assist and 3 residents are 1-2 person assist. 4) Resident #5 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required extensive to total two-person assist with activities of daily living. An interview was conducted with Resident #5 with family at bedside. The resident stated they do not have enough people to help get people out of bed in a timely manner. The resident's family member referred to yesterday 02/15/22 when the resident was supposed to be out of bed in order to go to physical therapy at 10:00 AM. Resident #5 and family member stated they did not get him out of bed until after lunch, after 1:00 PM. The resident and his family member stated they just don't have enough staff to take care of our needs. Things like that happen on a regular basis.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rates are not 5 percent or greater; the medication error rate was 8%. Two (2) medication errors were identified while observing a total of 25 opportunities, affecting Resident #257. The findings included: A medication administration observation was conducted on 02/15/23 at 9:00 AM, with Staff Z, a Registered Nurse, for Resident #257. Staff Z was observed pouring 5 milliliters (ml) of iron in a medicine cup. The labeling on the iron medication was 5 ml/220 mg. Staff Z, after gathering up the rest of the resident's medications, stated the resident was out of her Prednisone. Staff Z stated she would check the emergency kit for the medication. Staff Z returned with 2 pills of Prednisone 5 mg each (total 10 mg). Staff Z proceeded to administer a total count of 8 pills, and 3 liquids, verified together with the surveyor. A medication reconciliation was conducted with the medications Staff Z administered to Resident #257, and the resident's orders on 02/15/23 at 10:15 AM. A review of Resident #257's orders revealed an order dated 01/16/23 for Ferrous Sulfate Liquid (iron) 325 mg twice a day at 9:00 AM and 9:00 PM (220 mg administered). An additional order dated 01/16/23 for Prednisone 1 mg every other day at 9:00 AM (10 mg administered). An interview was conducted with Staff Z on 02/15/23 at 10:30 AM. Staff Z acknowledged the errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure safe medication storage on 1 of 5 resident units (3S), as evidenced by two observations of an unlocked and unattended medication cart on two separate occasions (on 02/13/23), and observation of an unlocked and unattended treatment cart for at least 45 minutes on 02/13/23. The findings included: Review of the policy Medication Storage in the Facility dated April 2018 documented, B. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. On 02/13/23 at 9:57 AM, the treatment cart on the 3S unit was noted unlocked and unattended. The 3S unit was a locked unit for memory impaired residents, with a centrally located common area and nurse's station. The unlocked treatment cart was pushed up against a wall in the common area with the drawers facing outward (Photographic Evidence Obtained). At the time of this observation, eleven residents were noted in the common area. Two nurses were observed at a medication cart, approximately 15 to 20 feet away, and also in the common area. The two nurses were engaged in the morning medication pass for the residents. Both nurses were focused on the medication cart and electronic record, leaving the cart intermittently to administer medications, and returning to the medication cart. The Assistant Director of Nursing (ADON) walked through the common area between the two carts, but did not notice the unlocked treatment cart. At 10:03 AM the Director of Nursing (DON) was on the unit and in the common area, but did not notice the unlocked and unattended treatment cart. Staff E, agency Registered Nurse (RN), passed right by the unlocked treatment cart to go down the 317-324 hallway, and did not notice the unlocked treatment cart. During an interview on 02/13/23 at 10:08 AM, upon surveyor introduction, Staff E, agency RN, stated it was her first day at the facility, and last night's nurse had stayed to help for awhile. During the continued observation on 02/13/23 at 10:15 AM, the night nurse had gone into a resident room while Staff E continued with the morning medication pass. Staff E left the medication cart unlocked and unattended in the common area, and walked down the hallway nearest the elevators. At 10:16 AM the night nurse returned to the medication cart, noticed it was unlocked, and upon return of Staff E, the night nurse reminded her to lock the cart when she left. An observation on 02/13/23 at 10:44 AM revealed the treatment cart remained in the same location, unlocked and unattended, with multiple residents in the common area. Different staff were in and out of the common area throughout the day, but there were times that the area was unattended by any staff. An observation at 11:12 AM revealed the treatment cart was now locked. The treatment cart was used for wound care for all residents of the 3S unit and contained wound supplies and medications. The treatment cart was observed being used for the provision of wound care by a direct care nurse on at least two occasions during the survey week. On 02/13/23 at 3:29 PM, the 3S medication cart was pushed up against the nurse's station, with the drawers facing out toward the common area, and it was noted unlocked again (Photographic Evidence Obtained). Staff E, RN, was sitting behind the desk working on her computer. At 3:32 PM when asked if there was any reason she had left the medication cart opened twice that day, Staff E jumped up and ran around the nurse's station stating, I left the cart opened? When asked again why she left the medication cart opened, the RN stated, No reason . just busy . and this is my first day. When told about the unlocked and unattended treatment cart that same morning, the RN was unaware, but agreed both carts should be locked when unattended. Observations of the 3S unit during the survey week revealed at least two of the 30 cognitively impaired residents, Resident #71 and Resident #84, were observed independently mobile throughout the unit. Resident #71 was transferred into the 3S unit on 11/16/22. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented the resident as severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 3, on a 0 to 15 scale. Resident #71 was usually in her wheelchair, but was seen by the surveyor independently ambulating from the common area to the nurse's station on one occasion, and from the common area into the staff bathroom in the nurse's station on another occasion. Resident #84 was admitted to the facility into the 3S unit on 01/22/22. Review of the MDS dated [DATE] documented the resident as cognitively impaired with a BIMS score of 5. On at least two occasions during the survey, the resident was noted independently wheeling herself from her room into the common area, the dining room, and back. Because of the location of this resident's room, she would pass by the nurse's station in front of where the medication cart was stored, in order to get to the common area or dining room.

