**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record reviews, review of the facility's policy titled, Advance Directive Policy, and review of the facility's admission Agreement-Statement of Acknowledgement, the facility failed to provide residents or resident representatives written information regarding choices and the right to accept or refuse medical or surgical treatment for one of seven sampled residents (R) (R56). This deficient practice had the potential to affect the resident or representative's ability to make informed decisions about their care. Findings included: Review of the policy titled, Advance Directive Policy, reviewed/revised date 11/21/2024 revealed under Policy Statement: It is the policy of [facility name] to establish, implement and maintain written policies and procedures for advance directive. Each resident with a decision-making capacity has the right to make their own decisions related to his/her medical care. An integral component of self-determination is the right to make choices pertaining to one's health, including the right to refuse or alter treatment plans, to accept or refuse medical or surgical treatment, refuse to participate in experimental research and to formulate advance directives. If a resident does not have decision-making capacity, this right may be exercised by an appropriately authorized representative for the resident. Review of the undated form titled, admission Agreement-Statement of Acknowledgement, revealed under section six, Please check all statements that apply: The Resident has executed an Advance Directive. The Resident has not executed an Advance Directive. The Resident has not executed an Advance Directive but would like to obtain additional information about advance directives. There was no statement marked. Record review for R56 revealed medical diagnoses of but not limited to anoxic brain damage, tachycardia, and protein calorie malnutrition. Review of Physician Orders included oxycodone HCl oral tablet 5 mg (milligram) give 1 tablet by mouth every hour as needed for pain/shortness of breath, please consult [name] Hospice per family request; admit Hospice- Dx (diagnosis) protein calorie malnutrition, and DNR (Do Not Resuscitate); POLST. Review of the care plan included, [R56] presents with a deteriorating/terminal condition/need for hospice, DNR. Self-care revealed the resident has a deficit in his self-care ability. He is blind in both eyes and hard of hearing. He is now fed by staff and needs maximum dependance assist from staff for activities of daily living (ADL) care. [R56] and his family have elected to make him a DNR. Interventions included, Complete/update Advanced Directives document. Interview on 11/19/2024 2:30 pm the Administrator in training revealed if the resident was unable to comprehend the information on the Advance Directive, the document should be provided to the family or resident representative for their signature. Interview on 11/21/2024 at 10:10 am the Social Service Director (SSD) revealed that advanced directives was a form in the admission packet. The SSD would give the document to the residents and/or family, and there was information for power of attorney, living will and code status. Once SSD gave the information to the residents/family member and they did not have any questions, they would sign the admission agreement and/or the POLST. If the resident was unable to sign the document, the family would sign it. Interview on 11/21/2024 at 2:15 pm the Administrator and Administrator in training revealed residents/representatives were given information about advance directives during the admission conference. The admission packet was completed by Social Services. If the resident was not able to document on the form, the responsible party would sign.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to submit for a Preadmission Screening and Resident Review (PASRR) Level II for a mental health diagnosis for one of 33 residents (R) (R82). This deficient practice had the potential for R82 not receive services and/or care according to his needs. Findings included: The facility revealed they did not have a policy on PASARR. Record review for R82 revealed pertinent diagnoses/conditions included secondary malignant neoplasm of bone (primary diagnosis), vascular dementia (12/7/2020), anxiety disorder, and psychosis not due to a substance or known physiological condition (4/27/2023). Review of Physician Orders included and order for treatment and evaluation as needed with [name] behavioral health services, refer to [name] related to cognitive decline, and Consult: Psychiatric/Psychology Services evaluation and treat as needed. Interview on 11/21/2024 at 10:00 am the Social Service Director (SSD) revealed clinical information was entered into the Georgia Medicaid Management Information System (GAMMIS) by the hospital; if the hospital did not enter the information the facility would enter the information. Criteria for Level II included depression, anxiety, insomnia, schizophrenia, and major depressive disorder. The SSD was made aware of changes in the diagnosis by communicating with the providers and staff during clinical meetings. Interview on 11/21/2024 at 12:30 pm with the SSD revealed R82 had diagnoses of dementia and unspecified psychosis not due to a substance or known physiological condition. She revealed she was