Based on resident attorney, medical records company representative, and staff interviews, record review, and facility policy review, the facility failed to provide a written copy of the residents' medical records within two working days of the initial written request for three (Residents #2, #9, and #10) of three residents reviewed for timely access to their medical records. Findings include: An undated facility policy titled, Release of Medical Records indicated, Medical records will be released with a valid request and in accordance with state and federal laws. The policy indicated, 2. Requests for records should be referred to the Director of Nursing or Administrator, or Medical Records Designee, previously designated by [the corporation's name]. The policy revealed, 5. Records Requests/Compliance should be notified of the request for records through the records request email. Records should not be released prior to discussion with a records request/compliance team member, to further validate authenticity of the request. 6. Upon receipt of the authorization request form for medical records, [the corporation's name] should notify the requesting party of the cost for obtaining records [sic] Copies should not be released prior to the receipt of payment for associated charges. 7. Fees for copying medical records are determined according to state regulations. The policy revealed, 8. Once a request for records is received, all records for that resident should be gathered and secured in a place inaccessible to anyone except the records request/compliance team, Administrator, Director of Nursing, or designee. The policy further indicated, Access Rights to Medical Information are as Follows 1. The resident (current resident) - the resident's record is accessible to him/her within 24 hours (excluding weekends and holidays) notice, following an oral or written request. The policy revealed, The resident or his/her legal representative may receive a copy of his/her record within 2 working days after the request has been made. If we need more time to process your request, we can take another 30 days if we notify you that additional time is needed. The policy revealed, 12. Attorneys - the resident or his/her legal representative's authorization must be obtained prior to release of information to attorneys. 1. Review of Resident #2's admission Record indicated the facility admitted the resident on 03/07/2018. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, vascular dementia, and diabetes mellitus. The admission Record indicated the facility discharged the resident on 07/13/2023. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/2023, revealed Resident #2 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term member problems per a staff assessment of mental status (SAMS). Review of Resident #2's Care Plan Report included a focus area, initiated 09/16/2019, that indicated the resident had impaired cognitive function and impaired thought processes related to diagnoses of vascular dementia with behaviors and Alzheimer's disease. Interventions directed staff to use the resident's preferred name, identify themselves during each interaction, face the resident when speaking, and to make eye contact (initiated on 04/30/2020); administer medications as ordered (initiated 09/16/2019); and to anticipate and meet resident's needs (initiated 08/22/2022). During a phone interview on 04/22/2025 at 4:46 pm, Attorney #7 stated their law firm had sent a Letter of Representation to the facility at the beginning of September 2024 and had given them 30 days to produce the requested medical records. Attorney #7 stated that after 30 days had past, a paralegal attempted to reach out to the facility a couple of times without being able obtain Resident #2's medical record for the timeframe from 08/20/2019 through their discharge date . Review of a letter from a law firm to the facility, dated 09/09/2024, indicated they were representing Resident #2 and requested the resident's medical records be sent to them within 30 days. The letter indicated it was sent via first class mail and certified mail and listed the return receipt tracking number. Review of a United States Postal Service request for proof of delivery, dated 09/26/2024 and matching the tracking number listed on the request for Resident #2's medical record, indicated the request was delivered to the facility and signed for by a front desk/receptionist on 09/12/2024 at 12:46 pm. Review of an email dated 10/10/2024 at 10:37 am and sent from the Senior Compliance Officer (SCO) of the facility's hired compliance office to the former facility owners, who owned the facility through 08/19/2024, revealed the SCO shared with them a medical record request and requested confirmation that they received the email and asked if the former owners would like to produce Resident #2's records for the timeframe the facility was under their operations. Review of an email dated 10/10/2024 at 4:39 pm from Medical Records (MR) #12 at the facility to the facility's Records Request email with an attached scanned document revealed the scanned document included the letter from the law firm sent to the facility requesting Resident #2's record. The scanned document also included a HIPAA [Health Insurance Portability and Accountability Act] Compliant Medical Authorization Form, signed by Resident #2's legal representative and dated 08/01/2024, and a signed Affidavit of Kinship signed by Resident #2's family member and dated 08/01/2024. Review of an email dated 10/10/2024 at 4:50 pm from the SCO to MR #12 revealed she informed MR #12 a legal request was signed by Resident #2's next of kin and asked her to ensure all hard copy records had been scanned into the electronic health record (EHR). The email indicated the SCO asked MR #12 to clarify when the request was received at the facility, because the request was dated 09/09/2024, which brought the facility to the 30-day legal response period. Review of an email dated 10/18/2024 at 12:49 pm indicated that the former facility owners forwarded the email from the SCO that was sent on 10/10/2024 to their own Quality Assurance Director in response to Resident #2's record request. Review of an email dated 10/21/2024 at 8:35 am from the SCO to MR #12 indicated that Resident #2's medical records from the current owners had been prepared as requested for the law firm, and the requested certification would need to be notarized prior to the release of the records. The email indicated that an invoice was also attached, and that once the facility received payment, the records and notarized certification could be released to the law firm. Review of an email dated 10/21/2024 at 8:35 am from the previous facility owners to Paralegal #8 indicated that they received the letter of request for records on Friday, 10/18/2024, and had gathered all of Resident #2's electronic records through 08/19/2024. The email requested a response from Paralegal #8 and indicated that they would then provide a link and password to access the requested records. Review of an email dated 10/21/2024 at 3:09 pm from the former owners to Paralegal #8 included the link and password to access Resident #2's medical record for one week to download or print as needed. The entire process took 39 calendar days to obtain Resident #2's medical record. 2.Review of Resident #9's admission Record indicated the facility admitted the resident on 12/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of atrial fibrillation and chronic obstructive pulmonary disease (COPD). Review of an admission MDS with an ARD of 12/09/2024, revealed Resident #9 had a BIMS score of 15, which indicated the resident had intact cognition. Review of Resident #9's Care Plan Report included a focus area, initiated 12/03/2024, that indicated the resident had an activity of daily living (ADL) self-care performance deficit related to weakness and debility. Interventions indicated the resident required one to two staff for bed mobility (initiated 12/03/2024), set up assistance for eating (initiated 12/03/2024), and required one to two staff for transfers (initiated 12/03/2024). Review of the form, Release of Information, dated 02/04/2025, revealed a law firm representing Resident #9 had faxed a medical records request to the facility and included a HIPAA [Health Insurance Portability and Accountability Act] Release Form. The HIPPA Release Form was signed by Resident #9 and dated 01/24/2025. A Facsimile (fax) coversheet indicated the request for Resident #9's records was sent on 02/04/2025 at 6:30 am. Review of an email, dated 02/14/2025 at 7:41 am and sent from Medical Records (MR) #12 to Records Request, indicated that they had received a request for records. An email within the same email chain, dated 02/17/2025 at 8:18 AM, from the SCO of a third party company used by the current facility owners to prepare medical records requests to MR #12 indicated the facility had received a legal request for records for Resident #9 and requested that she ensured all hard copy records had been scanned into the EHR. Review of an email from the same email chain, dated 03/11/2025 at 3:09 am, from the SCO to MR #12 indicated that Resident #9's medical record had been prepared as requested by the law firm. The email indicated that a link was provided for the law firm to access the EHR, and an invoice was attached to the email. The email provided instructions that revealed, Once the facility has received payment, you may release the records. The entire process from the initial request for Resident #9's medical record took 35 calendar days for the requester to have the ability to access the records. 3. Review of Resident #10's admission Record indicated the facility admitted the resident on 12/01/2023. According to the admission Record, the resident had a medical history that included diagnoses of diabetes mellitus, obesity, and hyperlipidemia (high cholesterol). Review of the quarterly MDS with an ARD of 04/15/2024, revealed Resident #10 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. Review of Resident #10's Care Plan Report included a focus area, initiated 12/07/2023, that indicated the resident had an activity of daily living (ADL) self-care performance deficit related to urinary tract infections, diabetes, kidney failure, obesity, arthritis, and neuropathy. Interventions indicated the resident required assistance from one to two staff for bed mobility (initiated 12/07/2023), set up assistance with eating (initiated 12/07/2023), and assistance from one to two staff for toileting (initiated 12/07/2023). Interventions also indicated the resident required the use of a mechanical lift for transfers (initiated 12/07/2023). Review of a letter to the facility dated 08/09/2024 from Resident #10's next of kin (NOK) indicated the NOK requested Resident #10's medical records. The letter indicated it was sent via certified mail. Review of a second letter from a law office representing Resident #10 and their NOK, dated 11/21/2024, provided proof of representation and listed multiple attempts by the law office to contact someone from the facility to assist in obtaining the medical records for Resident #10. The letter indicated the attempts to contact the facility that were unsuccessful were as follows: 09/25/2024, 09/26/2024, 09/30/2024, 10/03/2024, 10/18/2024, 10/22/2024, 10/30/2024 (facility receptionist said they would take the message to medical records staff, but no return call was received), 11/04/2024, and 11/14/2024. Review of an email dated 12/02/2024 at 1:19 pm from Medical Records (MR) #12 to the facility's Records Requests email indicated that she had just received a medical records request for Resident #10 that day. Review of an email dated 12/02/2024 at 1:32 pm from the SCO of a third party company used by the current facility owners to prepare medical records requests to MR #12 indicated that they had received the record request for Resident #10 that was sent in August of 2024. The email indicated that the notice referenced multiple attempts to make contact with the facility regarding the status of the request. The email indicated that the compliance office would get the record together as soon as possible to avoid a complaint and potential fine from the Office of Civil Rights. The email indicated that the facility had only 30 days to process a valid request. The email indicated that if there were still hard copy records, they needed to be sent to the SCO by the end of the business day that day (12/02/2024). Review of an email dated 12/03/2024 at 9:32 AM from the SCO to MR #12 indicated Resident #10's medical record was ready as requested by the law firm and included an attachment of the record. The email requested MR #12 send the invoice for payment that day [12/03/2024], as they were already past the 30-day regulated response time. The email indicated that once payment was received from the law firm, the facility could release the record. From the initial request for Resident #10's medical record to when the record was available for the law firm to access took a total of 116 calendar days. During an interview on 04/24/2025 at 10:16 am, the SCO, who stated she represented the compliance company hired by the facility to compile medical record requests, especially legal chart requests, stated the compliance company attempted to meet the 30-day response time given to them by an attorney's office. She stated that if there were circumstances in which they were busy and not able to meet those deadlines, the company tried to reach out to the lawyer's office to give an explanation for the delay. The SCO stated that when a medical records request was made, the facility received the initial request, then the medical records staff at the facility contacted the compliance company and forwarded the request. The SCO stated that she then contacted the facility's medical records staff and made sure all the hard copy records, if there were any, had been scanned into the electronic health record (EHR) prior to her gaining access to it. She stated the compliance company had remote access to the facility medical records system and was able to pull the information needed, once the EHR was completed from the facility's end. She stated that once the chart was verified as complete by the medical records staff at the facility, the turnaround time for processing a legal medical records request on the compliance end was between 15 and 21 days; however, there had been instances when it took longer. The SCO stated that not only was the compliance office compiling the record into a timeline format, but they were also scanning the documents for areas of liability, informing the company that owned the facility of any potential issues, and verifying the validity of the requestor of the record. She stated verifying was to ensure, for residents with a low BIMS score, that an unauthorized person was not seeking access to the resident's record without the proper permissions. After discussing the federal regulation for providing a resident's medical record to them in full within 48 business hours, the SCO stated it was her company's understanding, after having a conversation with a representative of the Office of Civil Rights (OCR) of Georgia, that the 48 hours regulation only applied to residents who were still actively residing in the facility. She stated that if a resident had been discharged from the facility and requested records afterwards, a 30-day rule applied to provide them with access to the record, like the timeframe provided by most lawyers' offices. She stated the compliance company had never met the 48-hour rule for outside requests for this facility, and often did not even get the initial medical record request from the facility within the 48-hour mark. During an interview on 04/24/2025 at 12:17 pm, the Director of Nursing (DON) stated she knew that when a medical record request was made, the corporate office was notified, who reviewed the record. She stated a resident had to fill out a form to request the record, and she was unsure how long the process usually took. During an interview on 04/24/2025 at 12:37 pm, the Administrator stated residents completed a form for a record request, the form was sent to medical records staff at the facility, and then the request was sent to a third-party company to process. He stated that once the record was compiled for the resident and sent back to the facility, the facility collected the charges for copying the file and then released it to the resident or representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and facility policy review, the facility failed to provide written notice of a room change prior to changing residents' rooms within the facility, which affected 4 (Residents #1, #7, #11, and #12) of 4 residents reviewed for multiple room changes. Findings include: A facility policy titled, Change of Room or Roommate, revised 07/2023, revealed, It is the policy of this facility to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the resident or resident representative. The policy also revealed, 4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. 5.The notice of a change in room or roommate will be provided in writing, in a language and manner the resident and representative understands and will include the reason(s) why the move or change is required. 1. According Resident #1's admission Record, the resident had a medical history that included diagnoses of end stage renal disease with dependence on renal dialysis, congestive heart failure, atrial fibrillation, diabetes mellitus, chronic pain syndrome, and traumatic subarachnoid hemorrhage (bleeding in the space below one of the thin layers that cover and protect the brain) without the loss of consciousness. The admission Record revealed the facility discharged the resident on 09/11/2024. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/17/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of Resident #1's Census report revealed the resident changed rooms on the following dates since their admission on [DATE]: 04/15/2024; 06/03/2024; and 07/05/2024. Review of Resident #1's Progress Notes revealed no documentation of written notification of a room change being provided to the resident or their responsible party on or prior to 04/15/2024. Review of Resident #1's Progress Notes revealed a note, dated 06/03/2024 at 11:22 AM and electronically signed by the Social Services Director (SSD), that revealed the SSD left a voicemail to update Resident #1's responsible party on a room change. The Progress Notes revealed no documentation of prior written notice being provided to the resident, or of a return call or conversation with the resident's responsible party. Review of Resident #1's Progress Notes revealed no documentation that a written notification of a room change was provided to the resident or their responsible party on or prior to 06/03/2024 or 07/05/2024. 2. Review of Resident #7's admission Record indicated the facility originally admitted the resident on 06/28/2021 and most recently readmitted the resident on 01/24/2024. According to the admission Record, the resident had a medical history that included diagnoses of congestive heart failure, schizophrenia, sick sinus syndrome, and paroxysmal atrial fibrillation. Review of an annual MDS with an ARD of 04/10/2025, revealed Resident #7 had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. Review of Resident #7's Census List report revealed the following dates the resident changed rooms following their readmission on [DATE]: 02/06/2024 (two different room changes on the same day); 02/07/2024; 02/08/2024; 09/06/2024; 09/11/2024; 09/12/2024; 09/17/2024; and 12/10/2024. Review of Resident #7's Progress Notes, for the timeframe from 2/01/2024 through 2/10/2024, revealed no documentation of written notifications of room changes being provided to the resident or their responsible party. Review of Resident #7's Progress Notes, for the timeframe from 09/01/2024 through 09/11/2024, revealed no evidence that prior written notification of transfer was provided to the resident or responsible party prior to or on 09/06/2024 or 09/11/2024. Review of Resident #7's Progress Notes revealed a Social Service note, dated 09/12/2024 at 4:24 PM and electronically signed by the Social Services Director (SSD), that revealed a telephone call was made to Resident #7's responsible party to notify them the resident had been moved to another room, however, the Census List report revealed a different room number than that in the note. Resident #7's Progress Notes, revealed no evidence that a written notification of a room change was provided to the resident or their responsible party prior to or on 09/17/2024. Review of Resident #7's Progress Notes revealed a Social Service note, dated 12/10/2024 at 2:38 PM and electronically signed by the SSD, which revealed a telephone call was placed to Resident #7's family member; however, there was no answer and no voicemail was left. The notes revealed no evidence the resident or responsible party was provided written notification of a room change prior to or on 12/10/2024. During an interview on 04/24/2025 at 10:40 am, Resident #7 stated the facility staff had moved them from room to room so many times I cannot remember them all. The resident stated the facility staff did not always give them the choice or tell the resident beforehand. Resident #7 stated the staff come in here and say they have talked to my family about it [the move] and that I am moving. The resident stated that they had never received written notice of a room change. 3. Review of Resident #11's admission Record indicated the facility admitted the resident on 12/16/2023. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, diabetes mellitus, and chronic obstructive pulmonary disease (COPD). Review of a quarterly MDS with an ARD of 03/19/2025, revealed Resident #11 had a BIMS score of 14, which indicated the resident had intact cognition. Review of Resident #11's Census List report revealed the following dates the resident changed rooms since their admission on [DATE]: 01/01/2024; 01/11/2024; 02/28/2024; 02/29/2024; and 08/15/2024. The Census List indicated the resident was transferred to a hospital on [DATE] and readmitted to the facility on [DATE] (nine days later), then changed rooms on 10/24/2024. Review of Resident #11's Progress Notes revealed no documentation on or prior to each of the room changes that the resident or their responsible party was notified in writing of a room change. During an interview on 04/24/2025 at 10:20 am, Resident #11 stated they had been moved several times within the facility and had never been given written notice of the move. The resident also stated that they were often not given any notice of the intent to move from room to room and that staff would just show up and get you and your belongings and don't really give you time to say goodbye. 4. Review of Resident #12's admission Record indicated the facility admitted the resident on 03/10/2023. According to the admission Record, the resident had a medical history that included diagnoses of congestive heart failure, diabetes mellitus, and atrial fibrillation. Review of a quarterly MDS with an ARD of 04/15/2025, revealed Resident #12 had a BIMS score of 15, which indicated the resident had intact cognition. Review of Resident #12's Census List report revealed the following dates the resident changed rooms since January 2024: 01/05/2024 and 01/07/2024. Review of Resident #12's Progress Notes revealed no documentation on or prior to 01/05/2024 or 01/07/2024 that the resident or their responsible party was notified in writing of a room change. During an interview on 04/24/2025 at 10:24 am, Resident #12 stated they had been moved several times from room to room in the facility and had never received a written notice of the room change at any point, either before or after the move. The resident stated, I have never even been given advanced notice of a move or the option to give my opinion about the moves. The staff show up and I am basically told I need to move to a new room because of new admissions or something, and it has never been presented as optional to me. Resident #12 stated there had been times when they (Resident #12) did not want to leave their roommate at the time and would have preferred to stay where they were instead of being moved. During an interview on 04/24/2025 at 10:16 am, Certified Nurse Aide (CNA) #5 stated that during a room-to-room transfer, she helped Resident #12 pack up their belongings and helped get them to the new room. She stated she had never seen a resident get any kind of written notification of a room change. During an interview on 04/24/2025 at 10:23 am, CNA #6 stated when there was a room transfer in the facility, she helped the resident pack their belongings and take them to the new room. She stated she had never seen a resident get any kind of written notification of the room change. noted she had completed many room changes. During an interview on 04/24/2025 at 9:51 AM, Licensed Practical Nurse (LPN) #1 stated that when a resident was being transferred from room to room in the facility, they notified the family and the resident and helped to move their belongings from room to room. She stated there was not any paperwork completed that she was aware of, noting the room number was just changed in the electronic health record (EHR). During an interview on 04/24/2025 at 10:05 am, LPN #3 stated that during an in-house room transfer, she notified the nurses' station associated with the new room, ensured medications were transferred over to the new unit, and contacted the unit manager and the family to let them know. She stated she had never seen any paperwork filled out for a room transfer or written notification of the change given to a resident. She stated the staff just changed the room number in the EHR. During an interview on 04/24/2025 at 10:09 am, Registered Nurse (RN) #4, a unit manager, stated that for a room-to-room transfer, she ensured a CNA knew to assist the resident with the move and that the family was notified of the new room number. She stated she changed the room number in the EHR, took the resident's medications and treatments to the new nurses' station, and gave report to the new nurse. RN #4 stated there was no paperwork involved in a room-to-room transfer, and she had not seen any written notification of the change given to a resident. During an interview on 04/23/2025 at 3:16 pm, the Social Services Director (SSD) stated she was the process owner for room transfers. She stated if a room transfer were to occur, she notified the family of residents whose BIMS scores were low and talked to the residents and asked if they were ready to move that day. She stated they resident was given an option of when the room change would take place. She stated there was not a written notice given to the residents or the family regarding room transfers, noting she was not aware that doing so was a federal regulation. During an interview on 04/24/2025 at 12:17 pm, the Director of Nursing (DON) stated her expectation for a room-to-room transfer was for staff to consider the personalities of the residents prior to the move. She stated that staff were to ask the resident their opinion of a transfer and if a resident was unable to make a decision, staff were to notify the resident's family. The DON stated the SSD documented room changes in the EHR, but there was not currently any paperwork that was filled out or handed out. During an interview on 04/24/2025 at 12:37 pm, the Administrator stated that for room-to-room transfers, they notified the resident and the family verbally and staff made the move as accommodating as possible. He stated he was not aware of a written notice of transfer given to the residents. He stated that EHR documentation was all that the facility had ever completed for room transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident family and staff interviews, and record reviews, the facility failed to notify the responsible party (RP) of new medication orders for one of 63 sampled residents (R) (R315). The facility census was 110. Findings include: A phone interview was conducted on 8/22/2024 at 11:30 am with the daughter of R315. She stated that she was concerned about the lack of concern that the facility had for her mother. She stated that her mother was a holiness (high religious dignitary) and did not believe in taking medications. She then stated that the only thing that she was supposed to be taking was a blood pressure medication. Review of electronic medical record (EMR) revealed that the only conversations between staff and the RP for R315 was on 3/8/2024 and 4/19/2024, not about medication. Review of the medication orders for R315 revealed that the resident was receiving the following medications, but was not limited to Topamax 50 milligrams (mg) by mouth, prescribed on 4/12/2024, Depakote 250 mg by mouth, prescribed on 2/6/2024, Ivermectin 12 mg by mouth, prescribed on 2/6/2024, and Lexapro 10 mg by mouth, prescribed on 12/22/2024. An interview with Registered Nurse KK on 8/22/2024 at 2:15 pm revealed that if she received any new medication orders, she would call the pharmacy, and then follow up until the medication was delivered. She was asked if there was anyone else that should be called and she stated no, except making sure the primary physician knows. An interview on 8/22/2024 at 5:00 pm with the [NAME] Director of Clinical Services revealed that it was his expectation that family and responsible parties were notified of any changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of facility's policy titled, Minimum Data Set, the facility failed to ensure accurate assessment for two of 63 sampled residents (R) (R413 and R68). The deficient practice had the potential to reflect an inaccurate status of the resident's current condition and progress. Findings include: Review of the facility's policy titled Minimum Data Set dated August 2024 revealed a Policy Statement: This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument, (RAI) specified by Centers for Medicare and Medicaid Services (CMS). Item three states, The assessment process will include direct observation and communication with the resident as well as communication with licensed and non-licensed direct care staff members on all shifts. 1. During an observation and interview on 8/19/2024 at 10:30 am, R413 was noted to be alert, oriented, and pleasant. R413 stated he needed some assistance but could get up in the wheelchair, bath himself, use a urinal, and used the restroom for bowel movements. A review of R413's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section H (bowel and bladder) documents presence of Foley catheter. Documentation on R413's medication administration record (MAR) revealed nursing removed the Foley catheter on 8/1/2024. 2. R68 was admitted [DATE] with diagnoses including but limited to neuropathy (numbness that can cause pain and numbness and worsen over time) and back pain. Review of R68 quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicates intact cognition. Section GG (functional status) revealed R68 was independent for activities of daily living (ADLs). Section M (skin assessment status) revealed R68 has one stage two pressure ulcer (open wound where deeper layers of skin are damaged). Section J (health conditions) revealed R68 had no pain issues. Care plan dated 7/11/2024 revealed the resident has potential for pain related to neuropathy, wounds, lumbar disc degeneration, history of urinary retention and complaints of lower back pain. Interventions to administer pain medication. The resident has right hip pressure ulcer with intervention assess/ record/monitor wound healing, measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress and treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. The resident has pressure ulcer development left hip. The resident has pressure ulcer development related to sacral area interventions for all three pressure ulcers same. Review of the Physician's orders dated 6/19/2024 revealed an order for oxycodone/acetaminophen tablet 5-325 milligrams (mg). Give one tablet by mouth every six hours as needed for chronic pain. An observation and interview on 8/20/2024 at 3:24 pm with R68 during medication administration, he stated he was in pain. R68 described pain in both feet which he stated he has had for a long time and took medicine when he needed to. Interview on 8/21/2024 at 1:00 pm with Registered Nurse (RN) LL revealed an expectation of pain assessment was done to include the location of pain, describe the pain, follow the nursing process. He then revealed intervention should be decided based on assessment, orders, and care plan.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to provide scheduled showers/baths for two residents (R) (R10 and R45) dependent on staff for ADLs. The facility census was 110 residents. Findings include: Review of the undated facility policy titled Activities of Daily Living revealed under Purpose: To attain or maintain the patient's highest practicable, physical, mental, and psychosocial wellbeing. The policy revealed under Practice Standards: 1. The Center must ensure that: 1.1 A patient is given the appropriate treatment and services to maintain or improve his/her ability to carry out ADLs; and 1.2 A patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of the electronic medical record (EMR) revealed R10 was admitted with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), hypertensive chronic kidney disease, and unspecified osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment from 7/12/2024 revealed that R10 had a Brief Interview for Mental Status (BIMS) score of 15, which suggests that cognition is intact. Review of a care plan completed for R10 on 4/14/2020 revealed R10 has an activities of daily living self-care deficit related to neuropathy, osteoarthritis, muscle weakness and lack of coordination. During an interview on 8/19/2024 at 3:15 pm, R10 stated that she received showers only once a week due to not enough staff members, but she wanted to receive showers two times per week. Review of the Activities of Daily Living task list from 7/25/2024 to 8/22/2024 revealed that R10 was scheduled for bathing on Tuesdays, Thursdays, Saturdays, and as needed (PRN). The task was marked only one time as complete, on 8/6/2024. 2. Review of the EMR revealed R45 was with diagnoses of but not limited to Parkinsonism, neurocognitive disorder with Lewy bodies, left ankle contracture, right hip contracture, right knee contracture, and right ankle contracture. Review of the significant change MDS assessment from 7/23/2024 revealed that the resident had a BIMS score of 15, which suggests that cognition is intact. Review of a care plan initiated for R45 on 6/3/2022 revealed R45 has a self-care deficit related to Parkinsonism, dementia with Lewy body, contractures, and muscle weakness. Review of Activities of Daily Living task list from 7/25/2024 to 8/22/2024 revealed that R45 was scheduled for bathing on Tuesdays, Thursdays, Saturdays, and as needed. The task was marked complete six out of 13 scheduled times. Interview on 8/22/2024 at 12:50 pm with Certified Nursing Assistant (CNA) AA revealed that CNAs were responsible for entering shower/bath tasks into the EMR. She stated that she started to work in this facility about one month ago and does not know the electronic system very good. CNA AA was not able to pull shower records for the entire month of August. Interview on 8/22/2024 at 1:20 pm with the Regional Director of Clinical Operations and Administrator revealed that the facility had sufficient staffing to provide showers as scheduled, but sometimes residents refused showers. When asked to provide refusal documentation, it was not available. Interview on 8/22/2024 at 3:10 pm, the Administrator confirmed that they did not have any additional documentation showing that R10 and R45 were receiving showers as scheduled.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Activities, the facility failed to develop and introduce an activities program for one of 63 sampled residents (R) (R 413). The deficient practice had the potential to place the resident at risk for a diminished quality of life. Findings include: A review of facility's policy titled Activities dated January 2024 revealed a Policy Statement: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designated to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. An interview and observation on 8/19/2024 at 10:30 am of R413 revealed he was awake and alert, lying in bed. He voiced concern around being moved into this room on 8/15/2024, that there was no television and that was his only entertainment. He was unaware of activities as no one had spoken to him about any activities. R413 further stated that he had asked about a television for several days as he needs something to do. He also stated he did ask the Administrator about getting him a television. A review of facility documentation titled Activities - Initial Review dated 7/26/2024 revealed he liked church services, read the bible, wanted to participate in activities and group activities, additionally indicated he would like to have some independent activities like reading, puzzles, etc. Activities Note also stated assistance should be provided to get resident to activity. An observation on 8/19/2024 at 1:22 pm, R413 had no television for him to watch in his room and had no visit from Activities. An observation on 8/20/2024 at 8:33 am of R413 revealed no television for him to watch in his room or visits from Activities. An observation on 8/20/2024 at 2:22 pm of R413 revealed no television for him to watch in his room. R413 revealed he does not know anything about activities, and no one has spoken with him about activities. He would like to know how to schedule activities. An observation on 8/20/2024 at 2:45 pm, R413 was in a wheelchair leaving his room to go to physical therapy. There was no television for him in his room. An interview on 8/19/2024 at 1:55 pm with the Administrator confirmed he was aware of the need for a television, and it was being worked on. An interview on 8/21/2024 at 4:46 pm with Activities Director (AD) revealed she started each day with smoke break and television in the dining room. The AD revealed the process was that initial assessments were done when admitted and follow up was done in one week. She was not familiar with R413, but will check the records. An interview on 8/22/2024 at 9:00 am AD confirmed there was no additional documentation for activities for R413. An interview on 8/22/2024 at 9:37 am with Administrator revealed an overview of the Activities Department right now was Activities had staffing issues. He further revealed the expected process was the AD would do the initial assessment, follow up, and include residents on relevant activities including one to one (1:1). The Administrator also stated he expected all newly admitted residents would have an activities assessment within 48 hours, then ideally a comprehensive assessment within 21 days. He also revealed the AD was responsible to evaluate and make changes within the care plan and Minimum Data Set (MDS) as needed. The Administrator also confirmed the facility does supply televisions for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and record review, the facility failed to follow the physician's orders for ointment and compression stockings for one of 63 sampled residents (R) (R413). The deficient practice had the potential to place the resident at risk for medical complications, and a diminished quality of life. Findings included: A review of the electronic medical record (EMR) revealed R413 was admitted with diagnoses including, but not limited to, cellulitis of the right lower limb, lymphedema, venous insufficiency chronic, and heart failure. A review of R413's admission Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). A review of R413's Physician Orders dated August 2024 revealed an order dated 8/2/2024 for skin assessment to be done on day shift every Friday. Further review revealed an order dated 8/15/2024 for wound care to bilateral lower extremities and to apply Dermaphor ointment (a moisturizing ointment) to bilateral lower extremities two times a day for dry skin with a start date of 8/15/2024. Continued review revealed an order dated 8/15/2024 for compression stockings every morning, remove at bedtime for bilateral lower leg edema, congestive heart failure with start date of 8/17/2024. An observation and interview on 8/19/2024 at 10:30 am of R413 revealed he did not have compression stockings on, his legs had a reddish-purple discoloration below the knees, and he had extremely dry, scaly skin with very thick areas on his feet building up thicker on the toes. His toes on bilateral feet were edematous and had discolored reddish-blue areas. Further observation revealed a large amount of flaked skin covering the lower area of the bed. During an interview, R431 stated a nurse had removed his compression stockings several days ago, and no one had put them back on. He further stated no one had washed his legs or applied ointment to his legs. Observations on 8/19/2024 at 1:22 pm and 8/20/2024 at 2:45 pm revealed R413's compression stockings were not on. An observation on 8/20/2024 at 4:58 pm revealed R413 sitting in a wheelchair in the dining area. Observation revealed both legs were dark in color, and increased swelling was noted. There were no compression stockings on his legs. An observation of R413 on 8/21/2024 at 11:18 am revealed compression stockings on both legs. In an interview on 8/20/2024 at 4:20 pm, Licensed Practical Nurse (LPN) II stated she was unaware of a physician's order for compression stockings for R413. She reviewed R413's physician's orders and confirmed the order for compression stockings to be put on at 6:00 am and stated the order had not shown on the Medication Administration Record (MAR) for her to place them. LPN II confirmed the order for Dermaphor ointment and stated the wound nurse would complete that. In an interview on 8/20/2024 at 4:30 pm, LPN JJ confirmed the physician's orders for applying compression stockings and applying Dermaphor ointment to R413's legs were on the MAR. In an interview on 8/21/2024 at 1:07 pm, Treatment Nurse LPN FF stated topical treatments for skin were administered by the nurses on the unit. In an interview on 8/21/2024 at 1:20 pm, Registered Nurse (RN) LL stated the Treatment Nurse managed wounds and would look at the skin when needed.