Based on observation, interview, and record review, the facility failed to follow ordered therapeutic diet for 1 of 4 sampled residents reviewed for a special diet (Resident #257). The findings included: On 02/15/23 at 9:30 AM, Resident #257 was observed coughing, and her private duty aid (PDA) was heard yelling at the resident to spit it out. Upon entering the resident's room, the resident was observed spiting out pieces of bacon into a napkin. A review of Resident #257's meal ticket on her breakfast tray revealed a diet of mechanical soft food order. Staff Z, a Registered Nurse, came into the resident's room, looked at the strips of bacon on the resident's tray and said the resident was not supposed to have that. An interview with Speech Pathology (ST) was conducted at Resident #257's bedside on 02/15/23 at 10:06 AM. SP stated the resident should not be eating bacon on a mechanical soft diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure antibiotic stewardship for antibiotic use for 1 of 1 sampled residents reviewed for antibiotic stewardship (Resident #76); and failed to provide antibiotics for infected wound in a timely manner for 1 of 1 sampled residents (Resident #28). The findings included: A review of the facility's policy titled, Antibiotic Stewardship Policy, dated 03/02/21, documented the purpose for our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. When a culture and sensitivity (C&S) is ordered, lab results and current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. 1) An observation was conducted of Resident #76 on 02/14/22 at 11:00 AM. The resident was observed sitting up in bed with a private duty aid (PDA) at his bedside. Resident #76 had a loud coarse wet sounding cough. The PDA stated the resident had had that cough for some time. Record review revealed Resident #76 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment. A review of Resident #76's orders revealed an order dated 11/19/22 for nebulizer/breathing treatment every 4 hours as needed for cough. Orders dated 02/10/23 for cough syrup every 4 hours as needed for cough/congestion for 7 days. Orders dated 02/10/23 for Azithromycin (antibiotics) for a total of 5 days. A progress note dated 02/12/23 documented antibiotics for cough with no adverse reaction noted. No fever. Further review of Resident #76 did not reveal any documentation of any indication for the need for antibiotics. No documented fever or abnormal labs. There was no documentation of Resident #76's condition. A review of Resident #76's Medication Administration Record (MAR) did not reveal any breathing treatments administered for a cough. Furthermore, no cough syrup was administered to the resident for a cough. An interview was conducted with Staff F, a Licensed Practical Nurse, on 02/16/23 at 11:43 AM. Staff F stated the resident's family member was complaining about a cough. Staff F notified medical staff, and received an order for antibiotics. Staff F stated she was not aware of the ordered breathing treatment as needed for cough, or she would have given the medication. 2) Resident #28 was identified as being on Transmission Based Precautions (TBP) because of a wound infection. The resident was admitted to the facility on [DATE] and developed a pressure ulcer of the left heel on 01/30/23. A wound culture was ordered and completed. Review of the laboratory results revealed an MRSA (Methicillin Resistant Staph Aureus) infection that was reported to the facility on [DATE] at 11:31 AM. This report identified which antibiotics were sensitive (meaning appropriate for use), with clindamycin on the report as appropriate for treatment. Review of the physician orders revealed the clindamycin was not ordered or initiated until 02/07/23, five days after the reported infection. Review of the wound care physician's visit report dated 02/06/23 documented the antibiotic choice was clindamycin. During an interview on 02/15/23 at 2:54 PM, when asked the process for receipt of abnormal culture results, Staff F, Licensed Practical Nurse (LPN), explained when a report comes in, they speak with the physician to report the findings and to see if they want any additional orders. When asked what happened with the wound culture for Resident #28 and the delay in antibiotic ordering and use, Staff F stated she was not sure what happened, but she was the one who contacted the physician on the day the clindamycin was ordered (02/07/23). Staff F confirmed she worked on the resident's unit on 02/02/23, 02/03/23, 02/05/23, and 02/06/23, but again stated she did not know how that culture result was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure provision of the influenza (flu) and/or pneumococcal (pneumonia) immunizations for 3 of 5 sampled residents (Resident #21, #78, and #97). Resident #97 was admitted to the facility after November 30th and before March 31st, and the facility failed to ensure the influenza vaccine was administered within 5 days of admission. The facility failed to assess all three residents for the pneumococcal vaccine within 5 working days of admission and provide it within 30 days of admission, as per their own policy. The findings included: Review of the policy Influenza Vaccine revised October 2019 documented, 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. 2. Employees hired or residents admitted between October 1st and March 31st shall be offered the vaccine within five (5) working days of the employee's job assignment or the resident's admission to the facility. Review of the policy Pneumococcal Vaccine revised October 2019 documented, 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission. 1) Review of the record revealed Resident #21 was admitted to the facility on [DATE]. The family representative for Resident #21 consented to the receipt of the pneumococcal vaccine on 09/15/22. Review of the record lacked any evidence of administration of that vaccine. During an interview on 02/16/23 at 9:35 AM, the Staff Developer/Interim Infection Control Preventionist (ICP) explained Resident #21 had infections in September and December that prevented them from administering the vaccine at that time, but agreed as of the survey, Resident #21 still had not received the Pneumococcal vaccine, and had no reason for the delay. 2) Review of the record revealed Resident #78 was admitted to the facility on [DATE]. Review of the record lacked any information related to the offering or administration of the influenza and pneumococcal vaccines. The Interim ICP was asked to locate and provide the information. During an interview on 02/16/23 at 9:28 AM, the Interim ICP provided documentation of consent for both vaccines as of 12/04/22, more than 5 days after admission to the facility. The Interim ICP further stated Resident #78 had a virus the end of December (12/29/22), which would have excluded her from receiving the vaccines at that time, but agreed to the continued lack of administration of both vaccines. 