in the process of submitting a Level II for R82 that day. Interview on 11/21/2024 at 12:45 pm with the Medical Records Coordinator revealed that for new admissions from the hospital that a DMA-6 was completed, and this document indicated the resident had diagnoses appropriate for admission to the facility. If the resident would be at the facility more than 30 days, the hospital would enter information in the Georgia portal; this information was shared with the facility. Diagnoses or criteria for Level II included dementia, schizophrenia, combative behaviors, and trouble adapting. The care plan nurse would identify behaviors and communicate this information to the appropriate person or the staff member responsible for submitting Level II. If a resident had a diagnosis of dementia, and other mental disorders, the Medical Records Coordinator revealed a Level II should be submitted. Interview on 11/21/2024 at 2:15 pm with the Administrator and Administrator in training revealed the hospital sends the PASARR information with the resident when they were admitted . Any kind of mental health diagnosis would be used to submit a Level II. Interview on 11/21/2024 at 10:00 am the SSD revealed for admission there were two clinical liaisons who communicated with providers to get documents; depending on what hospital they come from the information may be entered into GAMMIS by the hospital; if the hospital did not enter the information the facility would enter the information; Criteria for Level II includes mental health diagnoses. She used diagnoses when residents came into facility to see if a Level II would be triggered. Criteria for Level II included depression, anxiety, insomnia, Schizophrenia, major depressive disorder. SSD will talk with providers in building and during clinical meetings; this was how SSD was made aware of any change in diagnoses, through ongoing communication. Interview on 11/21/2024 at 12:30 pm the SSD revealed diagnoses for R82 included dementia and unspecified psychosis not due to a substance or known physiological condition. She revealed she was in the process of submitting a Level II for R82. The PASRR Level I was reviewed and revealed admission [DATE]. Interview on 11/21/2024 at 12:45 pm the Medical Director Coordinator revealed, for new admissions from the hospital, basically the DMA-6 stated resident could be admitted ; if Level I indicated less than a 30-day stay they do not have to key in information; if the resident would be here more than 30 days, the hospital would enter information in Georgia portal; this information was shared with the facility; if the resident stayed long term a new Level I was done and the facility was responsible for getting a new Level I. If admitted from another nursing home the level 2 was transferred. If the person came from home the facility would submit the information. Diagnoses or criteria for Level II included dementia, Schizophrenia, combative behaviors, and trouble adapting. The care plan nurses would identify behaviors and communicate this information to the appropriate person or who was responsible for submitting a Level II. If a resident has a diagnosis of Dementia and other mental disorders, they will still submit a Level II. Interview on 11/21/2024 at 2:15 pm with the Administrator and Administrator in training revealed there was someone who handled the PASARR process; the hospital sends the PASARRs with the resident. Any kind of mental health diagnosis would be used to submit a Level II.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled, Care Plan Policy, the facility failed to ensure that a care plan was developed and/or implemented for three of 23 residents (R) (R19, R24, and R6). Specifically, the facility failed to implement the care plan for (R19 and R24) for monitoring and recording meal intake and the facility failed to develop and implement a care plan for (R6) for oxygen use. Findings included: Review of the policy titled Care Plan Policy review/revision date March 28, 2024, revealed under Procedure, Number 5. It is the responsibility of the care plan coordinator to review timely a resident's status and any change in needs following a hospital stay or any other unexpected event as deemed appropriate. It is also the responsibility of the care plan coordinator to ensure concerns/changes for a resident are care planned and/or updated. 10. The CNA task record will be updated during the care plan conference to refect interventions defined on the care plan. 11. The DON, Nurse Manger and Licensed Charge Nurses are responsible for ensuring provision of care in accordance with the care plan. 1. Review of the clinical record revealed R19 was admitted to the facility with diagnoses of but not limited to Alzheimer's disease, vascular dementia, and major depressive disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Review of the care plan revised on 8/31/2024 revealed [R19] was at risk for weight loss secondary to periods of confusion, impaired cognition, inattention, edentulous status and disorganized thinking at times. Interventions included, give diet, fluids, supplements, snacks as ordered, record percentage eaten, offer food replacement for less than 25% (percent) food not consumed. Review of the Nutritional Task-Amount Eaten for September through November 2024 revealed that the percentage of meal eaten by R19 varied from 0% to 100%. Continued review revealed there was no documentation for intake percentages for 9/1/2024, 9/4/2024, 9/8/2024, 9/11/2024 to 9/12/2024, 9/15/2024 to 9/16/2024, 9/18/2024 to 9/20/2024, 9/22/2024, 9/25/2024 to 9/26/2024, 9/28/2024, 9/30/2024 to 10/1/2024, 10/3/2024 to 10/7/2024, 10/11/2024, 10/13/2024 to 10/16/2024, 10/20/2024, 10/23/2024 to 10/25/2024, 10/27/2024 to 11/3/2024, 11/6/2024 to 11/14/2024, and 11/17/2024 to 11/18/2024. 