Based on observations, staff interviews, and review of the facility policy titled, Oxygen (O2) Safety the facility failed to ensure O2 tanks were securely stored in a designated location to prevent accidents and hazards for one of eight residents (R) (R163) who use O2. Findings include: A review of the facility policy titled Oxygen Safety detailed 1. Safety is the responsibility of all staff, residents, visitors, and the general public. 4. Oxygen Storage- a. Oxygen storage location shall be in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors or gates that can be secured against unauthorized entry. c. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty. Observation on 8/19/2024 at 11:30 am revealed R163 sitting in a wheelchair in her room. Two O2 tanks (e-cylinder) were in the corner of R163's room between the bedside table and the bed. Both O2 tanks were in an upright position and one of the tanks had no regulator attached and there was a plastic cover on the tank where the regulator should have been. One of the O2 tanks was not in an O2 tank holder. There was an O2 concentrator (machine that makes O2 from room air) on the opposite side of R163's bed with O2tubing and face mask (undated) attached to the concentrator. There was no distilled fluid in the humidifier bottle attached to the concentrator. No O2 in use signage was posted on R163's room door. Review of the record for R163 showed no physician orders for O2 usage. Interview on 8/19/2024 at 11:50 am with registered nurse (RN) Unit Manager (KK), she revealed the O2 tanks were not supposed to be in R163's room. She verified and confirmed one of the O2 tanks was not in a holder. She revealed the O2 tanks have the potential to be dangerous and could cause damage, hurt, or harm to the resident if it fell and it was not secured in an O2 tank holder. The Unit Manager took the O2 tanks from the room and took them to storage area outside the facility. She placed the O2 cylinder with a plastic cover on the tank where the regulator should have been into the empty storage area in direct sunlight. Interview on 8/19/2024 at 12:30 pm with the Administrator, he revealed the O2 tanks should be kept in tank holders, and they should be stored in the storage area outside the facility when they are not in use. The Administrator further revealed the staff should take the O2 tanks out of the residents' rooms and place them in the storage area. He further revealed the maintenance staff would check the O2 tanks on Mondays each week before the tanks were picked up from the facility on Tuesdays. The Administrator revealed the staff received education on the usage and storage of O2 tanks. Interview on 8/19/2024 at 12:41 pm with the Respiratory Therapist (RT) NN confirmed the plastic cover on the O2 tank meant the tank was full. She revealed the full tanks go in the full side of the storage area and empty tanks go in the empty side of the storage area. The RT confirmed the staff would know the O2 tank was full if the plastic cover was on the tank. The RT revealed it was the staff's responsibility to remove the tanks from the residents' rooms and education on O2 tank usage and storage were provided to the staff. She revealed the O2 tanks had the potential to cause injury or harm to the resident if it fell and it could become a torpedo if it was not secured in an O2 tank holder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility's policies titled, Medication Administration, and Pain Management, the facility failed to ensure pain management was provided for one of two residents (R) (R68) reviewed for pain management. The deficient practice had the potential of unmet needs and a diminished quality of life. Findings include: A review of the facility's policy titled Medication Administration dated January 2023 revealed a Policy Statement as follows: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent infection or contamination. A review of the facility's policy titled Pain Management dated August 2023 revealed a Policy Statement as follows: The facility must ensure that pain medication is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Further review under Policy Explanation and Compliance Guidelines, revealed: The facility will use a systemic approach for recognition, assessment, treatment, and monitoring of pain. Under the section titled Recognition, item one stated: To help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain the facility will: item c. stated: Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. A review of the electronic medical record (EMR) revealed R68 was admitted to the facility with pertinent diagnoses including but was not limited to pain in right leg, pain in left leg, low back pain, other intervertebral disc degeneration, lumbar region, hereditary and idiopathic neuropathy. A review of R68's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicates R68 was cognitively intact. Section GG, functional status, revealed R68 was dependent for activities of daily living (ADLs). Section M, skin assessment status, revealed R68 has three stage one pressure ulcer. Section J, health conditions, revealed R68 was not in pain. Review of R68's care plan updated 7/11/2024 indicated resident has potential for pain related to neuropathy, wounds, lumbar disc degeneration. Monitor/document for side effects of pain medication. Interventions are to administer pain medication as ordered, attempt non-pharmacological interventions for pain; i.e. re-positioning, relaxation therapy/music, bathing, heat and cold application, muscle stimulation, ultra-sound. A review of Physicians Order 7/19/2024: oxycodone acetaminophen oral tablet 5-325 mg (milligrams) (oxycodone with acetaminophen) give one tablet by mouth every six hours as needed for chronic pain. Observation on 8/20/2024 at 9:05 am during medication administration, R68 complained of pain in both feet at level seven out of 10. Licensed Practical Nurse (LPN) II checked medication orders, opened the narcotic box and found R68 had none of the prescribed medication in stock. LPN II asked Unit Manager (UM) LPN JJ to check the emergency management back up medication dispensing system to see if the prescribed medication for chronic pain was available, and she agreed. During an interview on 8/20/2024 at 9:27 am LPN JJ returned and stated there was no oxycodone acetaminophen available in the emergency management back up medication dispensing system and stated it was requested from physician yesterday, she further instructed LPN II to administer Tylenol. LPN JJ stated she will resend the request for the oxycodone to physician. During an interview and observation on 8/20/2024 at 3:40 pm with R68, found he was lying in darkened room, head covered with blanket, easily aroused when knocked on door, R68 revealed he is still in pain; however, he stated pain has increased from seven to eight out of 10. He revealed he has gotten no relief from the medication given earlier, and further stated no one has been back to check on his pain. An interview on 8/20/2024 at 3:48 pm with LPN II revealed the oxycodone acetaminophen oral Tablet 5-325 mg has not come in yet and she did not followed up with resident's pain level. Interview on 8/20/2024 at 3:50 pm, with LPN JJ revealed there had been a new order signed just after 9:30 am this morning and she will go get it out of the emergency management back up medication dispensing system. LPN JJ revealed the process for pain management is nurse would check his pain in one to two hours after, assess and if needed reach out to the provider. LPN JJ confirmed it has now been around six hours and this is not the normal process the staff should be following. LPN JJ states she can obtain medication after getting code from pharmacy. LPN JJ confirmed once the order was signed by the physician the medication could have been retrieved from the emergency management back up medication dispensing system for administration. An interview on 8/21/2024 at 1:00 pm with the RN LL revealed his expectation of pain management consists of an assessment being done with location of pain, description of the pain, and following the nursing process. He confirmed pain should be re-assessed in one to two hours depending on intervention and it is unacceptable for a resident to be left in pain especially for more than six hours. a review of Nurses Note dated 8/20/2024 at 4:09 pm, revealed LPN II administered oxycodone-acetaminophen medication for chronic pain. A review of Nurses Note dated 8/20/2024 at 5:33 pm, revealed LPN II, documented follow up and pain was now a zero.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and review of the facility's policy titled, Medication Storage, the facility failed to lock the medication cart for one of two medication carts; and found expired, used and new items co-mingled in bags, sink, and storage box in one of two medication storage rooms. The deficient practice had the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart and staff to use contaminated items. The facility census was 110 residents. Findings include: A review of the facility's policy titled Medication Storage dated [DATE] revealed under General Guidelines: a. all drugs and biologicals will be stored in locked compartments under proper temperature controls. b. During a mediation pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 8. Unused medications: the pharmacy and all medication rooms are routinely inspected by the consult pharmacist for discontinued, outdated, defective, or deteriorated, medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our destruction of unused drugs policy. An observation on [DATE] at 8:45 am revealed Licensed Practical Nurse (LPN) II walked away from a medication cart and entered a resident room leaving the medication cart unattended. An interview on [DATE] at 8:48 am with LPN II, she confirmed the cart was not locked, and stated she forgot to lock the cart. On [DATE] at 10:20 am a tour of the medication storage room at the end of the 100 hall near the nursing station, escorted by LPN MM revealed the medication storage room had one side with a countertop and sink, directly across were some shelves hanging shoulder level with plastic storage containers with drawers, on the floor under those shelves were boxes, a brown bag, a laundry hamper full of medication in patient medication cards, and more brown bags full of various pharmacy items. The top shelf drawer contained a Foley Catheter with first layer of plastic wrapping open, inner layer closed, and an expiration date of [DATE]. The laundry basket with a lid unable to be fully closed, full of resident medication cards, was awaiting disposal. The sink was filled with various items including three, one-liter bags of intravenous (IV) fluids, one with a half torn patient label, several IV tubing sets, one with thick, white liquid in the drip chamber and tubing, one intravenous start kit, and an oxygen nasal cannula. An interview and review of item on [DATE] at 10:25 am with LPN MM revealed she would not have used it since it's open and before using she checked packaging and expiration date. LPN MM confirmed process for used tubing was to discard in the closest trash can and remove the bag from the resident room. An interview on [DATE] at 10:30 am with RN KK confirmed as Unit Manager she was responsible, and she organized the medication storage room yesterday, [DATE]. Upon viewing the sink and tubing with white fluid she stated, why would they do this? several times. She confirmed the used items should have been discarded and not returned to the medication storage room. She added the IV fluid bags should be sent back to the pharmacy with the other items, and they were not reused. LPN KK further confirmed brown bags full of items were not marked Do Not Use, although they should not be used, and the nurses know this, adding the pharmacy was supposed to have picked all of them up yesterday. LPN KK further revealed staff would not use them because they were aware they were to be returned, and confirmed there was no indication on the bags not to use the items. An IV box was observed on the counter underneath the brown bags with a content list on the box, with no expiration dates. The box was locked with a white plastic, break away lock.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Documentation in Medical Record, the facility failed to maintain accurate documentation of care and services provided for one of 63 sampled residents (R) (R413). Findings include: A review of the facility policy titled, Documentation in Medical Record, dated November 2023, revealed the Policy Statement stated, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents' progress through complete, accurate, and timely documentation. The section titled Principles of Documentation section three included a. Documentation shall be factual, objective, and resident centered. False information shall not be documented. A review of the clinical record revealed R413 was admitted on [DATE] with diagnoses including, but not limited to, cellulitis of the right lower limb, lymphedema, venous insufficiency chronic, and heart failure. A review of R413's admission Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment. A review of the Physician Orders revealed orders dated 8/2/2024 for a skin assessment to be done on the day shift, open skin check form, and complete from user-defined assessment every day shift every Fri for Skin surveillance with a start date of 8/2/2024. Further review revealed an order dated 8/15/2024 for wound care to bilateral lower extremity. Apply Dermaphor ointment to bilateral lower extremities two times a day for dry skin, start date, 8/15/2024. Continued review revealed an order dated 8/15/2024 for compression stockings every morning and remove at bedtime, for bilateral lower leg edema and congestive heart failure with the start date of 8/17/2024. A review of the medication administration record (MAR) dated August 2024 revealed the wound care order was documented as performed on 8/16/2024 at 9:00 am and 6:00 pm, 8/17/2024 at 9:00 am and 6:00 pm, 8/18/2024 at 9:00 am and 6:00 pm, and 8/19/2024 at 9:00 am. Further review of the MAR revealed the compression sock placement at 6:00 am and removal at evening/bedtime was documented as performed on 8/17/2024, 8/18/2024, and 8/19/2024. A continued review of the MAR revealed documentation that revealed the removal of an indwelling urinary catheter on 8/1/2024. Assessment of the catheter was documented as completed on 8/3/2024 in the pm, and twice daily from 8/4/2024 through 8/18/2024. Indwelling urinary catheter care was documented as performed on 8/3/2024 in the pm and twice daily from 8/4/2024 through 8/18/2024. Observations on 8/19/2024 at 10:30 am and 1:22 pm revealed that R413 did not have compression stockings on. In an interview on 8/19/2024 at 10:30 am, R413 stated no one had applied ointment to his legs. In an interview on 8/20/2024 at 4:30 pm, Licensed Practical Nurse (LPN) JJ confirmed both the physician's order for compression stockings and application of Dermaphor ointment to R413's legs were on the MAR and were documented as provided. She stated both needed to be addressed and walked away. In an interview on 8/21/2024 at 1:20 pm, Registered Nurse (RN) LL confirmed the documentation of the compression stockings and application of the Dermaphor ointment. He further confirmed the documentation of the urinary catheter assessment and care, which was documented after the removal of the catheter. He stated his expectations were for staff to document what they do and not falsify documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation on 8/20/2024 at 8:45 am revealed LPN II began to prepare resident medications and had to go to the medication storage room to retrieve multivitamins at which time she did not perform hand hygiene when returning to medication preparation. An interview on 8/20/2024 at 8:48 am with LPN II confirmed she did perform hand hygiene when she left resident before room but confirmed she did not after leaving the medication cart to go to the medication room and returning to complete medication preparation. Based on observations, record review, staff interviews, and review of the facility's policies titled, Catheterization of a Male, Infection Prevention and Control Program, and Transmission-Based Precautions, the facility failed to maintain infection control protocol during indwelling urinary catheter insertion for one of seven residents (R) (R15) with an indwelling catheter, to perform hand hygiene during medication administration for one resident (R53), and to keep doors closed for contact isolation in two of four residents (R23 and R25) on contact isolation. The deficient practice had the potential to cause infection and adverse health outcomes. Findings include: Review of facility's policy titled Catheterization of a Male revised August 2024 revealed under Policy: Urinary catheterizations will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma. Review of the facility's policy titled Infection Prevention and Control Program with a revision date of May 2023 revealed that when a resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by the current Centers for Disease Control (CDC) guidelines. Residents will be placed on the least restrictive transmission-based precautions for the shortest duration possible under the circumstances. Review of the facility's policy titled Transmission-Based Precautions with a revision date of 9/12/2022 revealed that any resident with a diagnosis of scabies, should be placed in contact precautions until twenty-four (24) hours after initiation of treatment. 1. R15 was admitted with diagnosis included but not limited to muscle weakness (generalized), cerebrovascular disease and benign prostatic hyperplasia (BPH). Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognition) a Brief Interview of Mental Status (BIMS) score of 15, which indicates intact cognition, Section GG (Functional Abilities) R15 was independent for eating and personal hygiene and dependent on staff for toileting. Review of care plan dated 8/2/2024 included but not limited to: The resident has Foley catheter related to neurogenic bladder size 18 French (FR)/10 cubic centimeters (cc). The resident will remain free from catheter-related trauma through review date. Catheter: Change per MD orders. Review of Physician ' s orders dated 8/19/2024 revealed orders included but not limited to: Foley catheter 18FR with 10cc balloon to bedside straight drainage for diagnosis/history of BPH benign prostatic hyperplasia). May change when Foley catheter is occluded, leaking or obtaining a new specimen as needed for BPH and every shift. May change Foley catheter when occluded, leaking, or to obtain urine specimen as needed for catheter care. Review of Physician ' s orders dated 8/31/2024 revealed orders included but not limited to: Change Foley Catheter monthly per MD (medical doctor) order as needed for catheter care every night shift starting on the last day of month, Change per night shift. Observation on 8/21/2024 at 2:31 pm revealed R15 in his room with Licensed Practical Nurse (LPN) FF preparing to change his indwelling catheter. R15 was on Transmission Based Precautions, signage on door. R15 complained of pain and unit Licensed Practical Nurse (LPN) EE gave him pain medication. LPN FF wore PPE (personal protective equipment) and provided privacy around R15's bed. LPN GG, Regional Skin Specialist was in attendance. LPN FF explained the procedure to R15 and assessed if he had pain. R15 stated he was not in pain and gave consent for her to start the procedure. LPN FF performed hand hygiene, donned (put on) gloves and cleaned R15's perineal (groin) area. She positioned R15, provided privacy and provided drapes to protect bed clothing. She began the procedure utilizing personal cleaning wipes, she performed perineal care and cleaned the insertion site of the indwelling catheter. LPN FF then removed gloves, performed hand hygiene with soap and water, and donned clean gloves. She withdrew 20 milliliters (ml) of clear fluid from the indwelling catheter bulb, then she slowly removed the indwelling catheter. She disposed of the indwelling catheter and drainage bag system in the receptacle beside the bed. She then removed gloves, performed hand hygiene with soap and water, and donned clean gloves. She then cleaned R15's penis starting at the tip working in a circular motion around where the urinary meatus (opening) should be, using a betadine swab down the shaft of the penis to the surgically created urinary meatus, cleaning the entire area with three swabs. She then placed a drape under the penis and placed the head of the penis on the drape. She disposed of her gloves, performed hand hygiene with soap and water, donned sterile gloves, opened supplies and attached the drainage bag to the bed frame. LPN GG suggested she change her gloves since she touched non-sterile packaging with her sterile gloves. LPN FF removed the gloves and disposed of them in the receptacle beside the bed. She did not perform hand hygiene, donned sterile glove on her right hand then picked up the other glove, fanned it in the air to open and donned glove on her left hand touching the inside of the glove with the other sterile glove. She used the sterile gloves to pick up the unsterile packet with the catheter and removed the outer packaging with the sterile gloves then removed all of the inner sterile packaging. She gathered all the catheter tubing in her hand, placed lubricant on the tip of the catheter and was about to insert the catheter when the surveyor stopped her. Review of education provided on Personal Protective Equipment (PPE) Competency Validation revealed LPN FF in attendance on 9/12/2023. Review of education provided on Hand Washing Competency Validation revealed LPN FF in attendance on 9/12/2023. Review of Validation Checklist Catheterization (Male) revealed LPN FF completed competency check on 9/12/2023. Interview on 8/21/2024 at 2:48 pm with LPN FF and LPN GG revealed: LPN FF acknowledged, confirmed and verified she did not maintain infection control protocol by not sanitizing her hands when she changed her sterile gloves. She confirmed and verified she did not maintain sterile procedure when she fanned the gloves in the air to open them which touched her wrist. She confirmed and verified she did not maintain infection control protocol when she coiled the catheter in her hand without its sterile packaging. She stated she should have sanitized her hands between sterile gloves change and she should have maintained sterile technique throughout the procedure and after donning sterile gloves. Interview on 8/21/2024 at 2:55 pm with LPN GG, she confirmed LPN FF did not maintain infection control protocol when she did not sanitize her hands between sterile gloves change, when she fanned the gloves in the air to open them which touched her wrist and when she coiled the catheter in her hand without its sterile packaging. LPN GG stated LPN FF should have maintained sterile technique throughout the procedure and after donning sterile gloves. She stated her expectations were for LPN GG to maintain sterile technique during catheter insertion and the highest possible outcome was infection to R15. Interview on 8/22/2024 at 12:55 pm with the Regional Director of Clinical Services revealed staff competencies were reviewed at orientation or during onboarding, and education was provided on certain topics periodically whenever the need arose. He revealed handwashing and use of PPE education were provided to the staff annually and as needed. He further stated that LPN GG also conducted education and competency checks to the staff annually and periodically. He further stated that his expectations were for the staff to always maintain the highest standard of practice when providing care and in the event of staff not maintaining sterile technique during catheter insertion, the highest possible outcome of not maintaining sterile technique was the possible development of an infection. 3. Review of the EMR for R23 revealed that he was admitted to the facility with diagnoses that included but were not limited to tremor, depression, anxiety, dementia, delusional disorder, schizoaffective disorder, and traumatic subdural hemorrhage. Review of the Dermatology note dated 8/15/2024 revealed that skin scaping results for R23 came back positive for Methicillin Resistant S. aureus (MRSA) and scabies. The review also revealed that resident was to be isolated and that the plan was to re-scrape at follow up visit and for staff to continue to monitor the resident. An observation occurred on 8/22/2024 at 10:34 am. The door to R23 room had a contract precautions door signage. On that sign revealed that the door was to remain closed. Resident was noted in the room, dressed, walking around. An observation occurred on 8/22/2024 at 5:10pm. The room door for R23 was noted to be open. Review of the EMR for R25 revealed that he was admitted to the facility with diagnoses that included but were not limited to legal blindness, vitamin deficiency, hypertension, unilateral inguinal hernia and history of COVID-19. Review of the progress note for the Dermatologist for R25 dated 8/15/2024 revealed that the resident had scabies throughout his trunk and contact dermatitis located on the left leg and trunk. An observation on 8/21/2024 at 4:40 pm of the R25 revealed the resident was in his room, walking around, pushing his wheelchair throughout the room. It was noted that there was a Contact Precautions sign on his door, and the door was noted to be open. An observation of the room of R25 occurred on 8/22/2024 at 10:45 am. The resident was noted sitting in his wheelchair, dressed. The door to his room was open and Contact Precautions signage was visible on his door. An interview on 8/22/2024 at 4:50 pm with the Infection Preventionist revealed that it was her expectation that the doors to the transmission-based precaution rooms be closed. She then stated that she expects staff to use proper PPE in transmission-based precaution rooms, because keeping the doors closed and the use of PPE are ways to prevent the spread of infection.

Based on observations, staff interviews, and review of the facility's policies titled, Sanitation, Refrigeration and Freezer, Food Receiving and Storage, and Food Preparation and Service, the facility failed to discard dry and frozen food by expiration dates, ensure proper food labeling, storage and dates, follow puree recipe, perform proper thawing procedure, and maintain proper sanitary conditions of two of two ice machines. The deficient practice had the potential to affect 108 residents who receive an oral diet from the kitchen. The facility census was 110 residents. Findings Include: Review of the facility policy titled Sanitation dated April 2024 revealed under 12. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy.16. The Nutrition Service Manager will be responsible for scheduling staff for regular cleaning of the kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Review of the facility policy titled Refrigeration and Freezer dated April 2024 revealed under 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases storage. Use by dates will be utilized on all prepared food in refrigerators. Expiration dates on unopened food will be observed and adhered to. Use by or open dates will be labeled on food items once opened. 8. Supervisors will be responsible for ensuring food items in pantries, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes. Review of the facility policy titled Food Preparation and Service dated April 2024 revealed the following under Thawing Frozen Food b. Submerging the item in the cold running water (70 F (Farenheit) or below). Review of the facility policy titled Food Receiving and Storage dated April 2024 revealed under 6. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated. Such foods will be rotated using a first in first out system. Observations during the kitchen tour on 8/19/2024 at 9:05 am with the Dietary Manager (DM) revealed in the walk-in refrigerator nine bowels of peaches, 32 prepared liquid gelatins in bowls, 30 prepared gelatins with fruit in bowls, four yellow like puddings in drinking cups, and three red like liquids in cups without correct wrapping storage, labeling, and dates. The freezer revealed two medium sized bags; one clear bag and one blue bag with unidentified frozen meat, one white like cream substance, and one clear wrapped french fries pack without proper labeling and dates. Observation of dry storage foods revealed 30 single packs of thickened coffee, eight 24 ounce gelatin bags, and two 32 ounce honey cartons with expired dates. The DM confirmed expired items, immediately discarded, and mentioned all three morning kitchen staff including himself were responsible for checking labeling, storage, and dates. The DM and Dietitian confirmed food was ordered and rotated out when food trucks deliver. Observation of black like substance on ice machines and confirmed substance by DM from white paper towel. The DM revealed dietary staff were responsible to clean the ice machines monthly, but no log was presented, and maintenance deep cleaned the ice machines quarterly. Maintenance provided cleaning log from the electronic maintenance work order system. Cleaning log revealed the last deep cleaning was 5/31/2024. Observation on 8/20/2024 at 11:27 am revealed three five-pound ground beef meats in a large sink thawing under steaming hot running water. Observation on 8/20/2024 at 11:27 am with [NAME] DD revealed morning cook not following the recipe puree process for eight residents who received pureed food. [NAME] DD confirmed she put beef base on 12 uncooked boneless pork ribs meat for baking process in place of pouring into the Robot Coupe (robotic arm) during the puree process. [NAME] DD mentioned it was her little trick to prevent meat from being dry. Observed [NAME] DD pour two cups of hot water into the puree. [NAME] DD confirmed she doesn't usually do that. Observation on 8/20/2024 at 12:37 pm revealed seven 60 fluid ounces of apple juice in emergency preparedness with expiration date of 4/24/2024. Interview on 8/21/2024 at 3:46 pm, the Dietitian confirmed she noticed the high temperature running water on frozen meat. She informed cook to make immediate correction.