3) Review of the record revealed Resident #97 was admitted to the facility on [DATE]. Further review of the record lacked any information related to the offering or administration of the influenza and pneumococcal vaccines. During an interview on 02/16/23 at 12:34 PM, the Interim ICP provided evidence Resident #97 had consented to receive both vaccines upon admission to the facility, explained the orders were not written and or entered into the electronic system, and thus the resident did not receive either vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure the provision of COVID-19 vaccinations for 3 of 5 sampled Residents (Resident #21, #78, and #97). The findings included: Review of the policy Infection Control: COVID-19 Vaccination - Resident effective 10/19/20 documented, Screening - All residents prior to admission to the home, shall be screened for their COVID-19 vaccination status. Offer of Vaccination - Any resident without evidence of full vaccination status will be educated on the risks and benefits of being vaccinated for COVID-19 and offered the vaccine to be administered upon it's next availability. Evidence of this education and consent or declination will be signed, dated, and scanned to the resident's medical record. 1) Review of the record revealed Resident #21 was admitted to the facility on [DATE]. Further review of the record revealed the resident's last COVID-19 vaccination was 02/07/21, as documented by Florida Shots (a website that tracks all vaccines). The Interim Infection Control Preventionist (ICP) was asked to locate documentation of either a consent or declination for the COVID-19 bivalent booster, the most recent booster available. During an interview on 02/16/23 at 9:35 AM, the Interim ICP explained Resident #21 had infections in September 2022 and December 2022, which would make her ineligible for a COVID-19 booster at that time. When asked the process for obtaining and administering any COVID-19 booster, the ICP explained a list of residents who wish to receive the booster is maintained, and when there are enough residents and staff who want it, they have a COVID clinic to administer the vaccine. The ICP was asked when the last few COVID clinics were held, prior to their December 2022 outbreak. During a subsequent interview on 02/16/23 at 12:36 PM, the ICP stated they had COVID vaccine clinics on 10/11/22, 10/13/22, and 10/28/22. The ICP agreed that Resident #21 had been missed. 2) Review of the record revealed Resident #78 was admitted to the facility on [DATE]. Further review of the record documented consent required under the COVID vaccination information. During and interview on 02/16/23 at 9:28 AM, the ICP explained the resident got COVID-19 the end of December (12/29/22), and review of the previous COVID clinic sign up sheet on 10/28/22 did not capture Resident #78. 3) Review of the record revealed Resident #97 was admitted to the facility on [DATE]. Review of the record documented the resident refused the Bivalent booster. The ICP was asked to locate and provide the education and declination of the booster. During an interview on 02/16/23 at 9:31 AM, the ICP explained she had just spoken to Resident #97 who said she refused the Bivalent booster because she had missed the second booster and thought she did not qualify. The ICP stated she educated the resident today and she subsequently consented to receive the Bivalent booster.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate grievances for 3 of 5 sampled residents (Resident #19, #35, and #70) related to snack preferences and missing personal items. The findings include: Review of the facility's grievances policy reveals that the facility promotes the reporting, investigation and resolution of complaints and grievance regarding resident and non-resident care issues that do not meet the definition of abuse, neglect, exploitation or misappropriation of resident property, initiated by individual patients/residents, their families or representatives, staff or other persons. Furthermore, the facility defines a formal grievance as a written or verbal complaint that is made to the facility by a patient/resident or the patient/resident's representative. During a meeting with the Resident Council members on 11/03/21 at 10:08 AM, some of the residents present raised a concern regarding ice cream that is served. Resident #19 and Resident #70 reported that months ago in their resident council meeting they had reported that they were dissatisfied getting ice cream from the carton while some other residents were getting scooped ice cream. They said that everyone used to get scooped ice cream, but for no apparent reasons the facility changed it and now they served ice cream in a carton/Styrofoam container. Some of the residents residing on the South side of the facility said they do not have that problem anymore, because they now get scooped ice cream. Yet, the residents on the North Side who had complained still did not have their preferences met. Review of the most recent Minimum Data Set (MDS) assessments revealed that Resident #19 & #70 both had a BIMS (Brief Interview for Mental Status) score of 15/15. This data indicates that their cognitive status is intact. In an interview with the Activities Director (AD), she reported on 11/03/21 at 10:09 AM that she usually writes the residents' complaints/grievances. She said that the residents complained about not getting the hand-dipped (scooped) ice cream during the last resident council meeting held in October 2021. She said that some residents currently receive the ice cream served in a Styrofoam cup. The AD said that she documented the complaints in the residents' council minutes, but she did not file a grievance on behalf of the residents. In addition, Resident #35 voiced that she was missing three night-gowns. She indicated that she had reported them missing to Housekeeping, the 1st of October 2021. Record review revealed Resident #35 was admitted to the facility on [DATE]. Her BIMS score was 13/15, indicating intact cognition. Her diagnoses include Anxiety Disorder, Major Depressive Disorder, and Psychosis. In a follow-up interview with the AD on 11/03/21 at 11:17 AM, she stated that she started working with the residents' council about a year ago. She reported that she is still learning the Resident Council process and how to file the grievances. She said that she became aware last Thursday (10/28/21) that Resident #35 had her missing night gowns. she indicated that she has not yet addressed that concern. She has been working with limited staffing resources. She said that she has not reported Resident #35's grievance to anyone. During a meeting with the Social Service Director Assistant (SSDA), on 11/03/21 at 11:47 AM, she reported that she has been working at this facility for more than a year and that she is responsible to address residents ' grievances. She confirmed that she did not yet receive the grievance of Resident #35. She added that she was neither informed about the residents' complaints regarding not getting the scooped ice cream. During an interview with the Food Service Director (FSD) on 11/3/2021 at 1:12 PM, she reported that she was aware of the ice cream issue, which was discussed with the food committee. She reported that the residents on the Northside was given scooped ice cream. However, since there was initially only one resident from the Southside complaining, they did not change the