2. Review of the clinical record revealed R24 was admitted to the facility with diagnoses of but not limited to adult failure to thrive, major depressive disorder, and abnormal weight loss. Review of the Quarterly MDS assessment dated [DATE] assessed a BIMS score of 14, which indicated little to no cognitive impairment. Review of the care plan revised 8/31/2024 revealed [R24] was at risk for changes in weight and nutritional deficits. [R24] is edentulous and receives a mechanically altered diet of soft and bite sized. Interventions included give diet, fluids, supplements, snacks as ordered, record percentage eaten. Review of the Nutritional Task-Amount Eaten for September through November 2024 revealed R24 consumed between 51-75% and 76-100% of meals. Continued review revealed there was no documentation for intake percentages from 9/1/2024 to 9/2/2024, 9/4/2024, 9/6/2024, 9/8/2024, 9/10/2024 to 9/13/2024, 9/15/2024 to 9/16/2024, 9/18/2024, 9/20/2024 to 9/23/2024, 9/25/2024 to 10/6/2024, 10/8/2024, 10/11/2024, 10/16/2024 to 10/18/2024, 10/20/2024 to 10/23/2024, 10/25/2024 to 10/27/2024, 10/29/2024, 11/1/2024 to 11/6/2024, 11/8/2024 to 11/12/2024, 11/14/2024 to 11/16/2024, and 11/19/2024 to 11/20/2024. Interview on 11/21/2024 at 12:20 pm Registered Nurse (RN) DD confirmed that percentage of amount eaten should be documented for every meal, and CNAs were responsible for documenting this information in facility electronic medical records (EMR) system daily. Interview on 11/21/2024 at 12:30 pm with Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that if the care plan had interventions to record percentage of consumed meals, it should be recorded daily and for every meal. CNAs were responsible for documenting consumed amounts in the EMR system, and to report them to the nurses. 3. Review of the clinical record revealed R6 was admitted to the facility with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis, atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the Quarterly MDS assessment dated [DATE] for R6 assessed a BIMS score of 10, indicating moderate cognitive impairment. Review of Section O (Special Treatments and Programs) reported oxygen use. Review of a Physician order dated 3/25/2024 revealed O2 (oxygen) at 2 liters per minute to keep O2 Sat 92% and above every shift for SOB, oxygen tubing and neb tubing change every Monday every day shift every Monday oxygen: tubing and humidifier change every Monday Review of R6 care plan dated 11/6/2024 revealed there was no care plan with specific goals and interventions for oxygen use. Observation during initial screening on 11/19/2024 at 10:00 revealed R6 in bed with the oxygen on and the oxygen was set at 2.5 L/M. Additional observations on 11/19/2024 at 12:20 pm, and on 11/20/2024 at 10:05 am revealed R6 had on oxygen and the oxygen was set at 2.5 L/M. Interview on 4/10/2024 at 10:19 am Licensed Practical Nurse (LPN) EE confirmed that R6's oxygen was on and set at 2.5 liter, and that the respiratory therapist checked the oxygen during visits and decided what level it should be set at unless there was a change by the physician. Interview on 11/21/2024 at 9:40 am the MDS Coordinator CC revealed that she was responsible for creating the care plan for oxygen for R6. She revealed that she linked the oxygen to COPD and had planned to go back to look at it to create a care plan for oxygen with more detailed goals and intervention but did not create the plan. Interview with DON and ADON on 11/21/2024 at 10:00 am regarding their expectation from staff when it came to physician order and care plan, the DON revealed that she expected staff to follow any physician order that was implemented. The DON revealed that if oxygen was ordered at 2 liters that she expected staff to set the oxygen at 2 liters and nothing more. She revealed that care plans were implemented according to diagnosis and if there was an order for oxygen that it should care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and review of the facility's policy titled Accident/Hazard Prevention, the facility failed to ensure a working door alarm to prevent the elopement of one of 31 residents (R) (R73) housed on a COVID unit. This failure had the potential to place R73 at risk for avoidable accidents and adverse consequences. Findings included: Review of the policy titled, Accident/Hazard Prevention initiated 6/10/2023 revealed, It is our policy to assure safety for our resident, employees, and visitors through the utilization of a program designed to reduce the likelihood of accidents. The Safety Program included: 5. Compliance monitoring will be completed as indicated by administration, DON/ADON, and maintenance director to include, but is not limited to storage of chemicals, locked medicine carts, locked med rooms, water temperature, spills, obstructive hallways, slippery floors, burned out light bulbs, torn window screens, broken glass, proper disposal of trash and garbage, electrical cords, and accessible spray containers. 