Based on observations, staff interviews, record review, and review of the facility policy titled, Handwashing and Hand Hygiene, the facility failed to follow proper infection control practices to prevent the spread of disease for one of seven sampled Residents (R) (R1). Specifically, staff entered R1's room, who was on contact isolation, without washing their hands or wearing gloves and a gown. Findings include: Review of the undated facility policy titled Handwashing and Hand Hygiene revealed under Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents. and visitors. 1. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty. b. Before and after direct contact with residents. c. Before preparing or handling medications. i. After contact with a resident's intact skin. m. After removing gloves. n. Before and after entering isolation precaution settings. p. Before and after assisting a resident with meals. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. Review of the electronic medical record (EMR) for R1 revealed the resident was admitted with diagnoses including, but not limited to acute renal failure, diarrhea, and possible clostridium difficile, and Urinary Tract Infection Methicillin Resistant Staphylococcus Aureus Infection (MRSA) meaning contagious bacteria resistant to antibiotics treatment. Review of R1's care plan dated 1/4/2024 revealed R1 had MRSA and was on contact isolation. The care plan directed staff to wear gowns and masks when in contact with R1. Observation on 6/11/2024 at 10:30 am revealed a red sign on R1's door which read Contact Precautions and instructed staff to sanitize hands before and after contact with R1. The sign also instructed staff to wear gloves before contact with R1. Observation on 6/11/2024 at 10:40 am showed Licensed Practical Nurse (LPN) AA in the hallway, behind a medication cart preparing medications. LPN AA did not wash or sanitize her hands before she entered R1's room, without a gown or gloves, and gave R1 his medication. LPN AA left the room and did not wash or sanitize her hands. LPN AA was observed touching the resident's empty water cup and proceeded to the medication cart when R1 asked LPN AA for a missing pain pill dose. LPN AA returned to R1's room, did not don (put on) a gown or gloves, and informed R1 that his pain medication was due later. LPN AA proceeded to her medication cart and did not wash or sanitize her hands and proceeded preparing medication for another resident. During an Interview with LPN AA on 6/11/2024 at 11:05 am, LPN AA revealed she forgot R1 was on contact isolation and did not read the sign on R1's door. LPN AA stated she should have washed her hands and donned gloves before and after contact with R1, as per facility policy. During an interview with the Infection Control Preventionist (CP) CC on 6/11/2024 at 2:20 pm. Confirmed R1 was on contact isolation precautions. CP CC stated she expected all staff to wear gowns and gloves before staff entered R1's room. CP CC revealed she expected staff to wash their hands before and after contact with R1. CP CC stated staff were instructed to wash their hands before entering R1's room, don gloves, wear a gown, and wash their hands after contact with R1. CP CC confirmed that LPN AA did not follow proper facility infection control procedures. During an interview with the Director of Nursing (DON) on 6/11/2024 at 2:30 pm, the DON stated that the facility placed a sign and Personal Protective Equipment (PPE) on R1's door as a reminder to staff and visitors to follow infection procedures when entering R1's room.

Based on resident's family and staff interviews, and record review, the facility failed to provide written notification to the resident, the resident representative (RP), or the family, with an explanation of why the move to a new room was required for one of one Resident (R) (R#20). Findings include: Review of the Electronic Medical Records (EMR) for R#20 revealed on the census tab R#20 was moved from a private room to a semiprivate room on 12/30/2022. Review of the EMR for R#20 revealed there were no written notices related to moving R#20 from a private room to a semi-private room. Interview on 6/20/2023 at 9:06 p.m. with family member of R#20. They stated R#20 was moved from a private room to a semi-private room on a covid unit while he was at dialysis. They stated he found out about the move after he returned. They reiterated that no one asked him if he wanted to move or if he minded moving, they revealed it was a shock to him to return from dialysis and be taken to a new room. She stated the staff moved his belonging while he was out of the building without his permission. She stated the family was not notified of this move. They discovered the move when they came to visit him. Interview on 6/22/2023 at 4:00 p.m. with the Social Service Director revealed reasons residents are moved to new rooms are by request of the resident, need for a gender specific room, and sometimes because families request the move. She stated in every instance the resident is involved in the move. She stated they will ask the resident prior to moving if it is ok and they will show the resident the new room prior to moving. She stated she did not remember R#20. Interview on 6/23/2023 at 9:00 a.m. with the Director of Nursing (DON) revealed she expected the staff to speak with the resident and gain permission from them to move prior to moving. During the move the resident should be present to help direct placement of their personal items.

Based on staff interview, record review, and review of the facility's policy titled, Abuse, Neglect, and Exploitation, the facility failed to report misappropriation of property for one of one Resident (R) (R#36). Specifically, an allegation of misappropriation of resident's property was not reported to the State Survey Agency or to law enforcement in a timely manner. Findings include: Review of the facility policy titled, Abuse, Neglect, and Exploitation, revised 9/8/2022, revealed under VII Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the facility's document Facility Report Incident Form dated 9/28/2022 revealed resident stated her watch was missing for a month. She was unsure when she last saw it. The facility initiated a search. The facility will continue to search for the watch. A lockbox was offered to the resident to store items when not in use. Review of the facility's document Facility Incident Follow-up Investigation Report dated 10/05/2023 revealed resident voiced to staff that she misplaced her Apple Watch. The resident stated that she had not seen the watch for over a month. The Social Worker and Nurse Manager assisted the resident in trying to locate her watch. The {sic} [resident's] room and laundry department were searched. The statement obtained from staff states they have not seen the watch. Interview on 6/26/2023 at 5:14 p.m. with the current Administrator revealed he was not the administrator at the time the Apple Watch was reported missing. The Administrator further stated that misappropriation of a resident's property that could not be found should be reported to the state agency as soon as possible, usually within 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and a review of the facility's policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure that abuse allegations, including misappropriation of resident property, were thoroughly investigated for one of one resident (R) (R#36) reviewed for abuse. Specifically, R#36 had a watch go missing and the facility failed to complete a thorough investigation, failing to locate or reimburse R#36 for the watch. Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation, with a revision date of 9/08/2022. The Investigation of Alleged Abuse, Neglect, and Exploitation policy section included identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, and providing complete and thorough documentation of the investigation. A review of the facility's Grievance/Concern Form indicated that R#36 filed a grievance on 9/19/2022 stating that her Apple Watch was missing. This grievance was designated to the Administrator and the Social Service Department to act upon. The date assigned was 9/20/2023. Further review of the form revealed that the Resolution of Grievance/Concern section was blank. A review of the facility's investigation report indicated the Apple Watch was not recovered after the residents' room and the laundry was searched. The report indicated statements obtained from staff stating that they had not seen the watch. Further review of the investigations that were conducted revealed a statement regarding the Apple Watch from the resident and two other residents residing in the facility. Review of the investigations revealed no documented staff interviews during the investigation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating that R#36 was cognitively intact. Interview on 6/21/2023 at 2:10 p.m. R#36 revealed that she took her Apple Watch off and placed it on her bedside table as she always did, and she never saw it again. R#36 stated that she reported it to the staff, and they came in and searched her room but did not find it. R#36 stated that the previous Administrator informed her that she would try to file the insurance for the watch on her behalf. R#36 further revealed that the previous Administrator did not request any of her account information to file a report of the missing watch. R#36 further stated that this occurred last year, and no one has said another word to her regarding her watch. Interview on 6/21/2023 at 4:04 p.m. with Social Service Director (SSD) revealed that she was not working at the facility during the time R#36's Apple Watch could not be found. The SSD further stated that the process for valuable missing items that are not recovered is that a police report is filed, reported to the state office, interview staff, staff education, and provide the resident with a key to lock items in the bedside dresser drawer. Interview on 6/21/2023 at 4:37 p.m. with Social Service Assistant (SSA) CCC stated that when a resident reports items are missing they are required to file a grievance, with the resident's permission, search the room for the missing item, and if not recovered, it is reported to the Administrator and the Administrator drives the investigation at that point. SSA CCC further revealed that she searched R#36's room on two separate occasions for the Apple Watch and it was not retrieved. SSA CCC stated that she knew that it was reported to the state office at some point, but the police were not notified. SSA CCC stated that she did not follow back up with the Administrator regarding the investigation. SSA CCC further stated that as of today, there was no resolution to the missing watch. She further stated that she did not follow back up with R#36 regarding the issue. SSA CCC revealed that she was not sure if the staff was interviewed regarding the R#36's missing watch. Interview on 6/26/2023 at 5:14 p.m. with the Administrator revealed that he was not aware of the unresolved grievance until this survey. The administrator stated that he was not at the facility during the time the watch went missing and verified that the evidence provided does not represent a thorough investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and review of the facility's policy titled, Pressure Injury Prevention and Management, the facility failed to obtain an order at the time of admission addressing surgical wound care for one of three Residents (R) (R#26). Findings include: Review of the facility's policy titled, Pressure Injury Prevention and Management, revealed: The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure/ulcer injury, prevent infection and the development of additional pressure ulcers/injuries. 2. The facility shall establish a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale for Predicting Pressure Ulcer tool, on all residents upon admission/re-admission, weekly x 4 weeks, then quarterly or whenever the resident's condition changes significantly. 5. b. The attending physician will be notified of: i. The presence of a new pressure injury upon identification. ii. The progression towards healing, or lack of healing, of any pressure injuries weekly. iii. Any complications (such as infection, development of a sinus tract, etc.) as needed. Review of the electronic medical record (EMR) revealed R#26 was admitted to the facility on [DATE] with diagnoses listed but not limited to fracture of neck of left femur, atrial fibrillation (A-Fib), and congestive heart failure (CHF). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for R#26 revealed in Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) of 13, which indicates R#26 was cognitively intact. Section G - Functional Status revealed R#26 required extensive one person assistance with Activities of Daily Living (ADLs). Section H- Bowel and Bladder revealed she was always incontinent of bowel and bladder. M-Skin Conditions revealed surgical wound and pressure reduction device for bed documented. The Care Area Assessment (CAA) triggered ADL, urinary incontinence, fall, pressure ulcer/injury, and pain. Review of the care plan for R#26 dated 1/27/2023 indicated a problem of ADL self-care performance deficit related to left femur fracture and impaired skin integrity. Surgical incision - left femoral neck fracture. Goals included but not limited to maintain current level of function and left femoral neck fracture will be healed. Interventions included but not limited to required assistance by one staff member for toileting, caution during ADLs, monitor/document location, size, treatment of skin injury, report abnormalities, failure to heal, sign/symptoms of infection, and maceration, document weekly treatments include measurement of wound, exudate and other notable changes, and wound care per MD order. Review of nursing admission assessment dated [DATE] revealed a skin assessment with documentation included reddened area on upper extremities (right antecubital [inner or front surface of forearm]), reddened/bruised areas both hands (right hand back), and dressing covering surgical incision (face). Review of skin assessments completed on 2/4/2023 and 2/7/2023 documented a surgical site to left thigh with staples. Review of the EMR revealed physician's orders for R#26 included but was not limited to clean left hip wound, wash pat dry cover with dressing monitor for signs/symptoms of infection every dayshift on Monday, Wednesday, and Friday. Start date was 2/3/2023. Review of the Electronic Treatment Administration Recorded (E-TAR) revealed dressing changes began on Friday 2/3/2023 and occurred the following week on Monday, Wednesday, and Friday. She was discharged on 2/13/2023. She did not have wound care ordered at time of admission Friday, January 27, 2023, through Thursday, February 2, 2023. Interview on 6/22/2023 at 12:30 p.m. with the Director of Nursing (DON) revealed her expectation regarding surgical wounds upon admission was that she expected the skin assessment be completed on day one. If there are not any orders related to a wound discovered, then the nurse will call the physician or the nurse practitioner for wound care orders. She stated the nurse will start wound care the same day if the wound care nurse is not working, otherwise the wound care nurse will start the wound care on first day of admission. She revealed that she, the DON, was assessing all wounds in the facility with the wound care nurse. She stated they are doing weekly audits on all wounds during their morning meetings where they review all wound measurements.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policies, the facility failed to ensure one of one resident (R) (R308) reviewed for self-administration of medication had a physician's order to safely perform self-administration of medication. The facility's deficient practice had potential for medication errors to occur for R308. Findings include: Review of facility-provided policy titled ''Medication: Self Administration'' dated December 2021 revealed ''. A physician/mid-level provider order is required .To provide a safe, effective process for patient self-administration.'' Review of facility-provided undated policy titled ''Nebulizer Therapy'' revealed ''.Observe resident during the procedure for changes in condition.'' Review of R308's electronic medical record (EMR) under her ''Profile'' tab revealed she was admitted to the facility on [DATE]. Review of R308's ''Med Diag'' tab revealed multiple diagnoses to include renal failure and diabetes. Review of R308's physician's orders under ''Orders'' tab revealed no order for self-administration of medication. Review of R308's ''Medication Administration Record'' (MAR) for the month of July 2022 revealed no directive for self-administration of medication. Review of R308's care plan under ''Care Plan'' tab revealed no intervention for self-administration of medication. Review of R308's ''Assessment'' tab revealed an assessment with heading ''Health Condition'' dated 06/21/22 revealed the facility entered an answer of no for question of R308's self-administration of medication, indicating R308 was declined by the facility to perform self-administration of medication. An observation was conducted on 07/12/22 at 11:49 AM in R308's room of Licensed Practical Nurse (LPN) 5 entering R308's room. LPN5 applied a face mask to R308's face after instilling medication (administering breathing treatment) in the tubing container. LPN5 exited R308's room and was not present during administration of nebulizer treatment. An observation was conducted on 07/12/22 at 12:05 PM. LPN5 entered R308's room and removed R308's face mask and turned nebulizer machine off and exited room. During an interview on 07/14/22 at 1:20 PM, LPN5 she confirmed she did not remain with R308 during the administration of her nebulizer treatment on 07/12/22 and allowed R308 to self-administer her medication. LPN confirmed and verified R308 did not have a physician's order under ''Order'' tab to self-administer her medication. During an interview on 07/15/22 at 1:35 PM, Nurse Practitioner (NP) confirmed her expectation was for the nursing staff to monitor the administration of medication to the residents, including nebulizer treatments. NP confirmed adverse side effects for nebulizer treatments were possible and included increased heart rate and respiratory issues. During an interview on 07/16/22 at 2:37 PM, LPN4 confirmed the facility expected nursing staff to remain with resident for entire fifteen minutes for nebulizer treatment and nursing staff were required to administer facility resident's medications.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure basic accommodation of needs for one of one sampled residents (R) (R257) reviewed for accommodation of needs were provided. Specifically, the facility failed to ensure R257's call light was within reach, and also failed to ensure the residents bed was in good working condition. The foot board to R257's bed was observed to be broken and hanging off the bed. Findings include: Review of the facility's undated policy titled, ''Quality of Life-Dignity,'' indicated, ''Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.'' Review of the facility's undated policy titled, ''Answering the Call Light,'' indicated, ''When the resident is in bed . be sure the call light is within easy reach of the resident.'' Observation on 07/12/22 at 11:00 AM, revealed R257 lying in bed asleep. At this time, the resident's foot board of the bed was observed hanging off the bed while the resident was sleeping. At this time, the call light was also observed to not be in reach of the resident and was seen clipped to the privacy curtain and hanging on the wall. Observation and interview on 07/13/22 at 9:20 AM, revealed R257 lying in bed. At this time, R257's foot board was observed from the hallway as hanging off the bed. Further observation revealed the call light was not within reach of the resident. The call light was observed clipped to the privacy curtain and folded up on the wall. During interview R257 stated, ''When I first got here, they moved me to another room. Then they moved me to this bed, and it [referring to the broken footrest] was like this when I got here. The footrest has been hanging off ever since I have been in this room. I've told someone about it. They came in, seen it, and didn't say anything. They just patted it and walked on. It is just hanging on like this.'' R257 then stated, ''So, if I need to scoot myself up in bed, I try to keep my feet away from it because it will fall off. So, I have a hard time scooting myself up.'' When R257 was asked if he was able to use his call light, he stated, ''Well, I would use my call light if I knew where it was at.'' When the call light was pointed out to R257 as being clipped to the privacy curtain and folded up on the wall, the resident stated, ''I obviously can't reach it, so if I need help, I just wait to see if any nurses walk by to ask for help.'' Observation on 07/13/22 at 3:00 PM, revealed R257's call light to still be clipped to the privacy curtain and hanging on the wall as was first observed. The resident's foot board was also observed still hanging off the bed. Observation on 07/14/22 at 10:00 AM, revealed R257's call light to still be clipped to the privacy curtain and hanging on the wall as the day before. The resident's foot board was also observed still hanging off the bed. Review of a ''Face Sheet'' found in R257's electronic medical record (EMR) under the ''Profile'' tab revealed diagnoses to include lack of coordination, personal history of transient ischemic attack (TIA) and cerebral infarction, difficulty in walking, and muscle weakness. Review of R257's Discharge-Return Anticipated ''Minimum Data Set (MDS)'' found in the EMR under the ''MDS'' tab with an Assessment Reference Date (ARD) of 06/27/22 revealed the resident's cognitive skills for daily decision making were modified independence. Review of R257's ''Care Plan'' found in the EMR under the ''Care Plan'' tab initiated on 07/08/22 indicated, ''ADLS: (Activities of Daily Living)'' Resident is independent with most ADLs, requires supervision and some assistance.'' Interventions are: ''Keep call light within reach.'' During environmental rounds on 07/14/22 at 8:51 AM, the Maintenance Director (MD) was asked if he had received any complaints regarding resident equipment such as broken foot boards. The MD stated, ''The mounts on the bottom of the beds are poorly designed. I'm trying to figure out how to keep them attached and how they won't come off at this point.'' At this time when the MD was taken to R257's room and the resident's bed was observed to have the foot board hanging off the bed, the MD was asked if he had received any work orders to repair R2587's broken foot board. The MD stated, ''No, I don't have a work order for this. I would have to get him out of bed and get it popped back on. I was not aware of the foot board being off.'' During an interview on 07/14/22 at 2:15 PM, the Administrator stated, ''It would be my expectation for the staff to have the call light in reach.'' When asked if there were any complaints brought to her attention regarding resident broken equipment, the Administrator stated, ''We should have a work order that is put into our TELS [computer based] system and maintenance would take care of it.'' During an interview on 07/14/22 at 3:51 PM, regarding call lights being in place for residents, the Director of Nursing (DON) stated, ''It would be my expectation for residents to have call lights in place. Yes. Especially for those residents that are able to use it.'' The DON then stated, ''With [name of R257], yes, he is cognitively aware, and he would be able to use the call light if needed.''

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency for one of three residents (R) (R47) investigated for abuse. R47 reported having her call light taken away and placed out of her reach and her incontinence/toileting needs not being addressed for five hours. The incident was not reported to the State Survey Agency. Findings include: Review of the Abuse, Neglect and Exploitation policy dated 01/01/22 and provided by the facility revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property . Neglect means a failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R47 was admitted to the facility on [DATE]with diagnoses including Parkinson's disease, epilepsy, muscle weakness, difficulty walking, unsteadiness on feet, and voice and resonance disorder. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/19/22 located in the EMR MDS tab revealed R47's cognition was intact with a BIMS score of 15 (score of 13 - 15 indicates intact cognition). R47 was not documented as exhibiting any behavioral indicators. R47 required extensive assistance from one person for transfers, dressing and toilet use, and limited assistance for personal hygiene. The resident did not walk during the assessment period and was unsteady and only able to stabilize with assistance for moving from seated to standing position and moving on and off the toilet. Review of the Care Plan in the EMR under the Care Plan tab revealed R47 had, ADLS [activities of daily living]: Self-care deficit AEB [as evidenced by] resident requires extensive to total assistance with ADLS d/t [due to] limited physical mobility, Dx [diagnosis] Parkinson's disease, lack of coordination, muscle weakness and unsteadiness. The goal was for the resident's needs to be met and not to decline in ADL function. Interventions included in pertinent part, -Allow resident to proceed at her own pace. Offer rest periods as needed. -Allow sufficient time for dressing and undressing. -Encourage the resident to fully participate possible with each interaction. -Encourage the resident to use bell to call for assistance. -Ensure resident is clean, dry, odor free and dressed appropriately daily Q shift. Review of the Grievance/Concern Form dated 03/08/22 provided by the facility revealed R47 expressed a concern on this date. The description read, CNA [certified nursing assistant] snatched the call light and placed it on the other side of the room. Didn't get change [sic] from 12:30 AM - 5:30 AM. The investigation was assigned to the Nursing Supervisor/Manager. The actions taken to resolve the grievance/concern was documented in full, Moved the CNA in question to a different assignment. No further corrective action was documented and the section for resolution of the grievance was blank (not filled out). The grievance included a handwritten statement by the RN Supervisor [the Director of Nursing (DON) at the time of the incident] which read in full, Writer called and spoke with the CNA in question and she stated the incident did not occur. She said she changed resident multiple times during the shift and did what resident asked her to do. There were no other witness statements or documents associated with the grievance. During an interview on 07/15/22 at 1:31 PM, Registered Nurse (RN) Supervisor was interviewed and stated when the incident occurred with R47, she was the interim DON; however, now she worked as the supervisor on night shift and was not the DON. RN Supervisor stated the incident was reported to someone else who brought R47's concern to her. RN Supervisor stated she talked with R47 about the incident later the day it occurred and R47 stated she did not remember the incident. RN Supervisor stated she talked to the staff who worked the shift in question and determined nothing of the sort happened. RN Supervisor stated the CNA in question was moved to a different assignment from where the resident was. RN Supervisor stated she talked to the CNA in question and was told the resident was changed multiple times. RN Supervisor then stated all the aides that worked with R47 were moved to a different assignment; she could not say how many or who, but indicated they were agency staff and not facility employed CNAs. RN Supervisor stated she was not aware of R47 having a history of false allegations about staff. RN Supervisor stated the incident was not handled as an allegation of neglect and therefore did not meet the criteria to be a reportable incident because the resident could not remember when asked about it and the aides denied it happened. During an interview on 07/12/22 at 2:45 PM, R47 stated, Some staff are in a hurry. Some are impatient. Some have attitude when I ask to be changed. R47 stated she took a diuretic medication and needed to be changed frequently. R47 stated the staff told her, I just changed you. The resident became tearful during the interview and stated, A lot of CNAs don't listen. I have a low voice tone. I am not able to express self because they don't take the time. During a subsequent interview on 07/16/22 at 10:02 AM, R47 was asked about the grievance filed on 03/08/22. R47 stated she remembered the incident and reported, The CNA removed the call light twice. R47 stated the first time the CNA put it over the outlet, but she could still reach it. R47 stated when she used the call light again to be changed, the CNA put the call light under the dresser so she could not reach it. R47 stated, I waited a long time to get assistance with the bathroom. I was neglected. R47 stated she told the social worker (no longer employed by the facility) about it and was not sure what happened as a result. R47 stated that the CNA had not worked with her again. The log of Facility Reported Incidents to the State Survey Agency was requested and provided by the facility (from 01/01/22 - 07/14/22). The incident of neglect reported by R47 was not listed as being reported to the State Survey Agency. During an interview on 07/15/22 at 12:10 PM, the [NAME] President of Operations and the Administrator verified the allegation by R47 dated 03/08/22 met the criteria for neglect, meaning it should have been reported to the State Survey Agency. The Administrator was new in her position and had not been employed at the facility at the time of the incident. The Administrator indicated she was the designated abuse coordinator for the facility. During an interview on 07/15/22 at 12:14 PM, the Social Services Director (SSD) read the grievance. She stated she had not been involved and was not sure if there was a write up, a warning, or what the outcome was. The SSD stated the incident could be considered neglect if it was true. The SSD stated grievances went to the Administrator and if a case was borderline, it should be reported to the State Survey Agency. During an interview on 07/16/22 at 2:35 PM, the Administrator stated if an allegation of abuse/neglect were reported to her, she would report it to the State Survey Agency immediately and investigate it. She stated she had two hours to report an allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure an allegation of neglect was thoroughly investigated for one of three residents (R) (R47) investigated for abuse. R47 reported having her call light taken away and put out of her reach and her incontinence/toileting needs not being addressed for five hours. Findings include: Review of the Abuse, Neglect and Exploitation policy dated 01/01/22 and provided by the facility revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, . Neglect means a failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . Written procedures for investigation include: . 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R47 was admitted to the facility on [DATE]with diagnoses including Parkinson's disease, epilepsy, anxiety, muscle weakness, difficulty walking, unsteadiness on feet, and voice and resonance disorder. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/19/22 located in the EMR MDS tab revealed R47's cognition was intact with a BIMS score of 15 (score of 13 - 15 indicates intact cognition). R47 was not documented as exhibiting any behavioral indicators. R47 required extensive assistance from one person for transfers, dressing and toilet use and limited assistance for personal hygiene. The resident did not walk during the assessment period and was unsteady and only able to stabilize with assistance for moving from seated to standing position and moving on and off the toilet. Review of the Care Plan in the EMR under the Care Plan tab revealed R47 had, ADLS [activities of daily living]: Self-care deficit AEB [as evidenced by] resident requires extensive to total assistance with ADLS d/t [due to] limited physical mobility, Dx [diagnosis] Parkinson's disease, lack of coordination, muscle weakness and unsteadiness. The goal was for the resident's needs to be met and not to decline in ADL function. Interventions included in pertinent part, -Allow resident to proceed at her own pace. Offer rest periods as needed. -Allow sufficient time for dressing and undressing. -Encourage the resident to fully participate possible with each interaction. -Encourage the resident to use bell to call for assistance. -Ensure resident is clean, dry, odor free and dressed appropriately daily Q shift. Review of the Grievance/Concern Form dated 03/08/22 provided by the facility revealed R47 expressed a concern on this date. The description read, CNA [certified nursing assistant] snatched the call light and placed it on the other side of the room. Didn't get change [sic] from 12:30 AM - 5:30 AM. The investigation was assigned to the Nursing Supervisor/Manager. The actions taken to resolve the grievance/concern was documented in full, Moved the CNA in question to a different assignment. No further corrective action was documented and the section for resolution of the grievance was blank (not filled out). The grievance included a handwritten statement by the RN Supervisor [the Director of Nursing (DON) at the time of the incident] which read in full, Writer called and spoke with the CNA in question and she stated the incident did not occur. She said she changed resident multiple times during the shift and did what resident asked her to do. There were no other witness statements or documents associated with the grievance. During an interview on 07/15/22 at 1:31 PM, the RN Supervisor was interviewed and stated when the incident occurred with R47, she was the interim DON; however, now she worked as the supervisor on night shift and was not the DON. The RN Supervisor stated the incident was reported to someone else who brought R47's concern to her. The RN Supervisor stated she talked with R47 about the incident later the day it occurred and R47 stated she did not remember the incident. The RN Supervisor stated she talked to the staff who worked the shift in question and determined nothing of the sort happened. The RN Supervisor stated the CNA in question was moved to a different assignment from where the resident was. The RN Supervisor stated she talked to the CNA in question and was told the resident was changed multiple times. The RN Supervisor then stated all the aides that worked with R47 were moved to a different assignment; she could not say how many or who, but indicated they were agency staff and not facility employed CNAs. The RN Supervisor stated the incident was not handled as an allegation of neglect because the resident could not remember when asked about it and the aides denied it happened. The RN Supervisor verified there were no additional witness statements she was aware of beside her written statement regarding the CNA who stated she had changed R47 multiple times during the shift. The RN Supervisor stated she had been responsible for the investigation. During an interview on 07/12/22 at 2:45 PM, R47, Some staff are in a hurry. Some are impatient. Some have attitude when I ask to be changed. R47 stated she took a diuretic medication and needed to be changed frequently. She stated the staff told her, I just changed you. The resident became tearful during the interview and stated, A lot of CNAs don't listen. I have a low voice tone. I am not able to express self because they don't take the time. During a subsequent interview on 07/16/22 at 10:02 AM, R47 was asked about the grievance filed on 03/08/22. R47 stated she remembered the incident and reported, The CNA removed the call light twice. R47 stated the first time the CNA put it over the outlet, but she could still reach it. R47 stated when she used the call light again to be changed, the CNA put the call light under the dresser so she could not reach it. R47 stated, I waited a long time to get assistance with the bathroom. I was neglected. R47 stated she told the social worker (no longer employed by the facility) about it and was not sure what happened as a result. R47 stated that the CNA had not worked with her again. During an interview on 07/15/22 at 12:10 PM, the [NAME] President of Operations and the Administrator verified the allegation by R47 dated 03/08/22 met the criteria for neglect, meaning it should have been reported to the State Survey Agency and thoroughly investigated. The Administrator was new in her position and had not been employed at the facility at the time of the incident. The Administrator indicated she (or whoever the Administrator was at the time) was the designated abuse coordinator for the facility. The [NAME] President of Operations stated the previous Administrator and CNA named in the allegation had been terminated. During an interview on 07/15/22 at 12:14 PM, the Social Services Director (SSD) read the grievance. The SSD stated she had not been involved and was not sure if there was a write up, a warning, or what the outcome was. The SSD stated the incident could be considered neglect if it were true, but it would have to be investigated to find out. During an interview on 07/16/22 at 11:27 AM, the DON stated she had been in her position since May 2022 and not in the facility when the grievance from R47 was filed. The DON reviewed the grievance and stated it could be neglect and if she had received this grievance, she would have addressed it right away. She stated the staff in question should have been suspended immediately until the investigation was completed and not moved to a different unit. During an interview on 07/16/22 at 2:35 PM, the Administrator stated if an allegation of abuse/neglect were reported to her, she would report it to the State Survey Agency immediately and investigate it. A thorough investigation should be completed, and witness statements should be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure two of 33 sampled residents (R) (R256 and R52) had baseline care plans developed and implemented to address the resident's immediate needs within 48 hours of admission to the facility. R256 did not have a baseline care plan implemented. R52's baseline care plan did not address R52's dementia diagnoses. Findings include: Review of the facility's undated policy titled, ''Care Plans-Baseline,'' indicated ''A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services .the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop and interdisciplinary person-centered care plan. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to a. the initial goals of the resident, b. a summary of the resident's medications and dietary instructions; c. any services and treatments to be administered by the facility. During an interview on 07/14/22 at 1:27 PM, Family Member (F) 256 stated, ''On a daily basis, I would ask what is the plan for her [R256]. When are we going to get together to go over what her plan is while she is a resident here at the facility? I was told by the staff yes, we will be having a meeting to get things in place and just give us 72 hours and we will call in the family and talk about a plan of care.'' F256 stated, ''I tried talking to the main director. I would ask everyday including the director of the facility, the social worker and lead nurses asking again when are we going to have a plan, and nobody knew anything.'' Review of a ''Face Sheet'' found in R256's electronic medical record (EMR) under the ''Profile'' tab revealed R256 was admitted to the facility on [DATE] from the hospital and discharged from the facility on 05/30/22. The resident's diagnoses included Type II diabetes, heart failure, acute and chronic respiratory failure, COVID-19, and acute kidney failure. Review of R256's ''Social Service Comprehensive Evaluation'' dated 01/25/22 found in the EMR under the ''Social Services'' tab revealed an initial Social Services Assessment was completed on 01/25/22 (7 days after admission) by the social worker however, there was no documentation that the facility completed a baseline care plan or provided the resident and/or resident representative with a written summary of a baseline care plan. There was also no evidence of documentation to show that information was discussed with F256 within 48-72 hours of admission regarding R256's medications, initial goals, services, and treatment to be administered, primary diagnosis and discharge plan. Review of R256's admission ''Minimum Data Set (MDS)'' found in the EMR under the ''MDS'' tab with an Assessment Reference Date (ARD) of 01/25/22 revealed the resident had a ''Brief Interview for Mental Status (BIMS)'' score of 12/15, which indicated the resident was cognitively intact. During interview on 07/15/22 at 9:33 AM, regarding baseline care plans, the Director of Nursing (DON) stated, ''The Social Worker comes in and does care plan meetings within 48-72 hours. She is also supposed to contact the family.'' The DON then stated, ''If they [a resident] come in as a new patient, they have a care plan meeting with social services within 48-72 hours. She will also call the family and set up an appointment time if they want to come in or discuss things over the phone. She [social services] will call and set that up usually within 48-72 hours.'' During this interview, the DON stated, ''With baseline care plans, the admitting nurse on the floor does it, and it is part of the admission process. The admitting nurse would be going over everything with the resident. If we have a patient let's say who comes from the hospital and is non-interviewable, then we would need to reach out to the family that day. These are also supposed to be completed in [the EMR]. During interview on 07/15/22 at 9:49 AM, regarding baseline care plans, the Administrator stated, ''We do a 72-hour care plan with the family.'' When asked who does this? The Administrator stated, ''Social Services.'' During interview on 07/15/22 at 11:18 AM, the Social Services Director (SSD) stated, ''No, there was not a baseline care plan [for R256].'' The SSD stated, ''It [the baseline care plan] is usually done at admission and whoever is admitting the patient that same day, it should be completed.'' When the SSD was asked if a care plan meeting took place within the 48-72 hours of admission with F256, the SSD stated, ''I don't see anything except the initial social services assessment. If the resident is competent enough, initially, I will get information from them. Then I will set up the 48-hour meeting with the family to get more information. I didn't speak to the family. No. There was no baseline care plan completed.'' 2. Review of the facility-provided policy titled ''Dementia Care'' no date revealed ''. It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs or is diagnosed with dementia to meet his or hers highest practicable physical, mental and psychosocial well-being . The facility will assess, develop, and implement care plans . The care plan interventions will be related to each resident's individual symptomology and rate of dementia . progression with the end result being noted improvement or maintained . Care and services will be person-centered and reflect each resident's individual goals.'' Review of R52's ''electronic medical record'' (EMR) under his ''Profile'' tab revealed R52 was admitted to the facility on [DATE]. Review of 52's ''Med Diag'' tab revealed multiple diagnoses to include Alzheimer's disease with early onset of dementia and unspecified dementia. Review of 52's admission ''Minimum Data Set [MDS],'' with an Assessment Reference Date (ARD) of 06/02/22 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating R52 was cognitively intact. R52 had an active diagnosis of non-Alzheimer's dementia on the facility's assessment. Review of R52's ''Care Plan'' dated 05/30/22 under his ''Care Plan tab revealed no person-centered care interventions were developed or implemented for his dementia diagnosis. During an interview on 07/15/22 at 9:34 AM, the DON confirmed R52 had a diagnosis of dementia. DON confirmed and verified R52 did not interventions on his care plan that were person-centered to direct staff how to provide care for his diagnosis of dementia. DON confirmed the facility should have developed and implemented R52's care plan to include interventions for his dementia diagnosis. DON stated she was unsure why R52's care plan did not include interventions for his dementia diagnosis that was person-centered. DON stated the nursing staff on the units enter the baseline care plan when a resident was admitted . DON stated the nursing staff enter the resident's care plan as soon as the new resident was admitted to the facility. DON stated the nursing staff will assess the resident and enter the baseline care plan. DON stated the facility utilize the care plan to direct the staff to provide care for the facility's resident. DON stated resident's care plans were created individualized for the facility's residents. DON confirmed dementia diagnosis was very important to be included on a resident's care plan for interventions. DON stated it was important to include dementia interventions because the direct the staff need the interventions to direct them how to provide care for the facility's resident with the dementia diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for two of 33 sampled residents (R) (R3 and R41). Findings include: Review of the paper ''Care Plans Comprehensive Person-Centered'' undated policy, provided by the facility, revealed ''A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care planning process will reflect the resident's expressed wishes regarding care and treatment goals; The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition.'' Review of the facility-provided policy titled Dementia Care no date revealed It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs or is diagnosed with dementia to meet his or hers highest practicable physical, mental and psychosocial well-being .The facility will assess, develop, and implement care plans .The care plan interventions will be related to each resident's individual symptomology and rate of dementia .progression with the end result being noted improvement or maintained .Care and services will be person-centered and reflect each resident's individual goals . 1. Review of R3's Electronic Medical Record (EMR) revealed the undated ''Face Sheet'' under the ''Resident'' tab indicated R3 was admitted on [DATE]. R3 and had diagnosis of Alzheimer's disease, dementia with behavioral disturbance, adjustment disorder with mixed anxiety, and depressed mood. Review of R3's admission Minimum Data Set (MDS) dated of 04/06/22 revealed that R3 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R3 was cognitively impaired. The MDS documented R3 wandered daily. Review of the EMR Progress Notes tab reflected that R3 had a history of wandering into residents' rooms and yelling out. Review of R3's care plan, most recently updated 07/10/22, under the 'Resident Assessment Instrument (RAI) tab indicated there were no interventions in R3's care plan related to her behaviors. During an observation on 07/13/22 at 3:31 PM, R3 was in the hallway in wheelchair. R3 was observed to be alert with confusion and yelling out. During an observation on 07/14/22 at 11:46 AM, R3 was up in her wheelchair in dining room, yelling out. During an interview on 07/14/22, the Director of Nursing (DON) stated R3 was placed in a room where other residents were not bothered by her behaviors and once she goes to bed she was fine. The DON stated residents with behaviors were redirected. The DON did not know why R3 did not have a care plan for her behaviors. 2. Review of R41's EMR under her ''Profile'' tab was admitted to the facility on [DATE]. Review of R41's ''Med Diag'' tab revealed she had multiple diagnoses to include dementia. Review of R41's admission MDS'' dated 05/13/22 revealed a BIMS score of 99 out of 15, indicating R41 was unable to complete the interview. R41 had an active diagnosis of dementia on the facility's assessment. Review of R41's care plan dated 05/30/22 revealed ''Care Plan'' tab revealed no interventions for dementia. An interview was conducted on 07/15/22 at 9:14 AM with DON who confirmed MDS Coordinator created the care plans for residents. DON stated the facility utilized the care plan to direct the staff to provide care for the facility's resident. DON stated resident's care plans were created individualized for the facility's residents. DON confirmed dementia diagnosis was very important to be included on a resident's care plan for interventions. DON stated it was important to include dementia interventions because the direct the staff need the interventions to direct them how to provide care for the facility's resident with the dementia diagnosis. During an interview on 07/15/22 at 10:34 AM, Social Services Director (SSD) confirmed and verified R41 had a diagnosis of dementia. SSD confirmed and verified R41 did not have interventions or any entry on her care plan for her dementia diagnosis to direct staff how to provide care for her, except for nutrition related issues with dementia. SSD confirmed R41 should have interventions on her care plan for her dementia diagnosis to direct her care provided by the facility's staff. SSD confirmed R41 was admitted to the facility May 2022. SSD stated R41 wandered because of her diagnosis with dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to ensure one of 33 sampled residents (R) (R38) was being invited to regular care plan meetings. The facility also failed to have documentation to show the resident care plan meetings were being held regularly or with input from the resident. By not involving residents in their care, they are unaware of changes that may be made, or decisions made. Findings include: Review of the facility's undated policy titled, ''Care Plans, Comprehensive Person-Centered,'' Indicated, ''The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family . develops and implements a comprehensive, person-centered care plan for each resident . Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate . request meetings, request revisions to the plan of care, participate in establishing the expected goals and outcomes of care . The care planning process will: a. facilitate resident and/or representative involvement. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments.'' Review of the facility's undated policy titled, ''Promoting/Maintaining Resident Self-Determination,'' indicated, ''Each resident has the right to choose their schedules . consistent with their interests, assessments, and plans of care . All aspects of care and services will be discussed in the care plan meeting and documented as such.'' During an observation and interview on 07/12/22 at 10:00 AM, R38 was observed lying in bed. At this time, R38 stated, ''I'm my own responsible party, and I used to have care plan meetings regularly but those haven't happened in about a year. They used to do those quarterly, but not anymore.'' Review of a ''Face Sheet'' found in R38's electronic medical record (EMR) under the ''Profile'' tab revealed R38 was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, muscle weakness, and personal history of transient ischemic attack. Review of R38's quarterly ''Minimum Data Set (MDS)'' found in the EMR under the ''MDS'' tab with an Assessment Reference Date (ARD) of 05/16/22 revealed the resident had a ''Brief Interview for Mental Status (BIMS)'' score of 15 out of 15 which indicated the resident was cognitively intact. Review of ''Social Service'' progress notes found in the EMR under the ''Progress Notes'' tab dated 04/28/22 indicated, ''SSA [Social Services Assistant] mailed a letter to [name of R38's family member] to invite her to the care plan meeting on May 29th at 10am.'' There was no documentation in the progress notes to indicate R38 was made aware of the upcoming care plan meeting to be held on May 29, 2022. Further review of the Social Services progress notes revealed no documentation of any care plan meetings, or invitation to attend any care plan meetings with R38 since 04/05/21. The Social Services Progress notes indicated the last time a care plan meeting was held with R38 was on 04/05/21. During an interview on 07/14/22 at 4:30 PM, the Social Services Director (SSD) was asked if regular care plan meetings are held with R38. The SSD stated, ''Yes, our care plan meetings are held quarterly. He [R38] is his own responsible party.'' The SSD then stated, ''Usually, we will send out a letter to the family or take the letter to the resident to remind them that there is a care plan meeting coming up.'' The SSD stated, ''Most of the time, he will participate on his own.'' When the SSD was asked when the last care plan meeting with R38 was, the SSD stated, ''It looks like on 04/28/22, we mailed a letter to the daughter for a care plan to be held on 05/29/22.'' When the SSD was asked if R38 was informed of this upcoming care plan meeting to be held on 05/29/22, the SSD stated, ''Yes, I think so, but I don't see the documentation showing that. It just looks like we sent a letter to the daughter to let her know a care plan meeting was going to be held 05/29/22. I'm not seeing that he [R38] was invited though.'' When the SSD was asked if there was a care plan meeting that took place on 05/29/22, the SSD stated, ''I don't see anything. No.'' However, the SSD then stated, ''The last care plan meeting was 05/29/22 but I don't see a note that R38 was invited. The one before 05/29/22 should have been in February 2022, but I have no idea. I'm not seeing any notes where he [R38] was invited or attended that care plan meeting. I also don't see any documentation that a letter was given to him.'' During a second interview on 07/15/22 at 11:13 AM, the SSD stated, ''I could not find anything in the chart to say we had a care plan meeting with [R38] in May. We were supposed to have a meeting scheduled for 05/29. It did not take place.'' When the SSD was again asked when the last care plan meeting was held with R38, the SSD stated, ''Well, I have an attendance log that was started on 01/28/22. We did have a care plan meeting, but I don't see that [R38] attended, or signed the attendance sheet. We don't have proof that he attended or was invited.'' During an interview on 07/15/22 at 9:49 AM, the Administrator stated, ''Care Plans should be done quarterly. Yes. The residents should always come to the care plan meetings especially if they are cognitively intact.'' Regarding R38, the Administrator stated, ''We need to get a care plan set up. They are supposed to have them quarterly.''

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure resident's received care in accordance with nursing standards, specifically clarifying an order for an antibiotic without an end date and taking appropriate action when prescribed medications were not in stock, two out of 33 total sampled residents (R) (R59 and R46). R59 missed doses of an antibiotic prescribed by the physician and received the antibiotic for longer than the provider intended. R46 missed doses of a pain medication. Findings include: Review of facility-provided policy titled ''Unavailable Medication'' with no date revealed ''. If a resident misses a dose of medication staff shall follow procedures for medication errors, including physician/family notification . monitoring the resident for adverse reactions to omission of the medication.'' Review of the undated Medication Administration provided by the facility revealed, If medications(s) is not available, the nurse will: 5.1.1 Coordinate with pharmacy to procure the medication (s) as soon as possible and discuss substitution options with the pharmacist, if applicable. 5.1.2 Notify the physician . of the unavailability of the medication(s) 5.1.3 Discuss substitution options for ordered medication(s) with physician ., if applicable . 1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab, revealed R59 was admitted to the facility on [DATE]. Diagnoses include pressure ulcer of the sacral region, absence of the kidney, urinary tract infection, hypertension, and edema. Review of the quarterly Minimum Data Set [MDS] with an assessment reference date (ARD) of 06/07/22 revealed R59 was unimpaired in cognition with a Brief Interview for Mental Status score (BIMS) of 13 (score of 13 - 15 indicates intact cognition). The resident did not exhibit any behaviors during the assessment period. R59 received antibiotic medication three of seven days during the assessment period. Review of the care plan dated 05/04/22 in the EMR under the Care Plan tab revealed R59 was, at risk for adverse effects r/t [related to] receiving ATB [antibiotic] therapy for dx [diagnosis] UTI [urinary tract infection]. The goal was for the resident's urinary tract infection to resolve without complications through medication administration date. Interventions included, Administer antibiotic therapy as ordered. Observe/document for side effects and effectiveness. Review of Physician's Orders for the month of June 2022 and July 2022 in the EMR under the Orders Tab revealed a prescription for Zyvox (antibiotic) 600 milligrams (MG) twice a day for a diagnosis of UTI initiated on 06/03/22. There was no stop date for the antibiotic and the order was current as of the survey on 07/14/22. Review of the Medication Administration Record for June and July 2022 in the EMR under the Notes tab, revealed R59 was not administered Zyvox 18 times due to it not being available as follows: -5:00 PM dose on 06/06/22 -8:00 AM dose on 06/07/22 -8:00 AM and 5:00 PM dose on 06/16/22 -8:00 AM and 5:00 PM dose on 06/20/22 -8:00 AM and 5:00 PM dose on 06/21/22 -8:00 AM and 5:00 PM dose on 06/25/22 -8:00 AM and 5:00 PM dose on 06/26/22 -8:00 AM and 5:00 PM dose on 06/29/22 --8:00 AM and 5:00 PM dose on 07/09/22 -8:00 AM and 5:00 PM dose on 07/10/22 Review of the Progress Notes from 06/12/22 - 07/13/22 showed no documentation of nurses contacting the Pharmacy or Nurse Practitioner/Physician regarding the availability of Zyvox or the lack of a stop date. Review of the Note to Attending Physician/Prescribed dated 06/28/22 revealed the pharmacist identified an irregularity as follows, The resident has an order for Linezolid [Zyvox] 600 mg BID [twice daily] since 06/03/2022, which is subject to the stop order policy. Please clarify the order to include a stop date. The recommendation was reviewed by the Nurse Practitioner on 07/14/22 who agreed and wrote an order on this date to discontinue the medication. During an interview on 07/13/22 at 4:15 PM, R59 stated she had trouble getting medications for her kidneys and missed doses of the antibiotic because they were not in stock or not ordered. R59 stated she had a history of urinary tract infections. During an interview on 07/14/22 at 4:07 PM, the Director of Nursing (DON) stated she did not know about R59 missing doses of Zyvox. She stated the nurse passing medications or the charge nurse should call the pharmacy if they were out of a medication to see what the problem was. The DON stated the charge nurse would typically manage issues like this, but she would also like to know if there was a problem with availability of medications. During an interview on 07/15/22 at 11:10 AM, the Pharmacist stated he completed the drug regimen review on 06/28/22 and recommended a stop date on the Zyvox order. The Pharmacist stated the medication was started on 06/03/22 to treat a UTI. The Pharmacist stated if there was no medication in stock, the staff should call the pharmacy to let them know. The Pharmacist stated there was a stop order date on 07/14/22 from the provider. During a follow up interview on 07/15/22 at 12:09 PM, Pharmacist stated he researched the order with the pharmacy and the Zyvox antibiotic was a prescription for 10 days, but it was written for 2 months for the resident. The Pharmacist stated the pharmacy sent out the first ten-day supply of the medication to the facility and then later a second ten-day supply. The Pharmacist stated days were missed because the pharmacy was waiting on a prior authorization from the insurance company because this type of prescription required a stop order date. The Pharmacist stated the policy was for the pharmacy to notify the facility that prior authorization was required to refill the medication. During an interview on 07/15/22 at 12:42 PM, the Nurse Practitioner (NP) stated she prescribed the Zyvox, and it was to be administered for seven days total. The NP stated, I stopped it yesterday. The NP stated she saw the Pharmacist's recommendation and put in a stop order as a result. The NP stated nursing staff did not bring it to her attention that there was no stop date and further stated she would not order it for more than 10 days. The NP stated R59 had a history of UTIs. The NP stated the nurses should have, but did not, contact her when the medication was not available. During an interview on 07/16/22 at 9:50 AM, Licensed Practical Nurse (LPN)1 stated if a medication was out of stock or an antibiotic had no stop date, the nurse should check with the NP or doctor to follow up. LPN1 stated, typically, she would follow up with the physician and the pharmacy and it should be documented in the notes. 2. Review of R46's EMR under his ''Profile'' tab revealed he was admitted to the facility on [DATE]. Review of R46's ''Med Diag'' tab revealed multiple diagnoses to include chronic pain. Review of R46's admission MDS,'' with an ARD of 07/01/22 revealed a BIMS score of 14 out of 15, indicating R46's cognition was intact. R46's entry, by the facility revealed he received opioid medication for the 7 days out of 7 days. Review of R46's physician's orders under ''Orders'' tab revealed ''Oxycontin [opioid controlled substance pain medication] tablet ER (extended release) give 40 mg [milligrams] every with 8 hours for pain.'' dated 06/09/22. Review of R46's EMR ''Medication Administration Record'' for the month of July 2022 revealed administrations on 07/05/22 at 6:00 AM and 07/07/22 at 9:00 PM were blank, indicating the medication was not administered to R46. Review of R46's ''Prog Notes'' tab for 07/05/22 and 07/0722 revealed no entries regarding administering his pain medication (oxycontin) scheduled dose or notifying physician or family of missed does. During an interview on 07/12/22 with R46 and his family member (F46) by phone, stated the facility missed administering doses of his scheduled pain medication oxycontin. F46 stated the staff informed him the facility ran out of his medication. R46 expressed he suffered because the facility did not always have the right dose of his medications. During an interview on 07/14/22 at 3:24 PM, Licensed Practical Nurse (LPN) 5 confirmed and verified R46's MAR blank entries indicated the medication was not administered to R46. LPN5 confirmed the facility's staff did not inform the physician of R46's missed oxycontin doses for the month of July 2022. During an interview on 07/15/22 at 11:30 AM, Pharmacy Consultant (PC) verified and confirmed R46 had missing staff documentation (entries) on his MAR for administration of his oxycontin scheduled doses for the month of July 2022 and was considered a medication error. During an interview on 07/15/22 at 12:51 PM, NP confirmed her expectation for the facility's staff was to inform the physician of missed doses of medication and especially R46's oxycontin. NP stated R46's missed medication doses had potential to cause him adverse reactions, including poor pain control and pain medication withdrawals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide services to one of four residents (R) (R64) reviewed for limitations in range of motion (ROM). The facility failed to ensure residents with ROM impairments were provided services to maintain function or prevent declines. In addition, the facility failed to implement established restorative programs for residents with programs in place. Findings include: Review of R64's undated Face Sheet located in the electronic medical record (EMR) Profile tab, revealed R64 was originally admitted to the facility on [DATE] and his most recent readmission was on 01/25/06 from the hospital. R64 had diagnoses including quadriplegia, multiple sclerosis, contracture unspecified hand, and a contracture to right elbow. Review of the EMR under the tab ''Orders for July 2022 revealed R64 was to have range of motion (ROM) to bilateral upper extremities (BUE) with splinting and to place elbow splints to right elbow for four hours daily. Review of the quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 06/13/22, revealed R64's cognition was intact with a Brief Interview for Mental Status [BIMS] score of 11 out of 15. R64 required extensive staff assistance with activities of daily living (ADLs) such as bed mobility, transfers, and dressing. R64 had not walked during the assessment period. R64 was not steady and could not stabilize with staff assistance for moving from a seated to standing position, moving on and off the toilet and surface to surface transfer (between bed and hair or wheelchair). R64 had ROM limitations on both sides both his upper and lower extremities (arms, hands, legs, feet). Review of R64's care plan, dated 06/18/22 and located in the EMR under the Care Plan tab, revealed R64's requirement for extensive assistance with ADLs. The goal was for the resident's needs to be met. The care plan included donning and doffing of right hand and right elbow splints daily as tolerated. The care plan also included ROM to BUE with splinting to right elbow four hours daily as directed. Observation on 07/13/22 at 9:51 AM revealed R64 was in bed with no splints applied. He was alert and able to answer yes or no questions. R64 had his right hand curled up to his chest and was not able to open up his hand. Observations during the survey included: R64 did not have splints on at any time. During an interview on 07/15/22 at 1:00 PM, Licensed Practical Nurse (LPN) 4 said she was not aware R64 was to have splints on and did not know where his splints were located. LPN4 looked through R64's drawers in his room found one splint in a drawer and attempted to place it on R64 but did not know how to apply the splint. LPN4 said there was no restorative program at the time. During an interview on 07/13/22 at 4:51 PM, Certified Nursing Assistant (CNA) 9 said she cannot always get to the residents timely due to not enough help. CNA9 said she was not aware of R64 requiring splints and had not seen him with the splints on at any time. During an interview on 07/13/22 at 4:55 PM, CNA10 said he was not aware of R64 requiring splints and had not seen him with the splints on at any time. During an interview on 07/14/22 at 2:48 PM, the Administrator said her expectation was for resident's that required ROM and splints to be applied as ordered. During an interview on 07/14/22 at 3:53 PM, the DON said her expectations were that residents requiring ROM and splints received the appropriate care and the splints would be applied as ordered. There was no policy provided related to ROM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policies the facility failed to provide nutrition management for one of one resident (R) (R308) reviewed for dialysis to meet her nutritional needs. Specially, the facility did not adjust meal schedule to provide nutrition prior to or during dialysis clinic appointments three days a week. The facility's deficient practice had potential to affect R308's nutritional intake and blood sugar values (low blood sugar). Findings include: Review of the undated ''Resident Nutrition Services'' policy provided by the facility revealed, ''Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.'' Review of R308's electronic medical record (EMR) under her ''Profile'' tab revealed she was admitted to the facility on [DATE]. Review of R308's EMR ''Med Diag'' tab revealed multiple diagnoses to include renal failure and diabetes. Review of R308's physician's orders under ''Orders'' tab revealed ''.Liberalized Renal diet, Regular texture Regular Liquids consistency.'' dated 06/21/22 and no order for meal adjustment schedule for Monday, Wednesday, or Friday (schedule dialysis days), indicating no mealtimes were adjusted. Review of R308's EMR care plan under ''Care Plan'' tab revealed no interventions were implemented for dialysis care including mealtime adjustments for nourishment. During an interview on 07/12/22 at 12:20 PM, R308 stated she was transported to dialysis clinic for treatment three times a week, on Monday Wednesday and Friday. R308 stated the facility did not provide breakfast meals on those day prior to being transported. R308 stated she was transported from the facility to dialysis at 5:00 AM on those days and returned to the facility around 11:00 AM. R308 stated sometimes her breakfast meal was sitting on her bedside table when she returned, but the staff just remove it without her consuming because it was cold and had been sitting there for hours. R308 stated the facility did not provide her with meals or snacks to take with her to dialysis appointments. R308 confirmed she was a diabetic. During an interview on 07/15/22 at 1:06 PM, Nurse Practitioner (NP) confirmed R308 had a diagnosis of renal failure and attended dialysis three days a week. NP confirmed R308 dialysis appointment were at 5:00 AM on Monday Wednesday and Friday. NP confirmed R308 was transported to the outside dialysis clinic. NP stated usually R308 would eat breakfast early (prior to leaving for dialysis). NP stated R308 cannot eat during dialysis because it causes nausea for dialysis residents. NP confirmed R308 had a diagnosis of diabetes and eating regular meals was important. NP confirmed R308 did not have a physician order on her EMR for breakfast to be served before being transported to dialysis and she should have a physician's order for that to occur. NP confirmed and verified R308 did not have a physician order for early meals prior to dialysis. NP stated it was important for her to eat meals before her treatment and her not to miss meals. NP stated there should be a protocol in the system to order early meals for resident's who received dialysis. NP stated she would put a system in place at the facility to ensure meal protocols were included for dialysis residents. NP confirmed and verified R308 had a physician's order for the facility to check R308 blood sugars before meals and before bedtime. NP confirmed and verified R308 had a physician order for insulin administration daily. NP confirmed her expectation was for the facility's staff to provided R308 meals prior to R308 being transported to her dialysis appointment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy, the facility failed to ensure three of eight residents (R) (R14, R97, and R43) were treated with dignity and respect in a manner to enhance quality of life and individuality. Specifically, residents were observed in clothing that was not their own and was too small, improperly dressed in view of other residents, and in soiled clothing. Findings include: Review of the facility's undated policy titled, ''Resident [NAME] of Rights,'' indicated, ''Be Treated with Respect: You have the right to be treated with dignity and respect.'' Review of the facility's undated policy titled, ''Quality of Life-Dignity,'' indicated, ''Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality'' 1. ''Resident shall be treated with dignity and respect at all times.'' 