menu for the residents on the South. Consequently, Resident #19, and Resident #70 residing on the Southside did not receive the scooped ice cream as served to the residents on the Northside. The Food Service Director confirmed upon inquiry, that the scooped ice cream is of better quality than what is served in the Styrofoam containers. On 11/04/21 at 02:25 PM, the FSD clarified that she was aware that the residents had complained about the ice cream served since the beginning of the pandemic. She admitted that they had changed from the 'scooped ice cream' to the ice cream in the carton container because of a budget issue. The FSD agreed that they should have given Resident #19 and Resident # 70 scooped ice cream as they desire. Further review of Resident #19's clinical record revealed she is diagnosed with Parkinson's disease, unspecified severe protein-calorie malnutrition, and other recurrent depressive disorders. Review of the Care Plan dated 3/18/20 showed that Resident #19 has nutritional problem related to her Parkinson's disease and risk for malnutrition. During the exit conference on 11/4/2021, the information was presented to the facility, and no additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, facility staff failed to intervene to prevent resident to resident abuse for 1 of 1 sampled residents (Resident #30). Resident #23, a cognitively impaired resident, became verbally aggravated at Resident #30, another cognitively impaired resident, who was yelling/vocalizing a loud noise. Staff failed to intervene and Resident #23 slapped Resident #30 in the face. Furthermore, Staff H, an agency nurse, failed to immediately inform a supervisor of the abuse, as per their own policy. Thirty minutes later Resident #30 began vocalizing the loud noise again, Resident #23 became verbally aggravated again and proceeded to throw a cup of juice at Resident #30, which splashed her in the face. The findings included: Review of the policy Prevention, Identification, Investigation and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property effective 08/01/2017 documented, Policy: (Name of facility), it's employees, consultants, contractors, volunteers and other caregivers, will provide an environment for residents that is safe and free from abuse, neglect, exploitation, mistreatment and misappropriation, treating each resident with respect, dignity and the provision of privacy. Prevention: . The facility will identify, intervene and correct in situations in which abuse, neglect, exploitation or misappropriation of resident property is more likely to occur. 1. Identification: The facility will monitor and assess specific events, occurrences, patterns and trends that may constitute abuse, neglect, mistreatment or exploitation of a resident or the misappropriation of resident property. b. iii. Physical Abuse includes, but is not limited to, hitting, slapping, pinching and kicking. 2. After ensuring the resident is protected, Nursing Home Staff must immediately report to his or her Supervisor or the Administrator any allegation or suspicion of abuse, neglect, mistreatment, or exploitation, including injuries of unknown source as well as any allegation or suspicion of the misappropriation of resident property. During an observation of the 3 South unit's common area on 11/01/21 beginning at 10:48 AM, sixteen residents were noted sitting socially distanced from each other. At 10:55 AM, Resident #30, a cognitively impaired vulnerable adult who was sitting in her wheelchair at a table, began vocalizing a loud noise. Resident #23, another cognitively impaired vulnerable adult sitting in her wheelchair approximately eight to ten feet away, looking out the large picture window, became verbally upset, yelling shut up several times. Resident #30 continued making the noise and Resident #23 turned herself from the window and rolled over to Resident #30. Resident #23 leaned on the table and softly said something to Resident #30, who loudly stated, I don't understand and continued making the noise. Resident #23 reached out and slapped Resident #23's face on her left cheek with her open fingers, then her right cheek with the back of her fingers, then again on her left cheek with her open fingers, in a back and forth motion. Resident #30 yelled out report it . report it. Staff H, an agency nurse, had been standing at her medication cart at the back of the common area near the nurse's station. At this point, the nurse walked over and moved Resident #23 back to the picture window. The nurse went over to Resident #30 and asked her if she was okay. Resident #30 stated loudly, That wasn't nice. She hit me. Report it. The nurse consoled Resident #30 and went back to her medication cart. Both residents settled down. During the continued observation of the 3 South common area on 11/01/21 at 11:09 AM, Staff I, a Certified Nursing Assistant (CNA), was providing juice and snacks to the residents. At 11:21 AM, Resident #30 started yelling out again, making the same loud noise. Resident #23 turned again toward Resident #30 and yelled shut up or get out of here . out out. At 11:25 AM, Staff X, the CNA, provided Resident #23 a full cup of red juice. Resident #30 continued to intermittently yell out and make the noise. Resident #23 wheeled over to the table where Resident #30 was sitting, and threw the juice up in the air and across the table, hitting Resident #30 in the face and down her front. Staff I, the CNA, reported it to Staff J, the Restorative Nurse who had recently arrived on the unit, and to Staff H, the agency nurse. Staff then took Resident #30 to her room. On 11/01/21 at 11:52 AM, the Abuse Coordinator/Risk Manager was noted on the unit talking with staff about the incident. The Abuse Coordinator informed the surveyor she had been informed of one resident throwing juice on another resident. The Abuse Coordinator was asked if she was made aware of any previous incident between the two residents, and she stated, No, is there something else? asking the surveyor for further information. The Abuse Coordinator was asked to speak with the agency nurse to obtain further information, at that time, the agency nurse stated Resident #23 hit Resident #30. The Abuse Coordinator obtained a statement from the agency nurse. On 11/01/21 at 12:03 PM the surveyor provided a statement of the two incidents to the Abuse Coordinator. Review of the record revealed Resident #30, the victim, was admitted to the facility on [DATE]. The resident moved to her current room on 3 South on 11/20/19. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #30 was rarely/never understood, but had short and long term memory problems. Review of the current care plan initiated on 07/10/17 documented Resident #30 has disruptive outbursts on the unit throughout the day that affects other residents. One of the documented interventions was to redirect the resident when she has outbursts to ensure her environment is calm. Other interventions were to intervene before agitation escalated, to guide away from the source of distress, and to engage calmly in conversation. Review of the record revealed Resident #23, the perpetrator, was admitted to the facility on [DATE], with a readmission on [DATE] into her current room on 3 South. Review of the current MDS dated [DATE] documented Resident #23 had a Brief Interview for Mental Status (BIMS) score of three, on a zero to fifteen score, indicating the resident was severely cognitively impaired. Review of the current care plan initiated on 05/24/19 documented Resident #23 is at risk for behaviors associated with cognitive decline. This care plan further documented on 05/22/21 the resident threw a cup of orange juice in the face of another resident. Review of the associated progress notes revealed Resident #23 had thrown the orange juice in the face of Resident #30, related to her yelling out and making noise. During an interview on 11/02/21 at 2:17 PM, Staff I, the CNA in the common area on the morning of the incident of 11/01/21, stated she did not see Resident #23 hit or slap Resident #30. The CNA stated she believes Resident #30 makes the loud noise for attention and that is what upsets Resident #23. Staff X stated Resident #23 has yelled shut up to Resident #30 before, but has not hit or thrown anything at her. During this interview, Staff I confirmed she was at the juice cart (off to the side in the common area), and didn't notice anything until I saw her (Resident #23) throw the juice. During an interview on 11/03/21 at 10:30 AM, Staff K, a Licensed Practical Nurse (LPN) and the nurse who usually works the day shift on the 3 South unit, explained breakfast service starts in the dining room at 8:30 AM for the residents who can feed themselves, then another breakfast service is provided in the resident rooms and in the common area for those that need assistance. The LPN stated the breakfast usually takes about two hours. The LPN explained that after breakfast, staff takes turns watching the residents in the common area, in 30 minutes increments, to ensure the safety of the residents. The LPN explained that the residents have dementia and any little thing can get them frustrated. When asked if she was aware of the altercation between Residents #23 and #30, the LPN stated she was and was shocked, but stated Resident #23 does get upset/triggered by (Resident #30's) noise. Staff K stated Resident #30 has always made that noise. The LPN explained when Resident #30 makes that noise, she usually is stuck or wants something and it needs to be addressed. The LPN also stated when Resident #23 starts yelling shut up she needs to be redirected. During an interview on 11/03/21 at 4:00 PM, the Abuse Coordinator stated she originally found out about the incident when the Restorative Nurse called the Director of Nursing (DON) about the juice incident, as she was sitting in the DON's office at the time. The Abuse Coordinator was asked how she was doing with the investigation. The Abuse Coordinator stated she feels there were two issues. She explained one issue was why the agency nurse did not call somebody immediately after the first incident. The Abuse Coordinator stated the other issue was why did the abuse happen in the first place. The Abuse Coordinator went on to explain all she has done regarding the two incidents, and that the investigation and follow up is still in progress. When asked if she had determined an underlying cause, the Abuse Coordinator stated she was waiting to talk with psych (the psychiatrist) but believes they have been lowering the medications of Resident #23. The Abuse Coordinator also stated that Resident #30 is annoying (to other residents) and they have been trying to address it. When asked if the underlying cause of the abuse could be the failure of the staff to intervene timely between the two visibly upset cognitively impaired residents, the Abuse Coordinator agreed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based in observation, record review and interview the facility failed to promote healing and prevent development of a left heel pressure ulcer for one of one sampled residents reviewed, for pressure ulcer (Resident #82). The findings include: Resident #82 was admitted to the facility on [DATE] with a Brief Interview for Mental Status of 15, which indicates cognitively intact and diagnoses that included Pneumonia, Depression, Diabetes, Pressure Ulcer of the sacrum and buttocks, Deart Disease, Hypertension, and Thyroid Disease. Minimum Data Sheet dated 10/08/2021 documented that extensive assistance was required for all activities of daily living except eating which requires supervision. On 11/01/2021 at 4:05 PM, an observation of Resident #82 revealed bruising and a gauze dressing on her left arm that was unlabeled and falling off. Resident #82 stated she has ongoing issues with her arm weeping fluids. Her left foot and heel were wrapped with an unlabeled loose gauze dressing that the resident stated had not been changed today. On 11/02/2021 at 11:50 AM, an observation of Resident #82 revealed her left foot and heel were wrapped with an unlabeled loose gauze dressing. Beige drainage was noted on the gauze with an exposed blackened wound approximately the size of a quarter. The resident stated the dressing still had not been changed today or yesterday. Staff B entered the room and was shown the residents exposed heel wound by the surveyor. Record review of Resident #82's admission summary dated [DATE] at 22:40 by Staff N states skin assessment reveals bilateral heel redness non-blanchable (discoloration of the skin that does not turn white when pressed). Record review of Resident #82's Care plan dated 10/05/2021 for pressure injury intervention states administer treatments as ordered and observe for effectiveness. Record review of Resident #82's wound evaluation and management by the wound physician on 10/11/2021 stated a thorough wound care assessment and evaluation was performed today which revealed a pressure ulcer on the resident's coccyx and both buttocks with healed wounds on the second and fourth right toes. A diabetic and vascular exam of both feet were performed at that time with no abnormality noted. Both lower extremities were noted to be normal. Record review of progress note dated 10/14/2021 by Staff L states Resident #82's wounds were evaluated stating she has 3 wounds located on the coccyx, right and left buttock. Record review of Resident #82's wound evaluation and management by the wound physician on 10/18/2021 stated a thorough wound care assessment and evaluation was performed today which revealed has an unstageable deep tissue injury of the left heel for at least one day duration. There is no exudate (drainage). The left heel treatment plan was written for skin prep apply once daily for 30 days; off-load wound (minimize weight placed on the area); float heels (positioned in such a way to remove all contact between the heel and the bed) in bed and soft offloading heel boot to be worn in bed (heel boots are used to help prevent the development of heel pressure ulcers). Also documented was the statement that the plan of care was reviewed and addressed. Record review of Resident #82's Carmelites weekly wound documentation dated 10/14/2021 states a total of 3 pressure ulcer wounds, one on the coccyx and one on each buttock. Record