6.Maintenance request notebooks are located at each nurse's station for utilization by any employee to request prompt attention to needed repair work. Record review of the admission Record for R73 revealed diagnoses of but not limited to Alzheimer's disease with early onset, dementia, and wandering. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C- Cognitive Patterns assessed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment, Section I - Active Diagnoses-progressive neurological condition, hypertension, hyperlipidemia, Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, depression, Section P - Restraints and Alarms-not used. Review of R73's care plan dated 2/20/2024 revealed focus area, Wander/Elopement [R73] is at risk for injuries r/t (related to) wandering. R73 is on a closed dementia unit and can ambulate at will without assistance. R73 has diagnoses (dx) of dementia and has cognitive deficits. Goal: Safety will be maintained through the review date. Interventions included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book and providing structured activities. Review of nurses note dated 2/17/2024 at 4:45 pm revealed R73 was redirected several times during the afternoon shift, attempted leaving COVID isolation wing, noted ambulating without assistance, denies pain/Shortness of Breath (SOB) at this time, will continue with the current plan of care. Review of nurses note dated 2/17/2024 at 6:40 pm revealed R73 was noted outside by neighbors of this facility, neighbors summoned police, police returned R73 to facility. Observation on 11/19/24 at 11:27 am revealed R73 currently housed on the [NAME] Wing/locked unit. Interview on 11/21/24 at 10:40 am with Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed R73 was moved from the locked unit due to COVID, an alarm was placed on the door of the unit to ensure safety. R73 was last seen in her room at 5:50 pm washing her hands. The facility received a call around 6:40 pm stating that R73 was located at another facility about one minute away. R73 was able to bypass two doors to exit the facility. Interview on 11/21/2024 at 11:35 am with Maintenance Director (MD) revealed a system failure occurred with the alarm that was placed on the COVID unit, resulting in R73 being able to bypass two doors to exit the facility. Interview/walkthrough on 11/21/2024 at 11:55 am with MD revealed a door alarm was placed on the COVID unit where R73 was placed due to COVID. R73 was able to exit the unit due the alarm system failure and proceed to door two located in the hallway across from therapy as R73 pressed a green button to exit the facility. Interview on 11/21/24 at 1:00 pm with Licensed Practical Nurse (LPN) AA revealed R73 was moved to another unit due to COVID. R73 was not on one-on-one monitoring, but an alarm was placed on the door to ensure the resident's safety. Interview on 11/21/2024 at 2:13 pm with Administrator and Administrator in training revealed an assessment was completed upon admission, all wanderers or elopement residents are placed on the [NAME] Wing (lock down unit) so they can wander as they please. Administrator revealed there was an alarm on the door on the COVID unit, but it was inoperable, but after moving residents to that unit due to COVID, a working alarm was placed on the door. The Administrator revealed R73 should not have been moved from her unit, they were trying to figure things out with COVID going on, moving forward they had learned to keep residents who wander in their same environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews, and review of the facility's policy titled, Oxygen, Therapy, the facility failed to ensure oxygen was administered as ordered by the physician for one of twelve residents (R) (R6) receiving oxygen. The deficient practice had the potential to place R6 at risk for medical complications, and a diminished quality of life. Findings included: Review of the facility policy titled, Oxygen, Therapy Guidelines, review/revision date June 21, 2023 revealed under Purpose, This protocol would enable the Respiratory Therapist or Nurse to monitor and adjust the oxygen therapy to meet preset criteria and it will be done more quickly and seamlessly than the conventional way of responding to potentially serious changes in the patient condition , calling the physician and then obtaining an order to make necessary changes. Further review under Clinical Responsibilities 11, the following guidelines will be adhered to in all oxygen therapy patients at all times. The physician will be contacted within 24 hours so that an order may be received for the new liter flow if a change is made by the RT or nursing. Review of the clinical record revealed R6 was admitted to the facility with diagnoses of but not limited to chronic obstructive pulmonary disease, emphysema, chronic bronchitis, atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R6 had a Brief Interview for Mental Status (BIMS) score of 10, indicating little to no cognitive impairment. Review of Section O (Special Treatments and Programs) indicated oxygen use. Review of the Physician orders dated 3/25/2024 revealed O2 (oxygen) at 2 liters per minute (LPM) to keep O2 Sat (saturation) 92% (percent) and above every shift for SOB (shortness of breath), oxygen tubing and neb tubing change every Monday, every