2. ''Treated with dignity'' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.'' 4. ''Resident shall be encouraged and assisted to dress in their own clothes.'' Review of the facility's undated policy titled, ''Resident Agreement,'' indicated, ''Resident's Personal Property- The facility desires to provide the Resident with a home-like environment. Consequently, the Resident is encouraged to bring personal items from home to the facility . An inventory form listing the resident's personal items shall be completed . at the time of admission.'' 1. Review of R14's electronic medical record (EMR) revealed the undated ''Face Sheet'' under the ''Resident'' tab indicated R14 was admitted on [DATE]. Review of R14's quarterly ''Minimum Data Set (MDS)'' with Assessment Reference Date (ARD) of 4/12/22, located in the resident's EMR under the ''RAI [resident assessment instrument]'' tab indicated that R14 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R14 had moderate cognitive impairment. Review of R14's care plan located in the resident's EMR under the ''RAI'' tab indicated a problem with limited mobility, personal hygiene and bathing with intervention assist with all ADL needs including routine nail care. The care plan did not address privacy or dignity. During an observation on 07/12/22 at 4:31 PM, R14 was in her room with three other residents (roommates) uncovered brief showing with male visitors in her room. The privacy curtain was not pulled, and the male residents could see R14 exposed. During an observation on 07/13/22 at 3:37 PM, R14 was in her room in bed alert with confusion but answered yes or no questions. R14 was wearing a shirt and brief, uncovered, while two male visitors were in the room. During an interview on 07/13/22 at 4:47 PM, Certified Nursing Assistant (CNA) 8 said she had been off for the past two days and residents do not receive Activities of Daily Living (ADL) care or showers while she is off work. CNA8 verified R14 should be covered and not exposed to the male visitors or the other three roommates in the room. During an observation on 07/14/22 at 9:30 AM, R14 was in her room in bed. R14 was uncovered, wearing a brief with three roommates and one male resident in the room. During an interview on 07/14/22 at 9:35 AM, Licensed Practical Nurse (LPN) 4 verified R14 was uncovered and exposed, and she should be covered to maintain her dignity. During an interview on 07/13/22 at 4:51 PM, CNA9 stated she cannot always get to the residents in a timely manner due to not enough help. CNA9 stated R14 should always be covered, and the privacy curtain pulled during care. During an interview on 07/13/22 at 4:55 PM, CNA10 stated he noticed R14 was uncovered when he walked past the room or passed ice in the room; but stated that was not part of his job due to being on light duty. During an interview on 07/14/22 at 2:48 PM, the DON said her expectations were that all residents including R14 were treated with dignity and respect. During an interview on 07/14/22 at 2:48 PM, the Administrator indicated that her expectations were for all residents were treated with dignity and respect and provided privacy. 2. Review of R97's EMR revealed the undated ''Face Sheet'' under the ''Resident'' tab indicated R97 was admitted on [DATE] and readmitted on [DATE]. He had diagnoses of chronic kidney disease, major depressive disorder, muscle weakness, and anxiety disorder. Review of R97's quarterly ''MDS with ARD of 07/05/22 indicated that 97 had a BIMS score of 12 out of 15 which indicated R84 was cognitively intact. Review of R97's care plan under the EMR ''RAI'' tab indicated R97 had a self-care deficit with intervention to provide ADL care to ensure daily needs are met. Review of R97's undated care plan indicated he was totally dependent on staff for all ADL care. During an interview on 07/12/22 at 4:17 PM, R97 was observed seated in his wheelchair in a shirt soiled with food left over from lunch. R97 stated he did not receive assistance as needed with ADLS due to lazy staff. R97 said he sometimes laid in bed all night in a poopy brief because nobody checked on him and he cannot get up by himself. R97 stated that embarrassed him because he had roommates and they had to smell him all night. R97 stated he wants to be clean and not bother his roommates. R97 stated at times he did not get showers, or his sheets changed for days. R97's sheet at the foot of his bed was visibly dirty with brown unknown substance. During an observation on 07/13/22 at 2:30 PM, R97 was in his room sitting up in his wheelchair. The sheets were observed to be dirty on the end of bed with a brown unknown substance on his sheets. During an interview on 07/13/22 at 5:05 PM, LPN4 stated when they are short handed a lot of residents do not get showers or required assistance. She said she tells the DON and tries to make sure everyone gets what they need. LPN4 was unaware that R97 was laying in poop all night. During an interview on 07/13/22 at 4:51 PM, CNA9 said she could not always get to the residents timely due to not enough help. CNA9 said it depended on the staff and whether they are lazy. During an interview on 07/13/22 at 4:55 PM, CNA10 said he received a lot of complaints related to not receiving showers, ice, and assistance. During an interview on 07/14/22 at 2:48 PM, the Administrator stated her expectation was for residents to be cleaned by the CNAs. She said she did not receive any complaints regarding R97 laying in poop all night. The Administrator stated that all residents were to be treated with dignity and respect. During an interview on 07/14/22 at 3:53 PM, the DON stated her expectations were that incontinent care would be done and residents were kept clean. The DON said her expectation is residents will receive appropriate care, including, incontinent care, nail care, and soiled bed sheets changed. She said all residents were to be treated with dignity and respect. Review of the facilities undated policy titled Quality of Life -Dignity indicated: Staff shall promote, maintain and protect the resident's privacy including bodily privacy. 3. During observation and interview on 07/12/22 at 12:10 PM, R43 was observed sitting in a wheelchair in his room with three other roommates in a room of four residents. R43 was observed wearing a red shirt that was entirely too small. The t-shirt was observed to be tight and snug and only covering half of R43's arms, shoulders, and top breast area. R43s bottom breast area and whole stomach were observed to be fully exposed. When asked if this was his shirt, R43 stated, ''No, this is somebody else's shirt. I came from the hospital in an ambulance when I got here. This shirt belongs to someone else. It obviously doesn't fit me.'' When R43 was asked if he had mentioned it to any staff, he stated, ''Yes, and I'm not happy.'' At this time, R43's roommate heard the conversation, yelled across the room, and stated, ''I have a shirt you can wear. What size are you? I have a double XX shirt you can wear.'' At this time, R43's roommate was observed throwing one of his t-shirts across the room to give to R43. At this time, R43 was observed taking off his shirt red t-shirt and putting on his roommate's shirt that was just given to him. During observation and interview on 07/13/22 at 9:52 AM, R43 was observed wearing the same t-shirt from the day before that his roommate had given him. When asked where he got the t-shirt from, he stated, ''Well, my roommate gave me one of his shirts to wear yesterday.'' Review of a ''Face Sheet'' found in R43's electronic medical record (EMR) under the ''Profile'' tab revealed R43 was admitted to the facility on [DATE]. Review of the EMR under the ''Misc.'' (Miscellaneous) tab revealed no documentation of a resident inventory sheet or any documentation noted anywhere in the medical record of belongings when R43 was admitted to the facility on [DATE]. Review of R43's admission ''Minimum Data Set (MDS)'' found in the EMR under the ''MDS'' tab with an Assessment Reference Date (ARD) of 05/18/22 revealed the resident had a ''Brief Interview for Mental Status (BIMS)'' score of 14 out of 15, which indicated the resident was cognitively intact. Review of the section of the MDS that indicates residents ''Preferences for Routine & Activities'' R43 indicated that it was ''Somewhat important'' to him to choose what clothes to wear and ''Somewhat important'' to him to take care of personal belongings or things. Further review of the MDS indicated R43 was 275 pounds. Review of R43's care plan' found in the EMR under the ''Care Plan'' tab initiated on 06/02/22 indicated: ''ADLs (Activities of Daily Living): Self care performance deficit r/t [related to] requires assistance Dx [diagnosis]: obesity, blindness in one eye, kidney failure, and depression.'' Interventions are: ''Allow sufficient time for dressing and undressing . Ensure resident is . appropriately dressed . daily.'' During an interview on 07/13/22 at 4:27 PM, regarding R43's clothing the Unit Manager (UM) stated, ''The CNAs (Certified Nursing Assistants) are supposed to do the inventory sheets when someone is admitted . They are supposed to document what clothes the person is wearing, and if they have a watch, jewelry, shoes, just everything. They are supposed to write it down.'' The UM then stated, ''The CNAs are supposed to go over everything with the resident or family when they are admitted , and the social worker has a lot to do with that as well.'' When asked if she had received any complaints regarding clothing for R43, the UM stated, ''No, nothing to me however I have seen him with shorts that are too small. I have also seen him wearing too small of t-shirts before yes.'' When asked if she had told anyone about R43 wearing clothing that was too small, the UM stated, ''Yes, laundry.'' The UM then stated, ''When they come in, we tell them to write their names on their clothing when entering the facility. But yes, I have seen him before with clothes too small to be honest with you.'' The UM also stated, ''I did see him yesterday [07/12/22] in a red t-shirt and it looked too small too when I saw him.'' When the UM was asked what happens after an inventory sheet is completed when a resident is admitted to the facility, the UM stated, ''To be honest, we haven't even been keeping up with these and I'm not sure what is done with them.'' Review of a white binder labeled ''200 Hall Resident Inventory Sheets'' located at the nurses' station on the 200 unit revealed the binder to only have two pieces of paper with two residents personal inventory sheets in the whole binder. The rest of the binder was blank and there was no evidence of an inventory sheet for R43. During an interview on 07/13/22 at 4:45 PM, regarding R43's clothing, Certified Nursing Assistant (CNA) 5 stated, I have helped him get out of bed before, and when we get him up in the morning, if he even has any clothes, we will put them on, or we will have to borrow from the 'no name' area. I will be honest and tell you, he [R43] tends to run low on clothing.'' CNA5 then stated, ''The 'No-name' clothes are on a rack in the laundry.'' CNA5 stated, ''We do AM [morning] care, and he does therapy first thing in the morning, so if he had any clothes, they would be in his closet, but he has very little.'' During an interview on 07/13/22 at 4:55 PM, CNA6 stated, ''If he doesn't have any clothes, we get them from the 'no-name' clothes in the laundry that don't have anybody's name on them.'' During an interview on 07/13/22 at 5:15 PM, the Housekeeping Supervisor stated, ''We have no-name clothing available, and the staff will come down and get what they need for the residents.'' He then stated, ''If they [staff] let us know that a resident doesn't have any clothing, we will try to find clothing for them. If we know a resident doesn't have any clothes, we would be more than happy to give them some.'' When the Housekeeping Supervisor was asked if any staff have come to him asking for clothes for R43, he stated, ''No.'' During an observation and interview on 07/13/22 at 5:30 PM, an observation was made of R43's personal closet with the Housekeeping Supervisor. At this time R43's closet was observed to have 4 empty clothes hangers hanging, 1 small grey t-shirt, and 1 pair small silk shorts. Observation further revealed two hospital gowns, two white hospital blankets, and one blue Hoyer lift sling stuffed in the back of R43's closet on the floor. No additional pieces of clothing were found. At this time, the Housekeeping Supervisor was visibly upset, walked over to R43, and asked R43 his clothing sizes and informed R43 he would get R43 some clothes. At this time R43 replied with a smile and stated, ''Thank you.'' When the Housekeeping Supervisor was asked if he was made aware that R43 did not have any clothes, he stated, ''No, I was not informed of him needing clothes.'' During an interview on 07/13/22 at 5:42 PM, when the Social Services Director (SSD) was asked what the process was upon admission for a residents clothing and inventory, the SSD stated, ''Upon admission an inventory sheet located in a book at the nurses' station is supposed to be completed and it should be the CNA on the floor that completes the inventory sheet. If they [a resident] comes in from the hospital, then whoever is doing the admission, is the person that is supposed to go down to their room to see what they have.'' During an interview on 07/14/22 at 12:33 PM, when the Central Supply (CS) person was asked if there was an inventory sheet located in a thinned file for R43, she confirmed there was no inventory sheet completed when R43 was admitted to the facility. During an interview on 07/14/22 at 2:55 PM, the Physical Therapy Assistant (PTA) stated, ''There are times when he[R43] is wearing the same clothes every day.'' During an interview on 07/14/22 at 3:15 PM regarding resident clothing, the Administrator stated, ''It was my understanding that there is an electronic form that is sent to the family, and they will fill out an inventory sheet then send it back to us. The family completes the inventory sheet, but I do not know when this process started, I've only been here for two weeks.'' The Administrator stated, ''My expectation would be the CNAs should have let us know and the nurses as well. There should be some communication and I have not heard about this. We would have or should have also reached out to the family to see if they can help us.'' During an interview on 07/14/22 at 3:49 PM, the Director of Nursing (DON) stated, ''Initially we would call whoever their contact person is to see if they have clothes, they can bring in. My expectation as the DON is that anyone can fill out the inventory forms, but I do not see that was done for him.'' Surveyor: [NAME], [NAME]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure a clean, comfortable, and homelike environment for 10 of 33 sampled residents (R) (R48, R17, R45, R33, R257, R9, R31, R24, R59) and one supplemental resident (R155). Specifically, the facility had multiple rooms with holes in the walls, pieces of wall paneling coming off the walls, dirty bathrooms, missing bath bars for washcloths, towels, missing tiles, dirty/torn resident equipment, dirty air conditioner ducts, wall paneling being held together with duct tape, TV cables hanging down, and excessive noise. Findings include: 1. During the initial tour conducted on 07/12/22 at 9:30 AM, observation of Resident (R) 48's room revealed there to be large chunks of rotting food particles in the air conditioning wall unit located next to R48's bed. At this time, there was a large silver bolt sitting on the window seal. During observation on 07/13/22 at 9:07 AM, R48's room revealed the same rotting food particles were observed in the air conditioning wall unit located next to R48's bed as was the day before. The same large silver bolt was observed still sitting on the window seal. On 07/14/22 at 8:51 AM, during an environmental walkthrough with the Maintenance Director, (MD), the MD stated, ''If staff see something, they will put a work order in, and I can see them when I come in. Everything is electronic and any staff can log into the [name of the electronic system] and write up a work order.'' Regarding cleaning of the air conditioning wall units, the MD stated, ''Monthly I have a task and I do the AC (air conditioning) filters. I have to take the covers off and will spray them down if its dusty.'' When shown the rotting food particles in the air conditioning wall unit of R48's room, the MD stated, ''This whole unit needs to be pulled out. I wasn't aware of this. He [the resident] will have to be taken out of the room and the whole unit needs to be taken outside and hosed off, then dried and put back in.'' The MD then stated, ''I did not get a work order for this, but it needs to be taken off and cleaned out.'' 2. During observation of R17's and R45's shared triple room on 07/12/22 at 9:40 AM, revealed R45's right arm of the wheelchair was observed to be torn with padding sticking out. R45's bedside table (which was next to the resident) was observed to be dirty and had thick black build up material on the bottom of the metal frame. Further observation of the room revealed there to be a television (TV) mounted on the wall between bed A and B. The TV connector was observed coming out of the wall socket. At this time there was also a white cable connected to a metal adaptor that was also coming out of the wall. There was also a large hole observed in the wall to the left of the mounted TV. During observation on 07/13/22 at 9:40 AM, R45's right arm of the wheelchair was observed to be torn with padding sticking out. R45's bedside table (which was next to the resident) was again observed to by dirty with the same thick black build up material on the bottom of the metal frame as was the day before. Further observation of the room again revealed the TV mounted on the wall between bed A and B. The TV connector was again observed coming out of the wall socket. At this time, there was also a white cable connected to a metal adaptor that was also coming out of the wall. There was also a large hole observed in the wall to the left of the mounted TV. On 07/14/22 at 8:51 AM, during an environmental walkthrough, the MD was taken to R17's and R45's room and shown the bedside table for R45 being dirty with thick black build up material on the bottom of the metal frame, the MD stated, ''Housekeeping should be wiping it off.'' Regarding R45's wheelchair arm that was cracked and had padding sticking out, the MD stated, ''I was not aware of the wheelchair arm rest. No.'' Regarding the mounted TV cables between bed A and B, the MD stated, ''The TV cable is not supposed to be like this [meaning exposed from the wall]. You have to have a splitter where the cable comes out, but it should not be sticking out like this. No.'' The MD then stated, ''I was not aware of the hole in the wall either.'' 3. Observation of R33's triple room on 07/12/22 at 9:50 AM, revealed Bed A had large areas of the wall with chipped paint. R33 expressed concerns about the bottom of the wall paneling coming off. Observation revealed the wall leading to the resident's bathroom had much of the bottom of the wall paneling coming off. It was being held together with black duct tape however, the duct tape was not sticking, and the paneling was observed half on the wall and half on the floor. At this time large holes could be seen in the bottom of the wall through the plaster board. The flooring was hanging off the wall which hindered R33 from getting to the bathroom in his wheelchair without getting the wheels of his wheelchair caught. During interview R33 stated, ''The maintenance director put tape on it to hold it up, but it's still falling off. It has been like this for about two weeks.'' R33 then stated, ''I have gotten my wheelchair wheel caught on it when I'm trying to go to the bathroom.'' Observation, on 07/13/22 at 9:19 AM of R33's room revealed Bed A with the same large areas of the wall with chipped paint. Observation revealed the wall leading to the resident's bathroom with much of the bottom of the wall paneling coming off. It was again being held together with black duct tape. The duct tape was not sticking, and the paneling was observed half on the wall and half on the floor. Large holes could again be seen in the bottom of the wall through the plaster board. On 07/14/22 at 8:51 AM, during an environmental walkthrough, the MD was taken to R33's room and shown the wall paneling coming off. At this time, R33 was attempting to enter the bathroom with his wheelchair, it was observed that the wheel of the wheelchair caught in part of the flooring that was being held together with duct tape. The MD stated, ''I did see this [regarding the wall paneling] at some point, so I just taped it up with some tape. I can see where it came off. The whole wall needs to be fixed. The flooring has come down since I tacked it up. Yes, I can see where he [R33] gets his wheelchair caught on it.'' The MD then stated, ''I was aware of this, and I just threw some duct tape to get it up off the floor. It may have been a couple of weeks ago.'' The MD then stated, ''It can't be glued back up. The whole bottom part needs to be patched up to be fixed correctly. I just need to come back to it. I think we knew there is some extensive work that needs to be done here.'' Regarding the wall that have pieces of paint missing, are chipped, or have plaster on them the MD stated, ''The beds are so close to the walls, they are causing damage.'' 4. During observation of R257's four-person room on 07/12/22 at 11:00 AM, R257 was observed to have a broken foot board. Observation also revealed many pieces of paint on the wall near R257's head of the bed coming off. The wall on the B bed side was observed to have large pieces of chipped paint coming off and plaster. Observation of the bathroom (shared by four residents) revealed an empty urinal bag hanging where the call light was. There was also a large smeared brown substance on the toilet seat, and several pieces of white marble tile missing. Also observed missing was a bar holder where washcloths and towels are held. During observation of R43's four-person room on 07/12/22 at 12:15 PM, the wall on the B bed side had many pieces of chipped paint on the wall. During interview R43 stated, ''I have an issue in the bathroom with the pull chord. It was so nasty. There was brown poop on the pull chord and on the wall. This was about 3 days ago. I don't know if someone just wiped it down, or just cleaned it. I don't know.'' Observation of the bathroom revealed it to be dirty. During interview on 07/13/22 at 5:15 PM, the Housekeeping Supervisor (HKS) stated, ''We have a schedule we use. For deep cleans, we do a monthly schedule. For example, we will start at room [ROOM NUMBER] and so forth and deep clean. The bed is stripped, we move the furniture, clean the walls, dust. We check the curtains, clean the trash cans and bathrooms. Daily we pull the trash and line the trash cans, sweep and mop.'' When the HKS was asked if there were any environmental concerns brought to his attention, he stated, ''No.'' On 07/14/22 at 8:51 AM, during an environmental walkthrough, the MD was taken to R257's room at 9:36 AM, R257 was laying in bed with the broken foot board hanging off the bed. At this time, when the MD was asked if he was aware of this, or received a work order, the MD stated, ''No, I don't have a work order for this one. For this, I would have to get him out of bed and get it popped back on. We have brackets to hold the foot boards on. I was not aware of his foot board being off. No.'' When the MD was asked about the TV cables hanging down, the MD stated, ''I think the cables need to be cleaned up and attached to the wall someway. I was not aware of this either. As you can see, I have issues throughout the facility.'' When asked about the missing tiles in the bathroom, the MD stated, ''Yes, we have missing tiles and missing bath bars to place washcloths and towels. I agree, they are old, and the original tiles are missing. With the towel bars, I don't have any thoughts on that. I have not replaced any tiles, no. I've seen missing pieces throughout the building to the hand bars for holding washcloths and towels and I haven't replaced any.'' During an interview on 07/14/22 at 2:15 PM, regarding the environmental concerns, the Administrator stated, ''We have a work order that is put into [name of the electronic system] and maintenance would take care of it. If I see something, I will put a work order in.'' The Administrator then stated that she was not aware of any environmental complaints. 5. During an observation on 07/12/22 at 11:08 AM in R9's room, four white patched areas on the wall behind R9's bed were observed, one to two feet in diameter. There was also a larger patched area under the window of two by three feet in diameter. R9 stated the room had been like this since she had been living there. The walls were green in color and the patched areas were white. During an observation on 07/15/22 at 8:47 AM R9's room, the Maintenance Director (MD) stated the facility had just hired someone to drive the van and that this person was supposed to help him with maintenance. The MD stated right now this person was strictly driving and did not have time to assist him with maintenance. The MD stated he was notified of needed repairs through a computerized system that any employee could access to request repairs. The MD verified the wall had sections that had been patched but not painted and said corporate was coming in and applying plastic on the walls behind the beds for protection and after that would paint the rooms. 6. During an observation on 07/12/22 at 4:13 PM in R31's room, the top edge of the dresser was eroded to the particle board creating a rough surface along the top horizontal edge. None of the three drawers were able to be closed; all were partially open. R31 stated the dresser had been in disrepair since she was admitted , and the dresser had been provided by the facility. During a subsequent observation of R31's room on 07/15/22 at 8:59 AM with the Maintenance Director (MD), the MD stated they had recently replaced 20 nightstands in another part of the facility. The MD verified the dresser was in poor condition. The drawers were all partially open. R31 stated the dresser had been provided by the facility and it did not belong to her. 7. During an observation and interview on 07/12/22 at 11:56 AM in R24's room, R24, who resided in one of the four beds in the room, stated the alarms created a loud beeping noise that went off a lot and it was making her crazy. The resident put her hand against the wall and stated the wall vibrated from the noise. The alarms went off four times during the interview, which lasted approximately 30 minutes, and the surveyor and resident had to stop talking while the alarms were going off. The alarms were so loud a conversation was not possible. During an interview on 07/13/22 at 4:15 PM, R59, one of R24's roommates, stated it was noisy at times due to the alarms sounding. Observations of the nursing station area directly across from R24 and R59's room were made on 07/12/22 at 2:35 PM. The room was closest to the nurses' station and next to the door to the outdoor patio/smoking area. When call lights were activated for the unit, there was a continuous loud beep, beep, beep at the nurses' station until the light was answered. In addition, when the door to the smoking area was opened for residents to enter or exit, a loud continuous beep and a beep, beep, beep went off simultaneously until the door was closed as follows: -On 07/12/22 at 2:35 PM, the alarm for the exit door to the outdoor smoking area went off for three minutes while the door was propped open by staff so residents could go through to the smoking area. The alarm was piercingly loud. Licensed Practical Nurse (LPN) 1 stated it was their normal practice to prop the door open while residents were going out or coming back from smoking. -During observation on 07/12/22 from 4:18 PM - 04:34 PM, the continuous loud beep, beep, beep sounded from the call light system. The alarm sounded continuously for 16 minutes. During an interview on 07/14/22 at 2:45 PM, LPN3 stated the alarms were loud at the nurses' station area and it was frustrating for residents. LPN3 stated it was noisy when residents came in and out of the building to smoke because if the door was open too long it went off. LPN3 verified that call lights also sounded a beep, beep, beep and were loud until they were answered. During an interview on 07/15/22 at 8:59 AM, the MD stated the door to the smoking area sounded if it was open for more than 30 seconds. The MD evaluated the settings to the door alarm in the hallway near the nurses' station and stated it was currently set between 75% and 100% of maximum volume and, if he were instructed, he could turn down the volume. During the observation, call lights were going off in two rooms and the call light beep, beep, beep was sounding. 8. During an observation of R24 and R59's room on 07/12/22 at 11:56 AM, the wall behind one of the four beds in the room had numerous horizontal gouges, up to two feet long, in the sheet rock behind the bed. During an observation on 07/15/22 at 9:03 AM, the MD verified the wall was gouged behind one of the beds and that he was not aware of this. He stated corporate had provided a crew that was coming in and making repairs to the walls and painting throughout the building. The MD stated the building was about [AGE] years old. The MD stated repairs were initiated in the short term stay rooms and the four bed wards such as this one in the long-term care area, would be last to be repaired. The MD stated he was not sure how long the project to repair the walls and paint the rooms would take but the corporate crew had been completing about two rooms per day when they were able to come. He stated he was the only full-time maintenance staff for the building, and it required a lot of attention. 9. During an observation on 07/15/22 at 8:56 AM in R24 and R59's room, a section of the base board approximately two feet in length in the closet area of room [ROOM NUMBER] had peeled away from the wall and was lying on the floor. The MD was in the room with the surveyor and verified it needed repair. The MD stated he had not been informed about the base board but would come back and tack it down. 10. During an observation on 07/13/22 at 4:28 PM of R155's bathroom, the bathroom light switch in the room was activated. The bathroom light did not come on and the bathroom was dark. It was a bathroom shared by two adjoining rooms. R155 stated at this time that he used the bathroom, and the light was on at times. The light switch from the adjoining room was checked and the light in the bathroom went on. During an observation on 07/15/22 at 8:55 AM, the MD stated he had not known that the light switch when activated in R155's room did not work. He verified the switch in R155's room did not work but the adjoining room did. The MD stated a three-way switch was needed and it was possible a two-way switch had been installed. During an interview on 07/16/22 at 2:55 PM, the Administrator stated she was new in her position but had identified the environment as an area that needed attention. She stated they had started work systematically and planned two phases for completion. The Administrator verified the plan to put plastic behind the beds and that they had a crew to assist with this. She stated, We know the rooms need work and further stated this included finishing painting, applying back board, base board, and furniture. She stated they had applied the back board behind beds in about 20 rooms thus far. The Administrator verified the 100 halls for long term residents would be addressed last because it was easier to tackle rooms as they were vacated which occurred more frequently in the short term stay section.