review of progress note dated 10/21/2021 by Staff L states Resident #82's wounds were evaluated stating she has 3 wounds located on the coccyx, right and left buttock. Record review of Resident #82's wound evaluation and management by the wound physician on 10/25/2021 stated a thorough wound care assessment and evaluation was performed today which revealed a deep tissue injury partial thickness of the left heel. The treatment plan was written to apply skin prep once a day for 23 days; Off-load wound; Float heels in bed; Soft offloading heel boot to be worn in bed. Record review of Resident #82's Health status note on 11/02/2021 at 12:34 PM by the ADON states the resident had history of non-blanchable redness to the left heel that today is observed to have necrosis (dead black tissue). Record review of Resident #82's wound note by Staff B on 11/02/2021 at 13:45 PM states a skin assessment revealed dark necrotic (dead black) tissue noted on the residents left heel approximately the size of a half dollar piece. The note documents the physician was notified, pain medicine was given, cultures, antibiotics and treatments were ordered for the residents left heel wound. On 11/01/2021 at 4:05 PM in an interview with Resident #82. Resident #82 she stated she has ongoing issues with her arm weeping fluids. She stated she would like heel boots because she rubs her feet on the bed at night and her left heel hurt. She stated she had asked for them a while ago but never got them. She stated she asked several times. On 11/02.2021 at 1:46 PM, during an interview, Staff B stated she was unable to find wound care orders for the left heel wound. She stated the Assistant Director of Nurses (ADON) came to help with Resident #82 and was also unable to find treatment orders for the left heel wound. Staff B said the ADON then called the Resident's physician from the resident's room. Upon the physician's request, she took pictures of the left heel wound with her phone and sent them to him for review. Orders were received at that time for blood flow studies of the leg, wound cultures, antibiotics, and lab blood work. On 11/02/2021 at 2:28 PM in an interview with Resident #82 she stated they just changed my heel dressing. They had not changed it in a week. She went on to say the wound nurse does not listen. I told her my heel hurts. She did not remove the dressing or look at my foot and that was over one week ago. She only looked at my back. On 11/02/2021 at 4:06 PM in an interview with Staff A stated Resident #82 does not have an order for a Soft offloading heel boot to be worn in bed. When asked if the wound care physician wrote in the treatment plan for the resident to have a heel boot would it be ordered, she stated yes it should be. Staff A stated the wound care nurse makes round with the Wound Care Physician and puts the orders in. On 11/04/2021 at approximately 10:00 AM in an interview with Staff L when asked if the wound care physician wrote in the treatment plan on 10/18/2021 for Resident #82 to have a heel boot, should it have been ordered? She replied, definitely it should have been ordered. She stated she has been off for a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the nursing staff failed to ensure blood pressure readings were obtained prior to administration of an antihypertensive medication with physician ordered parameters, for 1 of 5 sampled residents reviewed (Resident #42). The findings included: Review of the record revealed Resident #42 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #42 had a Brief Interview for Mental Status score of 6, on a 0 to 15 scale, indicating the resident was cognitively impaired. Review of the current physician orders documented as of 08/31/21 to give Norvasc (an antihypertensive medication/a medication to lower blood pressure) in the morning daily and to hold it if the systolic (top blood pressure number) was 110 or less. Review of the Medication Administration Records (MARs) for Resident #42 for the months of September, October, and November 2021 lacked any documented evidence of the daily blood pressures. Review of the vital sign record lacked blood pressure readings on 32 of 65 days, between 09/01/21 and 11/04/21. The following days lacked any documented blood pressure reading: 09/07/21, 09/09 - 09/11/21, 09/15/- 09/19/21, 09/21 - 09/24/21, 09/29 - 10/02/21, 10/07 - 10/09/21, 10/11/21, 10/16 - 10/17/21, 10/20/21, 10/21/21, 10/27/21, 10/28/21, and 10/30 - 11/03/21. The blood pressures that were documented in the electronic record revealed the systolic numbers ranged from 111 to 151. Further review of the orders revealed Resident #42 was started on a second antihypertensive medication on 09/01/21. During an interview on 11/04/21 at 3:20 PM, Staff K, a Licensed Practical Nurse (LPN), agreed with the lack of documented blood pressure readings. The LPN stated she always does the blood pressures. When asked where they were documented, the LPN stated they should be on the MAR with the administration of the Norvasc. The LPN further explained whoever entered the physician order into the electronic record, failed to enter it to allow the nurses to document the blood pressure readings on the MAR.

Based on facility policy, observation, and interview, the facility failed to ensure proper labeling of medications in 3 of 5 sampled medication carts observed during the medication cart storage review. The findings include: The facility policy titled Medication Storage in the Facility dated April 2018 provided by the DON, 11/02/2021 states: C. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date. G. All expired medications will be removed from active supply and destroyed in the facility. On 11/02/2021 at 11:00 AM, an observation of Medication Cart #2 on floor 2 South with Staff B revealed the following: 1) Brimonidine 0.2% eyedrops labeled date opened 10/13/2021 Expires 3/2023. Photographic evidence taken. Manufacturer instruction states discard 4 weeks after opening. 2) Latanoprost .005% eyedrops labeled date opened 10/13/2021 Expires 12/2022. Photographic evidence taken. Manufacturer instruction states discard 6 weeks after opening. 3) Tresiba Flex Injectable Pen labeled opened 10/13 Expires 1/2/21. Photographic evidence taken. Manufacturer instruction states discard 8 weeks after opening. 4) Timoptic 0.5% eyedrops labeled 10/13/2021 with no designation of what date is opened or expired. Photographic evidence taken. 5) Latanoprost .005% eyedrops labeled opened 10/18/21 with no expiration date. Photographic evidence taken. 6) Brimonidine 0.2% eyedrops labeled opened 10/24 with no year opened and no expiration date. Photographic evidence taken. 7) Travoprost .004% eyedrops labeled opened 10/18/2021 expires 11/18 with on year of expiration. Photographic evidence taken. 8) Semglee Insulin Pen labeled opened 10/5/21 with no expiration date. Photographic evidence taken. Manufacturer instruction states discard 28 days after opening. 