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide residents their showers as scheduled and nail care according to the Plan of Care ADL (Activities of Daily Living) for four of six residents (R) (R59, R14, R97, and R3) reviewed for ADL care in the sample of 33. Findings include: Record review of the undated ADL policy: Activities of daily living (ADLs) include Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the center must provide the necessary care and services to ensure that patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrates that such diminution was unavoidable. To include hygiene, bathing, dressing, grooming, and oral care, to attain or maintain the patient's highest practicable physical, mental, and psychosocial well-being. The Center must ensure a patient is given the appropriate treatment and services to maintain or improve his/her ability to carry out ADLS and a patient who is unable to carry out ADLS receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab, revealed R59 was admitted to the facility on [DATE]. Diagnoses included dementia, fibromyalgia, and pressure ulcer of the sacral region. Review of the quarterly Minimum Data Set [MDS] with an assessment reference date (ARD) of 06/07/22 revealed R59 was unimpaired in cognition with a Brief Interview for Mental Status score (BIMS) of 13 (score of 13 - 15 indicates intact cognition). The resident did not exhibit any behaviors during the assessment period. R59 required extensive assistance for activities of daily living (ADLs) including dressing and personal hygiene and was dependent for toilet use and bathing. Review of the care plan dated 01/11/22 in the EMR under the Care Plan tab, revealed the problem of, ADL self-care deficit AEB [as evidenced by] requires assistance d/t [due to] muscle weakness, dementia, fibromyalgia The goal was, Resident's needs will be met daily; she will not exhibit a significant change in ADL function through the review date. Interventions in pertinent part included: Bath/shower, shampoo, and routine nail care per facility protocol and residents' preference . Encourage the resident to participate to the fullest extent possible with each interaction. The care plan did not address personal hygiene or grooming specifically. Observations revealed R59 had greasy hair and thick, long, grey, and white chin hairs that were approximately one-half inch long, throughout the duration of the survey: -On 07/12/22 at 12:25 PM, R59 was lying in bed with her lunch tray on the over-bed table with the door wide open. R59 was noted with greasy hair and long chin hairs. R59 shared a room with three other residents. -On 07/13/22 at 4:15 PM, R59 was lying in bed with the door wide open and noted with greasy hair and long chin hairs. R59 stated she was aware her hair needed to be washed and of the chin hairs and stated she needed help from staff to remove them, stating, I can't do it myself. -On 07/14/22 at 12:46 PM, R59 was lying in bed with the door wide open and noted with greasy hair and long chin hairs. -On 07/14/22 at 2:51 PM, R59 was lying in bed with the door open and noted with greasy hair and long chin hairs. -On 07/16/22 at 9:38 AM, R59 was asleep in bed with the door wide open and noted with greasy hair and long chin hairs. They had not been removed. During an interview on 07/14/22 at 9:48 AM, the DON stated residents were scheduled to be bathed three times a week. If they refused, staff were to go back and offer again. During an interview on 07/14/22 at 2:31 PM, Certified Nursing Assistant (CNA) 2 stated facial hair was removed with showers or in between shower days if she needed. CNA2 stated R59 could have the hairs pulled or she could shave her. CNA2 stated she had provided care to R59 a long time and the resident refused care at times, however, if she went back later, she was always able to provide the care. During an interview on 07/14/22 at 2:51 PM, Licensed Practical Nurse (LPN) 3 stated shaving facial hair for women was normally completed during showers when residents had their hair washed. LPN3 stated it a resident refused; it was supposed to be documented on the shower sheet. LPN3 went into R59's room with the surveyor at this time. R59 stated she wanted the chin hairs removed and stated it itched. R59 stated, I know my hair is greasy and needs to be washed. LPN3 stated the staff would give her a shower and remove the facial hair the next day. After leaving the room, LPN3 verified R59 needed her chin hairs removed and stated R59's hair was greasy and needed to be washed. During an interview on 07/14/22 at 4:05 PM, the Director of Nursing (DON) stated if R59 refused showers, staff should check with her daily and staff should document the refusals. The DON stated female's facial hair should be removed during shower time. CNAs should ask R59 if she wanted to be shaved. During an interview on 07/16/22 at 9:48 AM, LPN1 stated there was a schedule in the shower room and CNAs bathed residents per the schedule. There were bath sheets for each resident on a clipboard and there should be a sheet for R59. LPN1 stated she was not aware of any recent refusals regarding showers or removal of facial hair for R59; however, the resident did refuse at times which should be documented on the bath sheets. The clipboard with the bath sheets for the 100 hall residents was reviewed on 07/16/22 at 9:52 AM. There were no bath sheets for R59. During an interview on 07/16/22 at 11:19 AM, the DON stated hygiene, including the removal of facial hair, should be completed with showers or in between. If it was not done due to refusal, it should be documented as refused. The DON stated the bath sheets were intended to let the nurses know whether a bath had been completed or refused. Each bath sheet was for a one-week period; a new sheet would be started each week. 2. During an observation on 07/12/22 at 4:36 PM, R14 was observed in her room in bed. R14 was noted to have a brown substance underneath her fingernails on both hands. R14's hair was oily and uncombed. R14 was alert with confusion and only answered yes or no questions. Review of R14's EMR revealed the undated Face Sheet under the Resident tab indicated R14 was admitted on [DATE]. Review of R14's quarterly MDS with ARD of 4/12/22, located in the resident's EMR under the RAI [resident assessment instrument] tab indicated R14 had a BIMS score of 9 out of 15 which indicated R14 was cognitively impaired. Review of R14's care plan located in the resident's EMR under the RAI tab indicated a problem with limited mobility, personal hygiene and bathing with interventions to assist with all ADL needs including routine nail care. During an interview on 07/13/22 at 4:47 PM, CNA8 stated she had been off for the past two days and residents do not receive ADL care or showers while she is off work. CNA8 verified R14 had a brown substance underneath her fingernails on both hands and her hair was oily. CNA 8 also verified R14 also had dried food on her shirt. During an interview 07/13/22 at 4:55 PM, CNA10 stated he was on light duty and worked three days a week. CNA10 said he passed ice and noticed R14 appeared to be unkempt and in need of ADL care. CNA 10 said he received a lot of complaints related to not receiving showers, ice, and assistance. CNA10 said that was not part of his job due to being on light duty. 3. Review of R97's EMR revealed the undated Face Sheet under the Resident tab indicated R97 was admitted on [DATE] and readmitted on [DATE]. R97 had diagnoses of chronic kidney disease, major depressive disorder, muscle weakness, and anxiety disorder. Review of R97's quarterly MDS with ARD of 07/05/22 indicated that R97 had a BIMS score of 12 out of 15 which indicated R97 was cognitively intact. Review of R97's care plan under the RAI tab indicated R97 had a self-care deficit with intervention to provide ADL care to ensure daily needs are met. Review of R97's undated care plan indicated he was totally dependent on staff for all ADL care. During an interview and observation 07/12/22 at 4:17 PM, R97 was up in his wheelchair and had food left over from lunch on his shirt. R97 said he did not get assistance as needed with ADLs due to lazy staff. R97 said he sometimes laid in bed all night in a poopy brief because nobody checked on him and he cannot get up by himself. R97 said at times he did not get showers, or his sheets changed for days. His sheet at the foot of his bed was visibly dirty with brown unknown substance. During an observation on 07/13/22 at 2:30 PM, R97 in room sitting up in wheelchair sheets dirty on the end of bed with a brown unknown substance on his sheets. During an interview on 07/13/22 at 5:05 PM, LPN4 said when they were short handed a lot of residents did not get showers or required assistance. LPN4 said she tells the DON and tries to make sure everyone gets what they need. 4. Review of R3's EMR revealed the undated Face Sheet under the Resident tab indicated R3 was admitted on [DATE]. R3 had diagnosis of: Alzheimer's disease, dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood. Review of R3's MDS with an ARD date of 05/20/22 revealed that R3 had a BIMS score of 5 out of 15 which indicated R3 was cognitively impaired and was extensive assist of one nurse aide for personal hygiene and for bathing. Review of R3's care plan under the RAI tab indicated R57 had a self-care deficit with intervention provide ADL care to ensure daily needs are met. During observation on 07/13/22 at 8:53 AM, R3's fingernails were dirty with brown substance underneath her nails on both hands. During observation on 07/13/22 at 3:31 PM, R3 was in the hallway in her wheelchair yelling out. R3 was alert with confusion. R3's fingernails had brown substance underneath them on both hands. R3's hair appeared disheveled, and she was noted to be wearing the same clothes she wore on 07/12/22. During observation on 07/13/22 at 3:50 PM, R3's fingernails appeared dirty with brown substance underneath nails on both hands. During an observation on 07/14/22 at 11:49 AM, R3 was in dining room and up and down the hallway. R3's fingernails were observed with brown substance underneath fingernails on both hands. During an interview on 07/13/22 at 3:03 PM, CNA8 said she gives R3 showers but gets complaints about residents not getting service while she is off. CNA8 was off the last 2 days and said residents did not receive ADL care. During an interview on 07/13/22 at 5:00 PM, Licensed Practical Nurse (LPN) 4 stated when the facility was short staffed residents did not get showers or other assistance with ADL care. LPN4 said she tried to ensure residents received assistance they needed. LPN4 said she reported the issues to the DON. During an interview on 07/13/22 at 4:51 PM, CNA9 stated she cannot always get to the residents in a timely manner due to not enough help. CNA9 said it depended on the staff working if residents receive appropriate care. During an interview on 07/14/22 at 2:48 PM, the DON said her expectations were that nail care would be done and kept clean, she said showers were given three times a week but sometimes they refuse. The DON said she required staff to ask the residents twice to take a shower after they refused. During an interview on 07/14/22 at 2:48 PM, the Administrator indicated her expectations were for resident's nails to be cleaned by the CNAs. The Administrator said she was unsure of how often residents received showers but maybe twice a week. She said staffing was challenging and she had not received complaints about residents not getting showers or required assistance with ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policy the facility failed to ensure five residents out six (R) (R307, R88, R308, R46 and R153) reviewed for advance directives had their code status consistently documented throughout their electronic medical record (EMR) for easy access to the clinical staff. Findings include: Review of facility-provided policy with no date, titled ''Code Status Orders'' reveled ''Code status communicates to the clinical staff whether the patient, desires cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest . code status will be easily accessible to the clinical staff for all patients. All patients require a code status order as soon as possible upon admission '' Review of facility-provided policy, with no date titled ''Cardiac and/or Respiratory Arrest'' revealed ''.The Center will perform CPR on all patients, except in limited circumstances, unless there is a written physician's order . not to resuscitate (DNR) . Purpose To ensure patient's wishes are followed in the event of cardiac arrest. To provide a process to determine when to initiate CPR/AED [automated external defibrillator] and what steps to follow when providing CPR/AED '' 1. Review of R307's ''Admissions Record,'' located under the ''Profile'' tab of her electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Review of R307's ''Code status'' heading was blank under her ''Profile'' tab, indicating the facility did not enter R307's code status information. Review of R307's ''Diagnosis'' tab of her EMR revealed multiple diagnoses to include angina [chest pain caused by inadequate blood flow to the heat] and streptococcal arthritis right knee. Review of R307's admission ''Minimum Data Set [MDS],'' with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating R307's cognition was intact. Review of R307's physician's orders under EMR ''Order'' tab revealed no order for code status, indicating the facility did not document a physician's order for her code status. Review of R307's EMR ''Medication Administration Record'' (MAR) for [DATE] under the heading ''Advance Directives'' was blank, indicating her code status information was no documented. Review of R307's ''Misc'' tab on her EMR contained no documents for advance directives, Provider Orders for Life-Sustaining Treatment (POLST), or code status indicating no such documents existed on her EMR. During an interview on [DATE] at 2:49 PM, Licensed Practical Nurse (LPN) 2 confirmed the staff located the resident's code status on the resident's EMR under patient's ''Profile'' tab next to word code status or on the residents electronic MAR under heading advance directive and if not on either place the staff would look under orders tab to verify residents code status in the event of unresponsive and or cardiac arrest. During a second interview and record review on [DATE] at 3:26 PM, LPN 2 confirmed and verified R307's EMR under ''Profile'' tab did not have her code status information and was blank next to code status heading. LPN2 confirmed R307's MAR did not have her code status and her care plan did not have her code status information or her physician's orders. LPN2 confirmed R307's code status should be consistent and included on her EMR. During an interview on [DATE] at 3:58 PM, Unit Manager (UM) confirmed R307 did not have her code status wishes documented on her EMR to include on her ''Profile'' tab next to heading ''Code Status'' was blank, her ''MAR'' under the heading ''Advance Directives'' was blank and her physician's orders under ''Orders'' tab did not have an order for her code status. UM stated she was unsure why R307's code status was not documented on her EMR. UM stated the social services staff should verify R307's code status on her admission to the facility. During an interview conducted on [DATE] at 9:53 AM, Social Services Director (SSD) confirmed and verified R307's EMR under ''Profile'' tab code status was blank, and she had no physician order under ''Orders'' tab for her code status. SSD stated she had R307's ''POLST'' documents in her office, inaccessible to the clinical staff on nights and weekends when her office was closed. R307 confirmed clinical staff would not know where to look for R307's POLST. Review of facility-provided paper document titled ''POLST'' revealed the code status section was not completed and was signed and dated by resident and physician on [DATE]. During an interview on [DATE] at 2:35 PM, SSD stated she corrected R307's ''POLST'' document, continuing she went and spoke with R307 to make the correction to the document. SSD provided surveyor with R307's paper document titled ''POLST'' that was completed and had ''Allow Natural Death'' marked signed and dated [DATE] for review. 2. Review of R88's ''Admission'' located under the ''Profile'' tab of her EMR, revealed she was admitted to the facility on [DATE]. Review of R88's ''Med Diag'' tab of his EMR revealed multiple diagnosis to include diabetes and chronic kidney disease Stage 3. Review of R88's admission MDS with an ARD of [DATE] revealed her BIMS score of 15 out of 15 indicting she was cognitively intact. Review of R88's ''Code Status'' heading under her ''Profile tab'' was blank indicating her code status was not consistent/documented throughout R88's EMR Review of R88's EMR ''Orders'' tab MAR under heading ''Advance Directive'' revealed no entry and was blank, indicating R88's code status was not documented or consistent thought-out her EMR. Review of R88's physician's orders under ''Orders'' tab revealed no physician order for code status or advance directives. Review of R88's ''Misc'' tab revealed no documents regarding code status, advance directive or POLST. During an interview and record review on [DATE] at 3:19 PM, Licensed Practical Nurse (LPN) 2 verified and confirmed R88 did not have her code status on her EMR under ''Profile'' tab next to the heading code status or her MAR under the heading ''Advance Directives'' was blank. LPN2 verified and confirmed R88 did not have a code status included on her care plan or her physician's orders under ''Orders'' tab. During an interview and record review on [DATE] at 3:55 PM, UM who verified and confirmed R88 did not have a code status entered under her ''Profile'' tab or on her MAR next to heading ''Advance Directive.'' UM verified and confirmed R88 did not have a physician's order for her code status under ''Orders'' tab. UM confirmed R88 should have a code status included on her EMR for staff to access the information in case of an emergency. UM stated the information was imperative so the staff would know how to respond to resident in an emergent situation. During an interview on [DATE] at 9:53 AM, SSD confirmed and verified R's code status was not consistent on his EMR under the ''Profile'' tab next to the heading code status was blank, there was no information under R88's ''Misc'' tab regarding code status or his advance directive. SSD confirmed she had R88's ''POLST'' document in her office, somewhere, and her office was inaccessible to clinical staff after hours and on weekends. SSD stated she would provide surveyor with R88 documents for review. Director of Nursing entered SSD office on [DATE] at 10:00 AM and joined the interview. DON confirmed the facility's clinical staff access the facility resident's code status on the resident's EMR under ''Profile ''tab next to the heading. DON stated if the resident's code status was not listed under profile the staff would be expected to look on their EMR MAR to verify code status and if there was no information there the staff would look under Orders tab to verify the resident's code status. Review of facility-provided paper document titled ''POLST'' dated [DATE] that revealed ''.Do Not Attempt Resuscitation'' signed by physician and resident dated [DATE]. 3. Review of R308's EMR under ''Profile'' tab revealed R308 was admitted to the facility on [DATE]. Review of R308's EMR ''Profile'' tab next to heading code status was blank. Review of R308's EMR ''Orders'' tab had no physician's order for code status. Review of R308's EMR ''Misc'' tab had no documents for advance directives or code status. Review of R308's EMR care plan' under ''Care Plan'' tab revealed no information regarding code status or advance directive. During an interview and record review on [DATE] at 3:22 PM, LPN2 who verified and confirmed R308's EMR ''Profile'' tab and her MAR did not have her code status information. LPN2 verified and confirmed R308's care plan did not include information regarding her code status. LPN2 confirmed R308's code status should be consistent and included on her EMR. During an interview and a record review on [DATE] at 4:02 PM, UM who verified and confirmed R308's EMR under ''Profile,'' MAR, and physician's order next to heading code status were blank and did not have information entered. UM confirmed R308's wishes and desires for code status should be accurately and consistently documented on R308's EMR. Requested R308's advance directive or code status information from Social Services Director (SSD) on [DATE] at 11:36 AM. No information was provided, and SSD stated no information was available or documents were available including advance directive acknowledgement. R308 was not available for an interview about her code status. 4. Review of R46's EMR ''Profile'' tab revealed he was admitted to the facility on [DATE] and ''Code Status'' heading was blank and had no information entered. Review of R46's ''Med Diag'' tab revealed multiple diagnoses to include shortness of breath. Review of R46's admission MDS'' with an ARD of [DATE] revealed a BIMS score of 14 out of 15, indicating R46's cognition was intact. Review of R46's physician orders under ''Orders'' tab revealed '' .DNR .'' dated [DATE]. Review of R46's MAR revealed heading ''Advance Directive'' was blank and revealed code status was not consistently documented by the facility throughout R46's EMR. Review of R46's ''Care Plan'' tab revealed '' .DNR '', indicating physician's order for code status to be DNR. Review of R46's ''Misc'' tab revealed no information or documents regarding advance directive or DNR documents. Review of facility-provided paper document titled ''POLST'' revealed ''.Allow Natural Death. (DNR) signed and dated [DATE]. During an interview on [DATE] at 9:53 AM, DON verified and confirmed R46's EMR did not have code status under his ''Profile'' tab or his MAR, and had a DNR physicians order under his ''Orders'' tab. DON verified and confirmed R46's EMR was inconsistent and was missing data regarding his wishes and desires for DNR. 5. Review of R153's EMR under ''Profile'' tab revealed ''admission Record'' R153 was admitted to the facility on [DATE] and discharged on [DATE] and under the heading ''Advance Directive'' was blank indicating inconsistency or omission of code status on her medical record. Review of R153's ''Med Diag'' tab revealed multiple diagnosis to include acute respiratory failure, chronic kidney disease, thrombosis due to vascular prosthetic devices, atrial fibrillation. Review of R153's EMR MAR dated for the month of [DATE] under the heading ''Advance Directive'' was blank and no code status was entered. Review of R153's EMR ''Prog Note'' tab revealed ''.Was called to room by CNA [Certified Nursing Assistant] and patient passed away in her sleep. Notified Supervisor on duty. Could not identify if patient was a DNR or Full Code. Ran to room to start CPR then supervisor determined that patient is a DNR. CPR was NOT Started.'' dated [DATE] at 9:21 PM and ''.Resident observed with no visible respirations or audible breath and heart sounds via auscultation. Resident DNR per hospital records. Pronouncement of death at 2115 [9:15 PM]. Attempted to call all family members and phone numbers, left several messages to please return our calls. Unable to speak to any family members to notify. Call placed to [sheriff's office] to request for them to assist us with location and notification of next of kin. [Husband] returned call to facility and I notified him of her passing. He stated that he will be notifying his son so that he can assist make arrangements. [funeral home] arrived at the facility to pick up her remains.'' dated [DATE] at 4:05 AM. Review of R153's ''Misc'' tab revealed document titled ''PRONOUNCEMENT OF DEATH'', dated [DATE] revealed ''. MEDICAL CERTIFIER'S NAME . [Medical Director].'' There was no document titled Advance Directive or POLST. Review of R153's document titled ''Hospital Record'' revealed ''. Code Status: DNI/DNAR [Do Not Intubate/Do Not Attempt Resuscitation]. During an interview on [DATE] at 10:01 AM, Registered Nurse (RN) 2 stated there was not a POLST available to her in the EMR for R153 on [DATE]. RN2 stated she was called to R153's room where R153 was not breathing and had no pulse. RN2 stated she called out to one of the other nurses to ask what R153's code status was. RN2 stated the nurse responded that she did not see R153's code status. RN2 stated the nurse would have looked on R153's EMR MAR for her code status. RN2 stated there was no information on her MAR for her code status. RN2 stated normally staff would do a full code if we would start CPR. RN2 stated she did not recall if the staff started CPR on R153 or not. RN2 stated R153 had no order on her medical record in EMR for a code status. RN2 stated there were several staff in the room but she was unsure who the staff were. RN2 stated she left the room to research R153's code status in her EMR and found the hospital record under the MISC tab and reviewed and found note the regarding DNR. RN2 stated R153's MISC'' tab had no POLST or Advance Directive. RN2 stated she told someone in the hallway to let the staff that were in the room with R153 know that she was a DNR. RN2 stated it was important to have resident's code status on a resident's EMR so treatment can begin immediately. RN2 stated the facility's policy was if there was no code status on resident's EMR to start CPR immediately. RN2 stated she was uncertain if CPR was started on R153. RN2 stated it was important to start CPR immediately because it saves lives, and the chance of survival rate is higher. RN2 stated if staff began CPR and later discovered resident was DNR the staff would stop CPR. During an interview on [DATE] at 9:29 AM, SSD stated advance directives were on facility's residents EMR under documents or in a file in her office. SSD stated her responsibility regarding advance directive on resident's admission was to talk to resident and inquire of resident's wishes for advance directive or if advance directive exists. SSD stated she reviewed residents; POLST quarterly. SSD confirmed resident's code status should be on their profile tab next to the heading ''Code Status'' to indicate resident's wishes and desires. SSD stated she would inform the nurses by email to DON to change code status or enter information on the profile next to heading code status. SSD stated she did not enter the resident's code status information on residents EMR under ''Profile'' tab next to heading code status. SSD confirmed residents should have a physician's order for code status. SSD stated the nurse or DON acquired a physician's order for resident's code status. SSD confirmed the facility's expectation was resident's EMR at the facility had a physician's order for all the code status including full code and DNR code status. SSD confirmed clinical staff verified a resident's code status in EMR under profile tab under the heading code status in an emergent situation that required life sustaining treatment. SSD confirmed the second place the clinical staff verified residents code status was on resident's EMR under ''Misc'' tab under documents and if no information was there the staff should start CPR and treat resident as a full code. SSD confirmed consistent code status on resident's EMR was important to direct clinical staff how to provide treatment for resident. SSD confirmed resident's inconsistent medical records for resident's code status could cause potential harm to residents (physical harm) and or harm for resident's family (emotional harm).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to have a system in place to ensure respiratory equipment was bagged when not in use, date/label oxygen tubing and humidifiers when changed out, and clean respiratory filters. The facility also failed to ensure respiratory care consistent with professional standards of practice was provided for four of four residents (R) (R43, R48, R84, and R46,) reviewed for respiratory care/oxygen therapy. Findings include: Review of the facility's policy titled, ''Oxygen Administration,'' revised on 12/12/20, indicated, ''Oxygen will be administered as per MD [medical doctor] order to aid in breathing . Date and initial tubing and humidifiers when started each week. Pre-billed humidifier bottle need only to be changed weekly or when empty if this is before week has been completed.'' 1. Observation and interview on 07/12/22 at 12:07 PM, revealed R43 to be sitting in a wheelchair wearing oxygen via nasal cannula. At this time, R43 was observed to be on 3 Liters of continuous oxygen via nasal cannula, and the humidifier bottle attached to the oxygen concentrator was observed to be empty and dry. There was no date or label on the oxygen tubing or humidifier as to when the last time they were changed. During interview, when R43 was asked if anyone has come to change out the oxygen tubing or humidifier. R43 stated, ''They haven't changed my 02 tubing since I've been here. I've never seen anybody come to change them out.'' A second observation was made on 07/13/22 at 9:52 AM. During observation and interview, R43 was observed to be lying in bed. R43 was observed to be on 3 liters of continuous oxygen via nasal cannula again and the oxygen tubing was again observed to not be dated or labeled. The humidifier bottle attached to the oxygen concentrator was again observed to be empty and dry. During interview, R43 stated, ''I'm on 3 Liters of oxygen.'' When asked again, if anyone has ever come to change out the oxygen tubing or the humidifier, R43 stated, ''Well, no. No-one has ever come to change out my tubing since I've been here. The humidifier is usually empty too.'' Review of a ''Face Sheet'' located in R43's electronic medical record (EMR) under the ''Profile'' tab revealed diagnoses to include chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, chronic respiratory failure, congestive heart failure, and shortness of breath. Review of ''Physician Orders'' dated 05/12/22 located in R43's EMR under ''Orders'' tab indicated, ''Oxygen @ 2-3L/min (liters/minute) via nasal cannula every shift for COPD.'' Further review of the physician orders indicated, ''Change oxygen tubing once weekly in the morning every Mon [Monday] for oxygen maintenance.'' Review of the admission ''Minimum Data Set [MDS] found in the EMR under the ''MDS'' tab with an Assessment Reference Date (ARD) of 05/18/22 revealed the resident had a ''Brief Interview for Mental Status [BIMS]'' score of 14 out of 15, which indicated the resident was cognitively intact. The MDS further revealed R43 received oxygen therapy. Review of a ''Baseline Care Plan'' dated 05/12/22, found in the EMR under the ''Misc.'' (Miscellaneous) tab, indicated, ''Uses Oxygen therapy while a resident.'' Review of a ''Care Plan'' found in the EMR under the ''Care Plan'' tab initiated on 06/03/22 indicated, ''Respiratory: At risk for altered respiratory status r/t [related to] pulmonary edema, COPD, obesity, CHF, and respiratory failure with hypoxia.'' Interventions are: ''Administer Oxygen as ordered.'' 2. Observation on 07/12/22 at 9:35 AM revealed oxygen tubing that was not dated/labeled hanging over an oxygen concentrator. The oxygen tubing was touching the floor. At this time, the oxygen tubing was not in a bag and there was no date when the tubing was changed out. The humidifier bottle that was connected to the oxygen concentrator was also observed to be empty and dry. There was no date on the empty pre-filled humidifier when it was changed out. Observation and interview on 07/13/22 at 9:07 AM revealed R48 lying in bed eating breakfast. At this time, R48 was observed to have continuous oxygen on via nasal cannula at 2 liters/minute. At this time, observation of the oxygen tubing revealed no date/label when the tubing was changed out. The oxygen humidifier was again observed to be empty and dry with no date/label on it. During interview, R48 stated, ''I like to have the humidifier mist at night, but it has been empty for quite some time.'' When R48 was asked if any staff have come to change out the oxygen tubing, or the humidifier, R48 stated, ''No, nobody has come by to change it out. Nothing.'' Review of a ''Face Sheet'' located in R48's EMR under the ''Profile'' tab revealed diagnoses to include chronic obstructive pulmonary disease, unspecified asthma, and chronic diastolic congestive heart failure. Review of ''Physician Orders'' dated 05/27/22 located in R48's EMR under ''Orders'' tab indicated, ''Oxygen at 2 L/min [liters/minute] via nasal cannula continuously every shift for oxygen management.'' Review of the admission ''Minimum Data Set (MDS) found in the EMR under the ''MDS'' tab with an Assessment Reference Date (ARD) date of 06/03/22 indicated the resident had a ''Brief Interview for Mental Status (BIMS)'' score of 15 out of 15, which indicated the resident was cognitively intact. The MDS further revealed R48 received oxygen therapy. Review of a ''Care Plan'' found in the EMR under the ''Care Plan'' tab initiated on 06/08/22 indicated, ''Respiratory: The resident is at risk for altered respiratory status r/t [related to] COPD, Sleep Apnea, and Asthma.'' Interventions are: ''Administer oxygen as ordered.'' 3. Observation on 07/12/22 at 10:51 AM, revealed R84's oxygen tubing was connected to the O2 concentrator was not dated/labeled when it was changed out. The humidifier bottle that was connected to the oxygen concentrator was also observed to empty and dry. There was no date on the humidifier bottle when it was last changed out. Observation on 07/12/22 at 3:26 PM, revealed R84 in his room asleep in bed with oxygen on. At this time, observation of the oxygen tubing revealed no date/label when it was changed out and the humidifier bottle was again observed to be empty and dry with no date/label when it was changed out. Observation and interview on 07/13/22 at 9:15 AM, revealed R84 sitting up in his wheelchair. Observation revealed R84 to be on three and a half liters/minute of continuous oxygen. R84 was observed to have the oxygen nasal cannula in his nose. At this time, there was no date/label on the oxygen tubing as to when it was changed out. During interview when R84 was asked if staff come to change out the oxygen tubing or his humidifier, R84 stated, ''No, never.'' Review of a ''Face Sheet'' located in R84's EMR under the ''Profile'' tab revealed diagnoses to include unspecified combined systolic (congestive) and diastolic heart failure, pneumonia, and acute respiratory failure with hypoxia. Review of ''Physician Orders'' dated 07/08/22 located in R84's EMR under ''Orders'' tab indicated, ''Oxygen at 2-6L/min via NC [nasal cannula] for SOB [shortness of breath] and 02 sats<90 [oxygen saturations below 90%]. Review of the ''Discharge-return anticipated MDS'' found in the EMR under the ''MDS'' tab with an Assessment Reference Date (ARD) date of 06/29/22 indicated short term memory was ok and cognitive skills for daily decision making was modified independence. The MDS indicated R84 had shortness of breath, trouble breathing with exertion, and received oxygen therapy. Review of the ''Care Plan'' found in the EMR under the ''Care Plan'' tab revised on 05/21/22 indicated, ''ADLs [Activities of Daily Living]: Self-care performance deficit r/t requires assistance .'' Interventions are: ''Administer oxygen as ordered r/t SOB.'' During an interview on 07/13/22 at 1:49 PM regarding oxygen use for R43, Certified Nursing Assistant (CNA) 3 stated, ''He [referring to R43] is supposed to wear oxygen all the time. For the oxygen tubing, we change it as often as needed. We change it every other day. For the humidifiers, the nurses change out the humidifiers. We just let them know and the nurses change those out. But sometimes, if the nurse is busy during the days, then we can also change out the humidifiers.'' During an interview on 07/13/22 at 1:53 PM, the Administrator was asked how often the oxygen tubing was supposed to be changed, and humidifiers filled. The Administrator stated, ''I've only been here for two weeks. I would need to see the orders, and I would need to check our policy to let you know.'' During an interview on 07/13/22 at 1:57 PM, regarding oxygen, CNA8 was asked if she changes out the resident's oxygen tubing. CNA8 stated, ''No, when I'm here, I have never changed any out.'' When asked if she ever changes out resident oxygen humidifiers, CNA8 stated, ''I look at the humidifier and if they are low with water, I report it to the nurse to let them know. The response from the nurses is generally, ''I will go look and go check on it.'' During an interview on 07/13/22 at 2:29 PM, the Unit Manager (UM) stated, ''It is the night shift that are supposed to change out the oxygen tubing and they are supposed to date when it was changed out. They are supposed to change out the humidifiers and the tubing too.'' The UM then stated, ''I didn't even know the concentrators had filters to be honest with you. I really don't know who changes those out. But, with the humidifiers, it is the night shift who are supposed to change those out.'' During an interview on 07/13/22 at 2:52 PM, regarding oxygen, the Central Supply (CS) person stated, ''I change the oxygen tubing once a week. Every Wednesday, I clean the filters every Wednesday and the humidifiers can be prn [as needed] because they run out of water faster.'' The CS person then stated that she did not keep any documentation of when the oxygen tubing was changed out, humidifiers changed, or the oxygen concentrator filters changed out. The CS person stated, ''Everybody on oxygen, their tubing has to be changed out every Wednesday.'' The CS person then stated, ''When I change out the oxygen tubing every Wednesday, the 02 bag has to be changed with the tubing. I will also leave the tubing in the bag and date it.'' When the CS person was asked, what exactly do you date, she stated, ''I date the tubing.'' When asked about the humidifiers, the CS person stated, ''Those have to be changed more frequently than once a week. The nurses have the ability to change those out. They would know they need to be changed because they see them and are empty. Usually, they [the nurses] will change the humidifiers and all the tubing out but corporate said it was a waste of tubing, so we have to do it once a week.'' ) The CS person confirmed the lack of labeling/dating and humidification for R43, R46, R48, and R84. During an interview on 07/13/22 at 3:32 PM, regarding oxygen undated/labeled tubing and humidifiers, the UM stated, ''If we see an empty humidifier, we are supposed to change them out. Any of the nurses have access to the supply room and are supposed to change them out.'' During an interview on 07/13/22 at 4:55 PM, regarding oxygen CNA6 stated, ''I think the central supply person changes the oxygen tubing out every Wednesday. Other than that, I had no idea. I don't mess with the oxygen.'' During an interview on 07/14/22 at 11:11 AM, regarding oxygen, CNA5 stated, ''The 02 tubing and humidifiers get changed once a week. If the humidifiers are low, we [the CNAs] can just get another one. They are kept in central supply room. Either a CNA or nurse, whoever noticed it, can replace it. During an interview on 07/14/22 at 3:51 PM, the Director of Nursing (DON) stated, ''Central Supply should be verifying the oxygen has been tagged and labeled. If there is a humidifier empty, the CNAs are to let the nurse know and the nurse is able to get a humidifier out of the med cart, or they can get one in the storage room. They can get one, date it, and hook it up.'' 4. Review of R46's EMR under his ''Profile'' tab revealed he was admitted to the facility on [DATE]. Review of R46's ''Med Diag'' tab revealed multiple diagnoses to include shortness of breath and dependance on oxygen therapy. Review of R46's admission MDS,'' with an ARD of 07/01/22 revealed a BIMS score of 14 out of 15, indicating R46's cognition was intact. R46's entry, by the facility revealed he received oxygen therapy for the 7 days out of 7 days. Review of R46's physician's orders under ''Orders'' tab dated 05/09/22 revealed ''.O2 [oxygen] @ 2LPM [liters per minute] VIA NASAL CANNULA CONTINUOUS FOR SHORTNESS OF BREATH.'' There was no order for cleaning his oxygen concentrator filter. Review of R46's ''Medication Administration Record'' for the month of July 2022 revealed ''Oxygen at 2 liters'' was documented by the staff as administered, there was no directive for cleaning oxygen concentrator filter. An observation was conducted on 07/12/22 at 3:31 PM of R46 laying on his bed in his room. R46 had nasal cannula prongs in his nose that was connected to oxygen concentrator, receiving oxygen administration therapy. R46's oxygen concentrator was turned on and set at 3 liters flow rate. Oxygen tubing was dated with date of change of 06/05/22. The oxygen concentrator filter on the back was not clean and covered with dust particles. A small amount of water was in the bottom of the humidification (water) bottle, no date of change was on the water bottle. A second observation was conducted on 07/13/22 at 9:32 AM. R46 was laying on his bed, in his room. R46 had nasal cannula prongs in his nose that was connected to oxygen concentrator. R46's oxygen concentrator was turned on and set at 3 liters flow rate. Oxygen tubing had a date of change of 06/05/22 handwritten on the tubing. R46's oxygen concentrator filter on the back was not clean and covered with dust particles. R 46 oxygen concentrator water bottle was empty, and no date was labeled on the water bottle. R46 stated the facility's staff had not changed his oxygen tubing since last month. A third observation was conducted on 07/13/22 at 03:00 PM with Licensed Practical Nurse (LPN) 2 of R46 laying on his bed in his room with oxygen therapy administered. LPN2 verified and confirmed R46's oxygen concentrator was set at 3 liters per minute. LPN2 confirmed and verified R46's physician's order in EMR under Orders tab was for 2 liters oxygen flow rate. LPN2 verified and confirmed R46's oxygen flow rate on his oxygen concentrator was set incorrectly and was administered at a flow rate of 3 liters. LPN2 verified and confirmed R46 did not have a physician's order to clean or change his oxygen concentrator filter. During an interview and record review on 07/13/22 at 3:34 PM, UM verified and confirmed R46's physician order for oxygen flow rate was 2 liters under his ''Orders'' tab in his EMR. UM verified and confirmed R46's did not have a physician's order for his oxygen concentrator filter to be cleaned. UM verified nursing staff were responsible for maintaining oxygen therapy equipment. UM confirmed the nurses were required to verify resident's oxygen flow rate was correctly set on R46's MAR for his oxygen concentrator. UM verified and confirmed R46's MAR had directive for oxygen at 2 liters per nasal cannula flow rate and staff initials documenting his flow rate was correct and verified. UM confirmed and verified R46's oxygen concentrator was set incorrectly at a flow rate of 3 liters. UM stated the possible harm for R46 could lead to respiratory distress for resident. UM verified and confirmed R46 did not have a physician order to clean his oxygen concentrator filter. An interview was conducted on 07/14/22 at 10:21 AM with DON who confirmed nursing were responsible for changing oxygen tubing and maintaining oxygen equipment and the supplies were provided by the medical supply clerk. DON confirmed the facility expected the staff to label and date the oxygen supplies with date of change and clean the oxygen concentrator filter weekly. DON confirmed R46's oxygen flow rate should be set according to physician's order. DON stated the oxygen concentrator filters were expected to be cleaned once a week by the central supply clerk on Wednesdays.

Based on observations, interview, record review, and policy review, the facility failed to ensure palatable food was served to nine out of 33 sampled (R) (R59, R47, R31, R97, R71, R43, R38, R30, R46) and residents who attended the resident council. Food was burnt, lacking in flavor, poorly prepared, cold, and condiments were not provided. Findings include: Review of the undated Resident Nutrition Services policy provided by the facility revealed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 1. Residents expressed concerns regarding the palatability of food as follows: a. During an interview on 07/12/22 at 12:25 PM, R59 was observed with her lunch meal consisting of chicken/dumplings, beige beans, ice cream and iced tea. R59 stated she did not like the meal and it did not taste good. R59 covered the plate with a lid, indicating she would not eat it and would skip lunch. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/07/22 in the EMR under the MDS tab revealed R59 was cognitively intact with a Brief Interview for Mental Status Score (BIMS) of 13 out of 15 (score of 13 - 15 indicates intact cognition). b. During an interview on 07/12/22 at 03:06 PM, R47 stated the food was not good. She stated the flavor was not good and it was not hot. Review of the quarterly MDS with an ARD of 05/19/22 in the EMR under the MDS tab revealed R47 had a BIMS of 15 indicating she was cognitively intact. c. During an interview on 07/12/22 at 04:14 PM, R31 stated the food was not hot most of the time. Review of the quarterly MDS with an ARD of 04/27/22 in the EMR under the MDS tab revealed R31 had a BIMS of 12 indicating moderate impairment in cognition (score of 8 - 12 indicates moderate impairment). d. During an interview on 07/12/22 at 4:11 PM, R97 stated the food was cold. Review of the quarterly MDS with an ARD of 06/18/22 in the EMR under the MDS tab revealed R97 was moderately impaired in cognition with a BIMS score of 12. e. During an interview on 07/13/22 at 9:30 AM, R71 stated he would call the food, jailhouse food. He stated it was not tasty. Review of the MDS with an ARD of 6/18/22 in the EMR under the Profile tab revealed he was intact in cognition with a BIMS of 14. f. During an interview on 07/12/22 at 12:04 PM, R43 stated, The food really sucks here. Review of the admission MDS with an ARD of 05/18/22 in the EMR under the MDS tab revealed R43 was intact in cognition with a BIMS of 14. g. During an interview on 07/12/22 at 10:00 AM, R38 stated the food was horrible and had gone downhill. Review of the quarterly MDS with an ARD of 05/16/22 in the EMR under the MDS tab revealed R38 was intact in cognition with a BIMS of 15. h. During an interview on 07/12/22 at 3:09 PM, R30 stated, The food is bad. Review of the quarterly MDS with an ARD of 05/06/22 in the EMR under the MDS tab revealed R30 was intact in cognition with a BIMS score of 14. i. During an interview on 07/13/22 at 9:33 AM, R46 stated the food was poor; he stated he had resided in four facilities and this one had the worst food. He stated he was served cereal this morning without milk. Review of the admission MDS with an ARD of 05/16/22 in the EMR under the MDS tab revealed R46 was intact in cognition with a BIMs score of 15. 2. Resident council minutes (January 2022 - June 2022) reflected ongoing concerns about the palatability of the food: a. Review of Resident Council Meeting minutes dated 01/12/22 and provided by the facility revealed: -The residents basically complained about the food . -Concern: .Food - cold - not pleasant to eat. b. Review of Resident Council Meeting minutes dated 02/10/22 and provided by the facility revealed: -Food is cold or not done. c. Review of Resident Council Meeting minutes dated 05/23/22 and provided by the facility revealed: -Burnt toast, burnt lasagna, burnt grilled cheese, no seasoning. -No butter -No jelly -No dessert 3. Kitchen and dining observations revealed concerns with food palatability: a. 07/12/22 Lunch - The posted menu in the 100-hall indicated lunch consisted of chicken and dumplings, carrots, a dinner roll, and vanilla ice cream. Observations of meal service in the 100 hall at 12:43 PM revealed beige beans were substituted for carrots and corn bread for rolls. Residents were served chicken and dumplings with minimal chicken present, beans, corn bread and vanilla ice cream. All food items on the plate were shades of beige/yellow, lacking any contrast in color. No margarine, salt or pepper were served to residents. A container of salt and pepper packets was observed on the beverage cart; however, none of the residents on the 100 hall were offered any. There was no margarine available for the cornbread. b. 07/13/22 Evening Meal- The posted menu in the 100 hallway indicated the evening meal consisted of quiche, tomato slices, a muffin, a potato patty, and fresh fruit for dessert. Residents were served these foods. On 07/13/22 at 5:05 PM, observation of tray pass on the 100 hall from rooms there was no margarine served with the muffins and no salt and pepper offered. At 5:09 PM, Certified Nursing Assistant (CNA) 3 who was passing beverages on the cart that had the container of salt and pepper stated she only provided salt and pepper packets if residents asked for it. None was observed to be offered to residents in rooms 100 - 113. c. During observations in the kitchen on 07/14/22 at 9:15 AM, a full pan of cooked sweet potatoes was already prepared and in the steam table for lunch. The Dietary [NAME] stated lunch meal service started at noon. d. During an interview with the Dietary Manager (DM) and Registered Dietitian (RD) on 07/14/22 at 9:11 AM, the DM stated the dietary department was responsible for putting all condiments on the trays except for salt and pepper which the CNAs were responsible for. When notified of salt and pepper not being provided, the RD stated the dietary department might need to take responsibility for putting the salt and pepper packets on the trays. Both the DM and RD stated they were not aware that margarine was not served with the cornbread or muffins. e. On 07/14/22 at 9:21 AM, there were 27 trays on the carts from breakfast at the kitchen entrance. The DM and RD verified with the surveyor there was no evidence of salt and pepper packets on any of the trays. f. During observations in the kitchen on 07/14/22 at 11:29 AM, the Dietary [NAME] (DC) was preparing fried chicken by battering and deep frying it. The pieces were dark brown when removed from the fryer. The DC was observed preparing pureed chicken. Although the recipe called for low sodium chicken base to be added to the chicken, water, and thickener, regular chicken based was used. The DC stated she did not typically taste the food. The DC, RD and surveyor tasted the pureed chicken. The RD stated it was too salty which was verified by the surveyor. g. On 07/14/22 at 1:36 PM, a test tray of a regular diet from the last cart served to the 200 hall was evaluated by the DM and surveyor after the last resident was served. The temperature of the chicken was adequate; however, the sweet potatoes and green beans were cool to the palate at 108 degrees Fahrenheit (F) and 103 degrees F, respectively. The DM stated she agreed the sweet potatoes and green beans could be hotter. There were six open (not enclosed carts) sheet pan carts that were used to serve meals to residents. Each cart had approximately 20 trays when served. 4. During an interview on 07/16/22 at 2:53 PM, the Administrator stated she was aware the dietary department needed help to get up to standard. She stated they were hiring staff, had the RD spending extra time, and were providing training for staff.

Based on observation, interview, record review and policy review the facility failed to ensure nine out of 104 total residents (R) (R59, R47, R31, R24, R97, R71 R43, R46, R102) and residents who attended the resident council were provided with choices about food and beverages. Findings include: Review of the undated Promoting/Maintaining Resident Self-determination policy provided by the facility revealed, It is the practice of the facility to protect and promote resident rights by promoting and facilitating resident self-determination through support of resident choice .The facility will accommodate the resident preferences to the extent possible . 1. Choices regarding food and beverages Residents expressed concerns regarding a lack of choices regarding food, food portions and beverages during the survey as follows: a. During an interview on 07/12/22 at 12:25 PM, R59 was observed a lunch meal consisting of chicken/dumplings, lima beans, ice cream, and iced tea. R59 stated she did not like the meal, covered the plate with a lid having eaten minimal food, indicating she would not eat it and would skip lunch. She had a diet coke on the over bed table and indicated she had asked for ice, but staff did not bring it. Review of R59's tray card revealed she was to be served large portions. During lunch on 07/12/22 at 12:25 PM, R59 was served a regular portion. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/07/22 in the EMR under the MDS tab revealed R59 was cognitively intact with a Brief Interview for Mental Status Score (BIMS) of 13 out of 15 (score of 13 - 15 indicates intact cognition). b. During an interview on 07/12/22 at 3:06 PM, R47 stated the portions were small and she did not always get enough to eat. The resident's tray card was reviewed and there were no preferences, dislikes, or information about portion sizes noted. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/19/22 in the EMR under the MDS tab revealed R47 had a BIMS of 15 indicating she was cognitively intact. c. During an interview on 07/12/22 at 4:14 PM, R31 stated she did not have choices about what beverages were served. She stated juice was only available for breakfast and not at lunch or dinner. R31's tray card was reviewed. There was no information regarding beverage preferences or selections. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/27/22 in the EMR under the MDS tab revealed R31 had a BIMS of 12 indicating moderate impairment in cognition (score of 8 - 12 indicates moderate impairment). d. During an interview on 07/12/22 at 12:21 PM, R24 indicated she did not have choices regarding meals. She stated, When you don't like it, you put the top on [lid over the plate] and they take it away. They do not get you something else. R24 also indicated she did not have a choice about what beverage she was served. The resident's tray card was reviewed and indicated she did not like fried food, bacon, or sausage. R24 stated she was routinely served bacon and sausage. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/07/22 in the EMR under the MDS tab revealed R24 had a BIMS of 12 indicating moderate impairment in cognition (score of 8 - 12 indicates moderate impairment). e. During an interview on 07/12/22 at 4:11 PM, R97 stated he did not get enough food. The resident's tray card was reviewed and no dislikes, preferences or information regarding portion sizes was documented. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/18/22 in the EMR under the MDS tab revealed R97 was moderately impaired in cognition with a BIMS score of 12. f. During an interview on 07/13/22 at 9:30 AM, R71 stated he did not have choices about the meals and had not for about a year. He stated the staff had a menu the residents could review but if you did not like it, there was no other choice. He stated he would eat a little just to get something in his stomach. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/18/22 in the EMR under the Profile tab revealed he was intact in cognition with a BIMS of 14. g. During an interview on 07/12/22 at 12:04 PM, R43 stated there was not enough food and he would like to be served more food. He stated he asked for more food but did not get it. R43 stated he did not have any meal choices. He stated he told the certified nurse aides (CNAs), but nothing was done. Review of the resident's tray card revealed a preference for 2% milk and dislike for sweet tea. No other preferences/dislikes or notations about portions were noted. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/18/22 in the EMR under the MDS tab revealed R43 was intact in cognition with a BIMS of 14. h. During an interview on 07/13/22 at 9:33 AM, R46 stated there was a lack of food supply. He stated he was not supposed to eat pork because he had gout, but they served pork to him anyway. R46 stated he had requested no pork, but he was still served pork, typically bacon. R46's tray card was reviewed and no dislikes, preferences or information about portion sizes was noted. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/16/22 in the EMR under the MDS tab revealed R46 was intact in cognition with a BIMs score of 15. 2. Review of Resident Council Minutes reviewed from February 2022 through June 2022 revealed ongoing concerns with meal portions and choices: a. Review of Resident Council Meeting minutes dated 02/10/22 and provided by the facility revealed: Residents are receiving food on [tray] when it is a dislike or allergic reaction. b. Review of Resident Council Meeting minutes dated 05/23/22 and provided by the facility revealed: -CNAs [do not] want go back to the kitchen when the resident wants something. -Food portions are too small. c. Review of Resident Council Meeting minutes dated 06/02/22 and provided by the facility revealed: -R102 requested no mayonnaise or mustard on his sandwiches. The resident's tray card was reviewed during the survey and these preferences were not documented. -A concern with the portion sizes was voiced. 3. Kitchen and dining observations revealed concerns with food and beverage choices: a. 07/12/22 Lunch - The posted menu in the 100-hallway indicated lunch consisted of chicken and dumplings, carrots, a dinner roll, and vanilla ice cream. On 07/12/22 at 12:43 PM, observation of tray pass in the 100 hall from rooms 101 - 113 revealed residents were served chicken and dumplings, lima beans, corn bread, and vanilla ice cream. There were minimal, small pieces of shredded chicken served with the dumplings and the portion was small. The beverage cart in the hallway had a large container of sweet tea and small pot of coffee. No juice or milk was observed on the cart. The only beverage being served to residents in these rooms was sweet tea. The CNA went room to room and poured tea for the residents. Certified Nursing Assistant (CNA) 3 did not ask residents what they wanted to drink prior to delivering the trays. Two residents were observed with chef salads versus the meal according to the menu. b. 07/13/22 Evening Meal - The posted menu in the 100 hallway indicated the evening meal consisted of quiche, tomato slices, a muffin, a potato patty, and fresh fruit for dessert. On 07/13/22 at 5:05 PM, observation of tray pass on the 100 hall revealed the portion of quiche was small (approximately two-thirds the size of a deck of cards), the portion of sliced tomatoes consisted of one or two thin tomato slices, and the muffins were small (small muffin tin and below level of the top of the paper they were baked in). Beverage meal service was observed and there was iced tea, a pitcher of juice, and a few individual cartons of milk, and coffee. CNA3 served most of the residents tea; she did not ask the residents what they wanted, and the information was not observed on the tray cards. She was interviewed at this time and stated she knew what the residents liked. None of the residents were observed to be served coffee. c. Lunch 07/14/22 Beverage service was observed on 07/14/22 at 12:27 PM to the 100 hall. There was a large container of sweet tea, a small pitcher of unsweetened tea, and one regular carafe of coffee. No juice or milk was available on the cart. CNA3 stated most residents wanted sweet tea; she was not observed to ask residents what they wanted prior to delivering the drinks. 3. During the initial kitchen tour on 07/12/22 from 9:43 AM - 10:07 AM, the DM stated she had been employed for three weeks and was working to bring the dietary department up to standard. She stated alternates were not prepared; she identified this as a problem and was in the process of addressing it. She stated chef salads and grilled cheese sandwiches were currently available as a choice for meals. During an interview on 07/14/22 at 9:11 AM, the DM stated beverage service at meals was completed by the CNAs. They were supposed to get a cart that had iced tea, juice, coffee, and a bucket with ice and go around and ask residents what they wanted to drink and serve it. The RD, also present during the interview, stated they had not been interviewing residents to determine their beverage preferences and they might want to do this and put the information on the tray cards. The RD stated she had been employed as the RD only a short while and the position was temporary. She stated they were beginning to talk with residents to update their food preferences. The RD stated she had seen the chicken and dumplings that was served and stated it needed to be made with additional meat, verifying the lack of chicken in the entrée. The RD stated the facility did not have alternates per se, but residents could get a chef salad, sandwich, or soup if they wanted. When asked what the process was, she stated when the staff came to the kitchen after serving a meal the resident did not want, dietary staff made them something else. The RD verified there was no formal process to provide choices ahead of time. She indicated residents could also notify the kitchen if they did not want what was on the menu. During an interview on 07/16/22 at 2:53 PM, the Administrator stated she was aware the dietary department needed help to get up to standard. She stated they were hiring staff, had the RD spending extra time, and were providing training for staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, facility policy review, and Pest Elimination Service Reports, the facility failed to ensure an effective pest control system was in place for six of 33 sampled residents (R) (R33, R38, R71, R47, R31, and R34). Specifically, the facility had sightings of live and dead roaches in resident rooms, staff bathrooms, and multiple complaints from residents. Findings include: Review of the facility's undated policy titled, ''Pest Control Program,'' indicated, ''It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.'' Definition: ''Effective pest control program'' is defined as measures to eradicate and contain common household pests (e.g., .roaches .).'' During an interview on 07/12/22 at 9:50 AM, R33 stated, ''The bugs. They are our friends.'' When R33 was asked if he has seen cockroaches in his room before and if he has told anyone, R33 stated, ''Yes, they know about it.'' One large dead black cockroach was observed on the floor by Bed-B, three residents shared R33's room. During interview on 07/12/22 at 10:00 AM, R38 stated, ''It's horrible here. Things have gone downhill. In the evening and at nights, bugs are everywhere. They come in from the outside and they are in our room.'' R71 (R38's roommate) stated, ''Bugs, yes. I will be laying here in my bed at night, and I've seen them coming from the AC [air conditioning] unit. I've told the nurses before, and they also kill them out in the hallways. The response is that they have [a pest control company] lab person that comes out. They spray and it only works for a day or two.'' During an interview on 07/12/22 at 3:04 PM, R47 stated she had recently seen two roaches on the floor in her room. She stated she was unsure whether the facility sprayed or what they did to address it. During an interview on 07/12/22 at 4:13 PM, R31 stated she saw, water bugs [cockroaches] every now and then. An observation on 07/12/22 at 6:06 PM revealed a large live black cockroach in the staff bathroom next to the Social Services office. The cockroach was observed crawling out of the toilet paper roll that was sitting on the back of the toilet seat. The cockroach was then observed moving to the sink, then onto the floor and behind the trash can. During an observation on 07/14/22 at 12:32 PM, a large dead roach was observed on floor by the foot of R34's bed. R34 was not in the room at the time, and she was not interviewable. During an observation on 07/14/22 at 12:54 PM, Certified Nursing Assistant (CNA) 2 verified there was a dead roach on the floor at the foot of R34's bed. CNA2 stated, We usually see them at night. They come out when it rains; it not unusual. During an observation on 07/15/22 at 9:02 AM, the Maintenance Director (MD) stated he was not aware of any roach sightings in R34's room. He entered the room and verified the presence of the dead cockroach on the mat on the floor by R34's bed. He verified he had not been notified and picked up the dead insect and discarded it at this time. During an interview on 07/13/22 at 4:11 PM, Housekeeper 8 stated she was the housekeeper for the 100 hall and indicated she saw roaches about once a week. She stated they were typically dead when she saw them. During an interview on 07/14/22 at 2:49 PM, Licensed Practical Nurse (LPN) 3 stated she saw water bugs about once or twice a week, typically after it rained. She stated she saw a dead one today in the hallway and housekeeping cleaned it up. Review of the 07/06/22 ''Pest Elimination Service Report,'' revealed, ''Structural findings: Exterior Area-Structural Concerns: Underside of building needs to be sealed to prevent pest entry. Kitchen Area- Interior. Floor tiles or baseboards loose/missing. Action Needed: Please repair to eliminate potential pest harborage/breeding site. Patient/Guest Rooms-Interior: Exit door doesn't close/seal properly- 1/4-inch gap or greater exists. All ptech [sic] units need to be resealed as well as sliding glass doors in courtyard rooms. Action Needed: Exclusion measures here will reduce the number of pests entering the area. Install weather stripping. Install/replace door sweep. Rear Door- Introduction Point- exit door doesn't close/seal properly-1/4 inch gap or greater exists. Exit door off the kitchen needs door sweep. Action Needed: Exclusion measures here will reduce the number of pests entering this area. Install/replace door sweep. Side Door-introduction point- hole/gap noted. Sliding doors & Windows around courtyard area do not seal properly. Action Needed: Seal to prevent entry or harborage. Sanitation Findings-Patient/Guest Rooms-Interior. Food debris found. Rooms need to be on daily cleaning. No evidence of recent thorough cleaning. Action Needed: please clean regularly. Patient/Guest Rooms-interior-spilled food material found on the floor. Action Needed: Please clean to reduce pest attraction and source for breeding.'' Further review of the ''Pest Elimination Service Reports'' dated 06/29/22, 06/21/22, 06/16/22, 06/02/22 were reviewed. During interview on 07/14/22 at 8:51 AM, regarding the facility pest control system, the MD stated, ''We use Ecolab, and their normal visits are once a month. The kitchen is a separate visit. They [Ecolab] treat wherever we have issues. If we do start seeing issues, we bump them up to once a week.'' The MD stated, ''We have had Ecolab coming out weekly because we are getting more of an influx of bugs in the building.'' When the MD was asked if he has received any complaints regarding bugs/cockroaches, the MD stated, ''Yes, we have had more sightings than normal with bugs. Most of the sightings are in the resident rooms boarding the inside courtyard.'' Regarding further concerns, the MD stated, ''Yes, I will usually get a work order every now and then that someone has seen ants/roaches in the rooms. So, I will take whatever bug spray I have from Home Depot and treat the room. Then when the Ecolab guy comes out, he will see any rooms that we need to target.'' When the MD was asked if he has received any recent work orders regarding cockroaches, the MD stated, ''Yes, I got one. It was about roaches in room [ROOM NUMBER]. Roaches were seen on 07/13/22.'' The MD stated, ''When the Ecolab guy comes out, he will leave me a report. From April 2022 he was doing bi-weekly visits and in June we went to doing weekly visits. He will check in with me if there are any sightings and I will let him know of any specific areas people pointed out. When he comes out, he will treat inside the resident rooms and outside courtyard to try to take care of any pests that are harboring out there.'' Regarding cockroaches, the MD stated, ''I've been looking at the sliding doors in the resident rooms where roaches have been coming in. The pest control guy feels like they are coming in from the sliding doors which is entrance to those resident rooms along the inside courtyard.'' The MD acknowledged the recommendations from Ecolab for sealing gaps but had not had time to address it. Observation and interview made on 07/14/22 at 9:50 AM, of the inside courtyard of the facility revealed it to be damp. There was an area where water was draining from the roof from condensation to the ground. During interview, the MD stated, ''When Ecolab comes out, they just spray the area. It is mostly with the resident rooms that border this courtyard where we have seen the most activity with cockroaches.'' The MD stated, ''We were asked to cut the vegetation back and trim our trees, so we did that.'' The MD stated, ''I know we have had issues with room [ROOM NUMBER] with cockroaches, so we did a deep clean and sprayed in there. If someone tells me they are seeing things, then I can fix them, but I'm the only person here for maintenance, and I'm doing the best I can with the tools I have.'' During interview on 07/14/22 at 10:29 AM, the Ecolab Representative (ELP) stated, ''They [the facility] are actively having roach issues. They are American Roaches which typically live outside. They are coming in from the outside area through the doors and windows. We changed from coming monthly, to bi-monthly, and now are coming weekly.'' The ELP stated, ''[name of the MD] and directors mentioned their concerns to me as they were starting to see large cockroaches more, so I have been coming out weekly.'' The ELP stated, ''When I come, I treat baseboards, under the AC units, around the toilets, under the sinks and anywhere we can get a good barrier.'' The ELP then stated, ''Every time I come in, I let the [MD] know if there are any areas I need to address, and he will let me know what rooms are needed. One week someone will say, 'Yes I saw a dead cockroach,' then another week someone will say I saw one in the 200 hall.'' The ELP stated, ''With the resident rooms that surround the inner courtyard, it has heavy vegetation and I mentioned to them that we were starting to see more activity in areas like hallways and over the period of weeks, I noticed a trend of the courtyard area.'' During an interview on 07/14/22 at 11:11 AM, Certified Nursing Assistant (CNA) 5 stated, ''We have water bugs [cockroaches] here. When it gets warm outside, they come in and they are big.'' When CNA5 was asked where he has seen the roaches, he stated, ''Sometimes around the bathrooms, and sometimes, I have seen them in the resident rooms. I've mentioned it to our managers and maintenance.'' When CNA5 was asked if he has received any complaints from residents regarding roaches, CNA5 stated, ''Yes. One resident said they woke up and there was one [cockroach] on them and it freaked them out. This was within the last month.'' During an interview on 07/14/22 at 3:51 PM, regarding cockroaches, the Director of Nursing (DON) stated, ''This is an old building. When it rains, bugs come in and we have roaches come in. I do spot checks, and I expect things to be clean.'' Observation on 07/14/22 at 4:26 PM, revealed a small dead cockroach on the floor in the conference room. During an interview on 07/15/22 at 9:49 AM, regarding pest control, the Administrator stated, ''I have talked to the ECO lab guy several times. He does stop in from time to time however, I have not seen his recommendations [referring to the weekly Pest Elimination Service Reports]. He did talk to me about improvements that were needed, and I was the one who initiated the weekly visits from him.'' The Administrator then stated, ''He needs to find a way though to make sure I get his recommendations. I haven't seen the visit reports when he comes on a weekly basis.'' During a second interview on 07/15/22 at 10:45 AM, the ELP stated, ''On my last visit, my recommendations were to cut back on the vegetation. Some of the rooms sliding doors we were asking to be sealed up better. I saw another door that was not sealing up properly, and some of the rooms looked like they had spilled juice on the floor, so we recommended that more rooms have daily cleaning.'' When the ELP was asked if he communicates his findings to the Administrator, the ELP stated, ''I will call [name of MD] and whatever Administrator is there on my recommendations.''