9) Semglee Insulin Pen opened unlabeled for either opening or expiration date. Photographic evidence taken. Upon completion of the 2 South Medication Cart Review, Staff B validated the above findings. On 11/02/21 at 11:10 AM, an interview with Staff B when asked if the medication label documents when a medication is opened and when it expires, she stated yes. When asked how long eye drops may be used after opening, she stated she was not sure and would go ask. Upon returning she said they are good for 28 days. When asked if she goes by the opened/expired label on the medication for when they expire, she stated yes. When shown the 9 medications listed above, she stated none of them were labeled properly. On 11/02/21 at 11:16 AM, an interview with the DON after she was shown the opened/expired labels on the above noted 9 medications from the 2 South Medication cart #2, she stated that they were improperly labeled. She proceeded to correct the labels and stated she would discard the expired insulin and the opened undated insulin. On 11/02/21 at 11:30 AM, an interview with the Facility Pharmacist when asked how often the pharmacy checks the medication carts, she stated monthly, in fact they were just checked this morning. On 11/03/21 at 10:18 AM, during an interview with the Facility Pharmacist she asked for clarification of the potential issues with some of the medications found in the 2 South Medication Cart #2. The pharmacist was informed of the concerns regarding labeling of medications once opened. When shown the Latanoprost .005% eyedrops labeled date opened 10/13/2021 Expires 12/2022 and Brimonidine 0.2% eyedrops labeled date opened 10/13/2021 Expires 3/2023, she stated that was a problem. She went on the state that they have a lot of agency and new nurses and said how difficult it is to keep up with continually training them. When asked if a new nurse might follow the incorrect label, she stated yes. She stated she was going to start in-servicing today how to properly label medications after opening. On 11/03/2021 at 11:30 AM, an interview with Staff M stated she utilizes the documented open/expired labels for the date medications are good to be administered. 2) On 11/01/21 at 11:22 AM, the medication cart located at the 4th floor south was audited for medication storage, 1 bottle of expired aspirin was noted in the cart, the bottle had 13 pills remaining inside of it, on the bottle, there was an expiration date of 9/2021 noted. Staff F, a Licensed Practical Nurse, who was also present during the audit agreed with the finding. 3) On 11/01/21 at 1:19 PM, the medication cart located at the 4th floor North was audited, an expired bottle of Preservision soft gel eye vitamin was noted in the cart, there was approximately 50 pills remained inside the pill bottle, on the bottle there was an expiration date of 09-2021. Staff G, an Agency Nurse, who was present during the audit has agreed with the finding. On 11/03/21 at 4:09 PM, an interview was held with the ADON, she was made aware of the expired medication concerns found in the South and North medication carts, photographic evidence was shown, she agreed with the findings.

Based on observation and interview the facility failed to maintain food preparation equipment in a clean manner. The findings included: On 11/01/21 at 11:26 AM, a tour of the kitchen was conducted with the Food Service Manager (FSM) and the food Service Director. Multiple food-preparation cookware and bakeware were identified as heavily stained, scraped, dented, pitted, and in unsanitary conditions. The identified cookware were: 9 skillets/frying pan of varying sizes, one casserole dish, and one saucepan/pot. The bakeware were two baking trays, and one muffin tray. Concurrent with the tour, an interview was conducted with the Food Service Manager who confirmed that the cookware and bakeware were still being used for food preparation at the facility. During a follow-up visit to the kitchen on 11/03/21 at 1:25 PM, the FSM and the Director showed that they have cleaned up some of the identified pans and discarded the ones that were unsalvageable (photographic evidence retained).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10) On 11/03/21 at 2:22 PM, a side by side record review and interview was conducted with Staff E, an MDS Coordinator, of the Resident Care Plan signature sheet, dated 08/11/21, for Resident #489, as Staff E held the signature sheet, she has indicated this record documented via signatures of the staff who participated in the care plan review and revision process included: MDS, Rehab Director, Dietitian, and Resident #489's niece via phone. The MDS Coordinator confirmed there was no documented evidence of the Direct Care Nurse and CNAs participation in this care plan review. 11) On 11/03/21 at 3:42 PM, a side by side record review and interview was conducted with Staff E of the Resident Care Plan signature sheet, dated 10/14/21, for Resident #77, as Staff E held the signature sheet, she has indicated this record documented via signatures of the staff who participated in the care plan review and revision process included: Activity, MDS, Registered Dietitian, Social Services, and Resident #77's daughter via conference call. The MDS Coordinator confirmed there was no documented evidence of Direct Care Nurse and CNAs participation in this care plan review. 12) On 11/03/21 at 3:45 PM, a side by side record review and interview was conducted with Staff E of the Resident Care Plan signature sheet, dated 09/09/21, for Resident #36, as Staff E held the signature sheet, she has indicated this record documented via signatures of the staff who participated in the care plan review and revision process included: Direct Care Nurse, Activity Director, Registered Dietitian, and MDS. The MDS coordinator confirmed there was no documented evidence of CNAs participation in this care plan review. 13) On 11/03/21 at 3:49 PM, a side by side record review and interview was conducted with Staff E, an inquiry was made of this staff regarding evidence of required IDT members participation in Resident #70's Care Plan review and revision, staff E indicated that she did not have the Resident Care Plan signature sheet, staff E proceeded to review the care plan notes, Staff E revealed the members who participated in the care plan review and revision process included: Social Services, MDS, Registered Dietitian, and Direct care nurse. The MDS Coordinator confirmed there was no documented evidence of CNAs participation in this care plan review. 