Based on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of foodborne illness to all 104 facility residents. Concerns included improper dishwashing, inadequate sanitizer solutions, meat thawing, ice dispensing procedures, labeling, and food handling. Findings include: 1. The initial kitchen inspection was completed with the Dietary Manager on 07/12/22 from 9:43 AM to 10:07 AM. The following concerns were noted: a. The Dietary Manager (DM) stated she had been employed in her position for three weeks and was working on bringing the dietary department back up to acceptable standards. The DM stated, The dishwasher went down last night and indicated staff were using the three-sink method to wash dishware as well as pots and pan. The DM stated she called the company who serviced the dish machine to come and repair the machine, and in the meantime had started a deliming process. The DM stated staff used disposable dishware and silverware for serving breakfast. Coffee mugs and trays were being washed using the three-sink method and the DM tested the sanitizer solution in the third sink for concentration using a quaternary ammonia test strip. The test strip revealed 50 parts per million (PPM) of the sanitizer (quaternary ammonia), an inadequate concentration of sanitizer. The DM stated the solution was made about an hour and a half ago and staff should have rechecked but had not. She stated concentration should be between 200 - 400 PPM as she referred to a posted chart on the wall. The solution was drained, and the third sink was refilled with sanitizer solution. It was checked and again the concentration was 50 PPM. b. The vent of the ice machine was coated with a thick layer of dust and grease. The DM stated she had previously reported the concern to maintenance, who was responsible for the ice machine. c. The sanitizer solution for the wiping rags, being used to wipe the food carts, was checked and the concentration was 50 PPM of quaternary ammonia. d. There was a case of 4-ounce health shakes stored in the walk-in refrigerator. Neither the box nor the shakes had a label of when they had been pulled from the freezer and placed into refrigeration. The DM stated she pulled the shakes the evening before; she verified the shakes should be labeled when pulled from the freezer to ensure they would not expire. e. A bulk bin of sugar and a bulk bin of flour were observed, both noted to contain plastic scoops in the sugar and flour. The handles of the scoops were touching the sugar and flour. The DM removed both scoops, stated they should not be stored in the containers and that staff were aware of that. f. At 10:02 AM three sink pot-washing was observed. The concentration of the sanitizer was checked, and it continued to be inadequate at 50 PPM. The DM turned the dial of the sanitizer dispenser, and it did not dispense through the clear tubing into the sink. The DM shook the tubing, and some sanitizer was observed to go through the tubing and be dispensed into the sink, but it was not a continuous flow. The DM stated that while the dial was turned, it should dispense through the tube continuously. The hose for the sanitizer had been placed in the first sink which was the wash sink. The DM was notified, and she moved the hose to the third sink where the sanitizer should dispense. The third sink was filled, and the concentration was checked and was inadequate at 50 PPM. The DM stated she would talk to the Administrator immediately, verifying the dishware and pots and pans had not been adequately sanitized. The DM stated she would use disposable dishware and silverware for the lunch meal service. 2. A subsequent observation was made in the kitchen on 07/12/22 at 10:58 AM with the DM. The DM stated the Maintenance Director stated they had called the company who serviced the dish machine and they were coming to service the dish machine. The concentration of the sanitizer solution in the third sink was checked and it was at an acceptable level of 200 PPM. The DM stated the staff would re-wash everything from earlier due to the previous concentration of sanitizer not being strong enough. All dishware on the trays for lunch meal service was disposable, including plates and silverware. During an interview on 07/12/22 at 1:06 PM, the DM stated company who serviced the dish machine came and changed the sanitizer dispenser for the three-sink pot washing and it was not working properly. They had also repaired the dish machine and it was operational. 3. During an observation on 07/14/22 at 8:56 AM, a large, full box of raw chicken pieces was sitting in the kitchen at room temperature on a cart thawing at room temperature. 4. During an observation on 07/14/22 at 10:29 AM, the Dietary [NAME] (DC) was preparing pureed green beans. She was wearing disposable gloves and with her gloved hands touched the exterior surface of a can of green beans, kitchen utensils, the robot coupe food processor bowl, and controls. The DC prepared the pureed green beans and scooped the mixture out of the robot coupe with her gloved hands. The Registered Dietitian (RD), who was present, stated the DC should not use gloved hands to scoop the ready to eat food into the pan and indicated it was a sanitation issue. The DC was interviewed at this time and stated she should not use gloved hands for scooping the food out of the robot coupe bowl and should use a utensil instead. 5. During an observation on 07/15/22 at 11:15 AM, the same box of raw chicken pieces (first observed at 8:56 AM) continued to be located on the cart thawing at room temperature. There were several bags of semi-frozen chicken in the box. The DM stated the chicken was still frozen, so it was ok to serve it. She verified it should not be thawed at room temperature and took the remaining bags of chicken and placed them in a large colander in the sink under running water to thaw. The RD stated food should not be thawed at room temperature due to food safety concerns and allowable methods to thaw included under running water, under refrigeration, in the microwave if cooked continually or cooked from raw. 6. During an observation of meal service to residents in their rooms on 07/14/22 at 1:27 PM with the RD, a beverage cart used to serve beverages to residents eating in their rooms was observed. The plastic scoop was in the container of ice that was used for residents' drinks and the scoop handle was touching the ice. The RD stated the scoop should not be stored in the ice. During an interview on 07/16/22 at 2:53 PM, the Administrator stated she was aware the dietary department needed help to get up to standard. She stated they were hiring staff, had the RD spending extra time, and were providing training for staff. Review of the undated Chemicals for Washing, Treatment, Storage and Processing Fruits and Vegetables Criteria document provided by the facility, revealed, Ice scoops may be stored handles up in an ice bin . Review of the undated Dishwashing Machine Use policy provided by the facility revealed, Food service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or designee proficient in all aspects of proper use and sanitation . Dishwashing machine chemical sanitizer concentration and contact times were be as follows: . quaternary ammonium 150 - 200 PPM . Corrective action will be taken immediately if sanitizer concentrations are too low. Review of the undated Sanitization policy provided by the facility revealed, All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solution . Sanitizing of food contact surfaces must be performed with one of the following solutions . 150 - 200 PPM quaternary ammonium . Thawing Frozen Food 1. Food will not be thawed at room temperature . Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use.

Based on record review and staff interview, the facility failed to ensure that a Discharge Minimum Data Set (MDS) Assessment was transmitted within 14 days of discharge to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for one resident (R) (#1) out of 62 sampled residents. Findings include: Review of R#1's discharge record revealed she was discharged from the facility on 12/3/18. Review of R#1's MDS list revealed there was an Entry Assessment completed on 10/30/18, but there was no MDS Discharge Assessment listed. During interview with the Licensed Practical Nurse/MDS Coordinator HH on 4/17/19 at 9:19 a.m., she verified that R#1 was at the facility from 10/30/18 until the discharge date of 12/3/18 and stated that she forgot to complete the discharge assessment for her. She stated during continued interview that when a resident was discharged from the facility, she will complete an MDS discharge assessment within 48 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement the care plan related to completing the behavior monitoring flow sheet for one resident (R) (#80) who was receiving the antipsychotic medication, Abilify, out of five residents reviewed for psychotropic medication use. Findings include: Review of R#80's clinical record revealed that she had diagnoses including anxiety disorder, major depressive disorder, dementia, and psychosis. Review of R#80's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that she received an antipsychotic medication seven days of the assessment period, and that she received antipsychotics on a routine basis only. Review of a mood care plan revised 4/2/19 revealed that R#80 exhibited distressed mood symptoms as evidenced by sadness/depression, persistent anger/agitation, and anxiety. Review of the interventions included to complete behavior monitoring flow sheet, and to observe for changes in mood, behavior, and overall functioning and document. Review of a risk for complications related to the use of psychotropic drugs care plan revised on 4/2/19 revealed interventions to observe and document effectiveness and potential side effects and complete behavior monitoring flow sheet. Review of R#80's Physician Order Summary Report dated 4/18/19 revealed an order dated 7/23/18 for Abilify 5 mg (milligrams) at bedtime for psychosis and major depressive disorder. Review of R#80's January, February, March and April electronic Medication Administration Records (eMAR) revealed an order dated 7/23/18 for Abilify 5 mg at bedtime related to psychosis and major depressive disorder. Further review of the eMAR revealed that there was no evidence that monitoring was being done for efficacy of management of R#80's behaviors. During interview with Registered Nurse (RN) Unit Manager GG on 4/18/19 at 12:05 p.m., she stated that the nurse that took the order for an antipsychotic medication was responsible for entering the Code line on the eMAR where behaviors could be documented, and for some reason this had not been done for R#80's Abilify going back to at least the entire year of 2019. Cross-refer to F758

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policies titled Discharge and Transfer and Discharge Planning Process, the facility failed to complete discharge plan documentation, including information on the current status, the recapitulation of stay, and the reconciliation of medications for one resident (R) (#113) of three residents reviewed for discharge. Findings include: A review of the discharge policies titled, Discharge and Transfer and Discharge Planning Process last revised 2/1/19 revealed that a Discharge Transition Plan is given to be given to the resident or family and a copy placed in the records of residents who are discharging home or to other community settings. The Discharge Transition Plan must include, at a minimum, a recapitulation of the resident's stay, a final summary of the resident's status at the time of discharge, reconciliation of all of the resident's medications, a post-discharge plan of care, and an indication of the environment in which the resident plans to reside upon discharge. Review of the clinical records revealed R #113 was admitted on [DATE] for rehabilitative services following a fracture of the right femur. A review of the resident's orders revealed an order dated 2/25/19 for the resident to discharge home with the support of home health care on 2/27/19. A review of the discharge information included in the resident's records revealed a document titled Discharge Plan Documentation dated 2/27/19 that included the relevant sections - a recapitulation of the resident's stay, a final summary of the resident's status at the time of discharge, reconciliation of all medications, a post-discharge plan of care, and an indication of the environment in which the resident planned to reside upon discharge. However, only the sections related to the resident's discharge destination and the post-discharge plan of care was completed. The sections related to the recapitulation of stay, the resident's current status, and the reconciliation of medications was left unfinished and there was no indication that a copy had been furnished to the resident or family. During an interview on 4/17/19 at 3:12 p.m. with the social worker, it was revealed that staff is required to complete the Discharge Plan Documentation for all residents prior to discharge and the resident and/or family is given a copy. The Discharge Plan Documentation contains four sections to be completed by social services, the administrative staff, activity staff, and nursing staff, respectively. After reviewing the discharge document for R#113, the social worker determined that the nursing section, which contained the resident's final status, the recapitulation of stay, and the reconciliation of all medications, had not been completed as required. During an interview on 4/18/19 at 12:03 p.m. with Licensed Practical Nurse (LPN) CC, it was revealed that she normally completes the nurses' portion of the Discharge Plan Documentation. This section contains information about the resident's diet, dental, hearing, vision, level of assistance required upon discharge, the therapy services received during stay, and all current medications. LPN CC said she always reviews these items with the resident/family prior to discharge and that the resident is given a copy to take with them. LPN CC also said that it was important that residents who are being discharged receive this recapitulation of the services they received while at the facility, understand their current abilities/disabilities, and know what services or level of assistance they will need after they leave the facility. She said that she usually completes this document and provides the accompanying education to residents/family while she is in the building, but verified that said document had not been completed nor provided to R#113 and suggested that the normal process was not followed because R#113 was discharged in the evening after normal business hours and the nurse in charge had neglected to complete this requirement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the policy titled Psychotropic Medication Use, and staff interview, the facility failed to monitor the targeted behaviors for two (#107 and #80) of five residents reviewed for the use of psychotropic medications. Findings include: Review of the policy titled Psychotropic Medication Use last revised 11/28/16 revealed that all medications used to treat behaviors should be monitored for efficacy, risks, benefits, and/or adverse consequences. Staff should monitor the behaviors of residents receiving psychotropic medications using a behavioral monitoring chart or behavioral assessment record. Staff should monitor behavioral triggers, episodes, and symptoms, and should document the number and/or intensity of symptoms and the resident's response to staff interventions. 1. Review of the clinical record revealed Resident (R) #107 was readmitted from a hospital stay on 3/25/19 with diagnoses of anxiety disorder and depression. A review of the current physician's order sheet revealed the resident was prescribed sertraline (an antidepressant) 50 milligrams (mg) and quetiapine (an antipsychotic) 25 mg at bedtime. A review of the Medication Administration Records (MARs) for March 2019 and April 2019 revealed the resident received these psychotropic medications as ordered. However, a further review of the MARs for that period revealed no documentation that relevant targeted behaviors were being monitored. During an interview on 4/17/19 at 12:09 p.m. with Licensed Practical Nurse (LPN) AA, it was revealed that residents on psychotropic medications are monitored for targeted behaviors on the MAR which gives staff the option to enter any behaviors observed during the shift, the interventions undertaken by staff, and the residents' responses to those interventions. During an interview on 4/17/19 at 12:40 p.m. with the Director of Nursing (DON), it was revealed that residents on psychotropic medications are to be monitored for targeted behaviors. When residents are admitted with or placed on psychotropic medications, the nurse/nurse manager responsible for entering the medications into the electronic health record adds a code to the orders so that behavior monitoring is initiated. The nurses on the floor have codes that correspond to the behaviors that are to be monitored and these codes are added to the MAR based on the behaviors that are observed. During an interview on 4/17/19 at 12:52 p.m. with LPN BB, it was revealed that residents prescribed and receiving psychotropic medications are routinely monitored for targeted behaviors. However, she verified that R#107 did not currently have behavior monitoring in place. She attributed this oversight to the resident's recent hospital stay surmising that the order to monitor his targeted behaviors was inadvertently left off his current order sheet and MAR when he returned to the facility. Further interview on 4/17/19 at 5:35 p.m. with the DON revealed that if behavior monitoring is not documented on a resident's MAR then that resident is not being monitored for targeted behaviors. 2. Review of resident R#80's clinical record revealed that she had diagnoses including anxiety disorder, major depressive disorder, dementia, and psychosis. Review of R#80's Annual Minimum Data Set (MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 12 to 15 indicates no cognitive impairment). Continued review of this MDS revealed that she received an antipsychotic, antianxiety, and antidepressant medication seven days of the assessment period, and that she received antipsychotics on a routine basis only. Review of a mood care plan revised 4/2/19 revealed that R#80 exhibited distressed mood symptoms as evidenced by sadness/depression, persistent anger/agitation, and anxiety. Review of the interventions included to complete behavior monitoring flow sheet, and to observe for changes in mood, behavior, and overall functioning and document. Review of a psychosis care plan revised 4/2/19 revealed that R#80 exhibited anxiety, social withdrawal, and psychosis. Review of the interventions to the care plan revealed to monitor medications for side effects and resident's response contributing to psychosis. Review of a risk for complications related to the use of psychotropic drugs care plan revised on 4/2/19 revealed interventions to observe and document effectiveness and potential side effects; and complete behavior monitoring flow sheet. Review of a Nurse Practitioner's (NP) comprehensive visit notes dated 3/14/19 revealed that R#80 had dementia with intermittent psychosis, depression, and anxiety with fair control at present on clonazepam (an antianxiety medication), Namenda (a cognition-enhancing medication), Abilify (an antipsychotic medication), and Zoloft (an antidepressant medication). Further review of the Assessment & Plan section of this report revealed to notify the NP of increased behaviors. Review of R#80's Physician Order Summary Report dated 4/18/19 revealed an order dated 7/23/18 for Abilify 5 mg at bedtime for psychosis and major depressive disorder. Review of R#80's January, February, March and April electronic Medication Administration Records (eMAR) revealed an order dated 7/23/18 for Abilify 5 mg at bedtime related to psychosis and major depressive disorder. Further review of the eMAR revealed that there was no evidence that monitoring was being done for efficacy of management of R#80's behaviors. Review of a Location of Administration Report for 4/1/19 thru 4/30/19 revealed No site of administration data found for Behaviors-Interventions-Side Effects for R#80, and that No Order data found for Behaviors-Interventions-Side Effects. During interview with Registered Nurse (RN) Unit Manager GG on 4/18/19 at 12:05 p.m., she stated that the nurse that took the order for an antipsychotic medication was responsible for entering the Code line on the eMAR where behaviors could be documented, and for some reason this had not been done for R#80's Abilify going back to at least the entire year of 2019. During continued interview, RN Unit Manager GG stated that R#80 exhibited behaviors such as excessive worrying, being emotionally unsettled, and with somatic symptoms such as shortness of breath and sudden inability to walk. During interview with R#80's NP on 4/18/19 at 3:06 p.m. revealed that R#80 had numerous transient somatic complaints, had severe anxiety and psychotic behaviors, especially if she didn't get what she wanted.

Based on observation, record review and staff interview, the facility failed to ensure that one item (chopped sweet and sour meatballs) was held on one of two portable steam tables at 135 degrees Fahrenheit (F) or above. Findings include: On 4/16/19 at 5:20 p.m., Dietary Aide FF was observed plating food from the 200 portable steam table for dinner and stated during interview that five residents had already been served the chopped meat (sweet and sour meatballs) in the dining room. Dietary Aide FF was observed checking the portable steam table temperatures with the facility's calibrated thermometer and the chopped meatballs were noted to be 56 degrees Fahrenheit (F). The Regional Dietician/ District Manager EE was observed removing the chopped meatballs from the portable steam table and returning the food item to the kitchen to be reheated. When the Regional Dietician/District Manager EE returned with the chopped meatballs, the Dietary Aide FF checked the temperature of the chopped meatballs with the facility calibrated thermometer and the temperature was noted to be 144.5 degrees F. The Dietary Aide FF stated during interview that she had checked the temperature of all foods with the calibrated thermometer on the portable steam table prior to serving and they were all appropriate temperatures. On 4/16/19 at 5:36 p.m. an interview with the Registered Dietician/District Manager EE stated that she educates the staff monthly on how to calibrate the digital thermometers used to check the portable steam table temperatures. She said that kitchen aide staff are to notify the manager and remove the food items that are not the correct temperature from the cart to be reheated. On 4/17/19 at 10:01 a.m. an interview with the Dietary Manager (DM) revealed the Registered Dietician/District Manager EE brought the chopped meatballs into the kitchen on 4/16/19 during dinner and the temperature of the chopped meatballs was 130 degrees F; and he reheated the chopped meatballs. He stated the food temperature is supposed to be 135 degrees F or above. Review facility policy titled Food: Preparation revised 09/2017 revealed holding temperatures when hot pureed, ground, or diced food drop below 135 degrees F, the mechanically altered food must be reheated to 165 degrees F for 15 seconds. Review of the Service Line Checklist dated 4/16/19 revealed the temperature for chopped meatballs was 149.6 degrees Fahrenheit before leaving the kitchen to be served from the steam table in the dining room. Review of the undated document titled Tuesday Dinner Special revealed that the dietary aide took the temperature of the food items prior to serving during dinner in the dining room and the temperature noted for the chopped meatballs was 153.6 degrees F.

Based on record review and staff interview, the facility failed to ensure that the staff designated as director of food and nutrition services on 1/15/19 was a certified dietary or food service manager or had a similar food service management certification or degree. There were 105 residents receiving an oral diet. Findings include: Review of the Healthcare Services Group Dietary Manager Job Description qualifications revealed the Dietary Manager (DM) is to have specialized training in dining management and nutrition required, be a Certified Dietary Manager (CDM) or a certified food service manager, has similar national certification for food service management and safety from a national certifying body, or has an associate's or higher degree in food service management or in hospitality. Review of the ServSafe Certification dated 5/11/17 revealed the DM has a ServSafe certification that expires 5/11/22. Review of the (Name) Preceptor Agreement Form dated 3/18/19 revealed the DM applied at a university to become a Certified Dietary Manager. On 4/18/19 at 8:42 a.m. an interview with the Regional Dietician/District Manager EE verified the DM has a bachelor's degree in business management and marketing and stated that he has over 20 years of experience in the culinary field. She further stated the DM is registered to take an online CDM course. On 4/18/19 at 10:23 a.m. an interview with the DM revealed he has been approved by the university to obtain the CDM certification online and will be monitored by the Regional Director/District Manager. The DM verified having a bachelor's degree in Business Managing and Marketing. He stated the course would take up to a year to complete and the facility told him the requirements upon hire. On 4/18/19 at 2:05 p.m. an interview with the Administrator revealed she was not aware the DM was not certified because the hiring process is done through a third-party source.