14) On 11/04/21 at 12:50 PM, a side by side record review and interview was conducted with Staff E of the Resident Care Plan signature sheet, dated 09/09/21, for Resident #39, as staff E held the signature sheet, she has indicated this record documented via signatures of the staff who participated in the care plan review and revision process included: Direct Care Nurse, Activity, Registered Dietitian, MDS, and Resident #39's son via conference call. The MDS Coordinator confirmed there was no documented evidence of CNAs participation in this care plan review and revision. Based on record review and interviews, the facility failed to involve 2 of 20 sampled residents (Residents #35 and #69) in the care planning process. The facility also failed to reflect documentation of Direct Care Nurses and Certified Nursing Assistants participation in the Care planning process of 13 out of 20 sampled residents (Residents #23, 30, 36, 39, 40, 41, 42, 69, 70, 74, 77, 78, and 489). The findings included: 1) On 11/02/21 at 10:35 AM, an interview was conducted with Resident #35. The Resident reported that she was leaving the facility in two weeks and that she had not had a care plan meeting. Resident #35 reported that her son handles her financial affairs, but she is still responsible for her personal care. Review of the facility census record revealed that the resident was admitted to the facility on [DATE]. She is listed as the responsible party. Review of the Care Plan showed that it was initiated on 9/8/2021. During an interview with the Minimum Data Set (MDS) Coordinator, Employee E, on 11/02/21 at 3:32 PM, she reported that she was the one who initiated and developed the resident's care plan. She stated that the resident was not in the meeting because of COVID-19. However, she said that a conference was held with the resident's family member, the Resident's daughter-in-law who is listed in the clinical record as the Emergency Contact Person #1. Furthermore, the MDS Coordinator could not explain why the resident was not invite to be in the phone conference. Review of the MDS (section C) revealed that Resident #35 is alert and oriented. She received a score of 13/15 on the Brief interview for Mental Status (BIMS), indicating intact cognition. Review of the Social Service notes dated 9/8/2021 at 14:28 PM revealed, the care plan meeting was held for Resident #35. Her daughter-in-law was present via phone. They discussed the discharge goal to return home with help, as needed; addressed all questions and concerns; no scheduled discharge date at this time and Social Services to remain available as needed. The Nursing Progress notes dated 9/8/2021 at 15:29 PM showed that an interdisciplinary meeting was held to discuss the resident plan of care. The Resident's daughter-in-law was present via telephone for the conference call. They discussed all the resident's care concerns. The notes did not reflect the resident was physically present or present via phone conference. The MDS Coordinator reported that the Resident's daughter is the first emergency contact, but she did not have power of attorney. Via a phone conversation, the MDS Coordinator confirmed with the Social Worker that the Resident's daughter-in-Law did not have Power of Attorney to act on behalf of the resident. 2) On 11/01/21 at 11:43 AM, during an interview with Resident #69, she reported having no recollection of a care plan meeting nor discussing with anyone about her care. She said that her son has Power of Attorney (POA). The Clinical record showed that Resident #69 was admitted to the facility on [DATE]. The updated care plan (CP) initiated on 7/26/21 revealed, it was completed on 10/26/2021. The CP addressed the care needs of the resident as well as her discharge plan to the community. During an interview with the MDS Coordinator on 11/02/21 at 4:01 PM, she reported that she completed the CP for Resident # 69 on 7/8/2021. She however could not remember whether the resident attended the CP meeting. Review of the CP signature Sheet for the CP reviewed on 7/8/2021 revealed that the resident nor her representative was present during the meeting. Meanwhile, the Dietitian, the Rehabilitation Director, the Activity Director, the Social Services Director and the Director of Nursing signed the record indicating that they were present for the meeting. Furthermore, a request was made to review the signature page for the Initial CP meeting held in April 2021, and the Quarterly CP meeting held in [DATE]. The MDS Coordinator could not provide documentation upon request on 11/02/21 at 04:13 PM. The MDS Coordinator (Employee E) and her assistant (Employee O) reported that the records were probably scanned. They also reported that they were not working at the facility in April 2021. The records could not be found in the scanned documents and were not provided during the survey exit conference. 3) Review of the record revealed Resident #23 was admitted to the facility on [DATE], with a current readmission on [DATE]. Review of the Minimum Data Set (MDS) assessments revealed the most current quarterly assessment was completed on 08/20/21. Review of the corresponding care plan meeting signature sheet dated 08/30/21, which is the facility's mechanism to show Interdisciplinary Team (IDT) participation in the care planning process, lacked any participation from the direct care nurse or the direct care Certified Nursing Assistant (CNA). Resident #23 had known behaviors with the potential to be physically aggressive. The direct care staff would have the most contact with Resident #23 and thus would be beneficial in the care planning process. 4) Review of the record revealed Resident #30 was admitted to the facility on [DATE], with the most current readmission on [DATE]. Review of the MDS assessments revealed the most current significant change assessment was completed on 08/24/21. Review of the corresponding care plan meeting signature sheet dated 09/02/21 lacked any documented participation from the direct care CNA. Resident #30 had known behaviors and was recently admitted to Hospice services. 5) Review of the record revealed Resident #40 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessments revealed the most current admission assessment was completed on 09/05/21. Review of the corresponding care plan meeting signature sheet dated 09/16/21 lacked any documented participation by the direct care nurse or direct care CNA. 6) Review of the record revealed Resident #41 was readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessments revealed the most current quarterly assessment was completed on 09/06/21. Review of the corresponding care plan meeting signature sheet dated 09/14/21 lacked documented participation from the direct care nurse or CNA. Resident #41 was known to be impulsive and was at high risk for falls. Resident #41 ended up having a fall on 09/16/21. Participation by the direct care staff could have revealed a preventative measure to prevent falls. 7) Review of the record revealed Resident #42 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessments revealed the most current admission assessment was completed on 09/07/21. Review of the corresponding care plan meeting signature sheet dated 09/16/21 lacked any documented participation by the direct care nurse and CNA. Resident #42 was also at risk for falls. 8) Review of the record revealed Resident #74 was readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessments revealed the most current quarterly assessment was completed on 10/05/21. Review of the corresponding care plan meeting signature sheet dated 10/12/21 lacked documented participation from the direct care nurse or CNA. 9) Review of the record revealed Resident #78 was readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessments revealed the most current annual assessment was completed on 10/07/21. Review of the corresponding care plan meeting signature sheet dated 10/14/21 lacked documented participation from the Direct Care Nurse or CNA.