day shift; oxygen: tubing and humidifier change every Monday Observation during initial screening on 11/19/2024 at 10:00 revealed R6 in bed with the oxygen on and the oxygen was it was set at 2.5 LPM. Additional observations on 11/19/2024 at 12:20 pm, and on 11/20/2024 at 10:05 am, revealed R6 in bed with the oxygen on and it was set at 2.5 LPM. Interview on 11/20/2024 at 10:19 am Licensed Practical Nurse (LPN) (LPN EE) confirmed that R6's oxygen was set at 2.5 liters and revealed that the Respiratory Therapist decided what level it should be set at unless there was a change by the physician. Interview on 11/21/2024 at 9:40 am with the MDS Coordinator 1 revealed that she was responsible for creating R6's care plan for oxygen. She revealed that she linked the oxygen to COPD and had planned to go back and look at it to create a care plan for oxygen with more detailed goals and interventions, but did not create the plan. Interview on 11/21/2024 at 10:00 am with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON revealed her expectation from staff when it comes to physician orders and care plan, she expected staff to follow any physician order that was implemented on the floor. DON revealed that if oxygen was ordered for 2 liters that she expected staff to set the oxygen to 2 liters and nothing more. She revealed that care plans were implemented according to diagnoses and if there was an order for oxygen that it should be care planned.

Based on observations, staff interviews, record reviews, and review of facility's policy titled, Food Service Policy and Procedures, the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance of food. Specifically, the facility failed to use a recipe when preparing pureed food. This deficient practice has the potential to affect 13 residents who were ordered a pureed diet. Findings included: Review of the facility's undated policy titled, Food Service Policy and Procedure, under the section titled Pureed Diets revealed, To ensure that residents who have been placed on a puree diet receive the best possible product without compromising flavor and, texture food & nutrition will at all times adhere to strict preparation procedure. 1. Meats starches & vegetables will be placed in the food processor until well blended. 2. Gravy or broth will be gradually added to products until a gravy like texture has been achieved. When processing starches and vegetables, use the liquid that is strained from the starch or vegetable. Do not use plain tap water. Do not overly add liquid as this will affect the nutritional value. 3. Staff will then gradually add thickener (Thick-It) two teaspoons per four-ounces of food. Example, if you have processed 20 ounces of chicken, you would need to gradually add a total of 10 teaspoons of thickener to the chicken that is being processed. 4. Food & Nutrition staff will taste all products to ensure the desired flavor has been achieved. 5. Food processors will be clean prior to processing another product. Clean between uses. 6. When processing liquids such as water or fruit juices staff will add three to three and a half teaspoons to achieve a nectar consistency and 3 and a half to four teaspoons to achieve a honey consistency. 7. Always refer to instructions provided on each individual recipe Observation on 10/30/2024 at 10:00 am, and interview at that time, revealed [NAME] BB prepping boiled spaghetti to be pureed. The Food and Nutrition Manager (FNM) approached with a document outlining instructions for pureeing food, which was placed in front of [NAME] BB. Upon reviewing the document, [NAME] BB looked confused. When asked about the document, [NAME] BB revealed that was the first time she had seen the document. Further questioning about the process revealed that [NAME] BB measured the spaghetti by breaking it in half and placing it in a container. [NAME] BB was then observed using a ladle to scoop thickened powder from a bag, which she added to the grinder. When asked about the specific measurement of thickened powder, [NAME] BB explained that she used the size of the ladle as a reference, rather than following any precise measurement or recipe. [NAME] BB revealed that based on her experience working in the kitchen for a long time, she simply knew how much to add. [NAME] BB further revealed that the puree was intended for 10 residents, and that the desired consistency was supposed to be nectar thick. [NAME] BB did not refer to a formal recipe for guidance. Interview on 11/20/2024 at 10:56 am with the FNM revealed that her expectations were for cooks to be properly trained, follow recipes, and execute their duties correctly. FNM revealed being aware that the cook was not following the recipe but revealed that she could print them out for reference. The FNM clarified that the intended consistency for the puree was a nectar-thick liquid, and it was meant to serve 12 residents. Interview on 11/21/2024 at 10:20 am the Administrator revealed his expectations were that dietary staff were trained and knew how to properly puree items, and there should be a recipe followed for pureed diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and review of the facility's policies titled, Food Storage, Floor Stock, and Accepting Food Deliveries, the facility failed to ensure proper labeling and storage of food with open and expiration dates, failed to discard food items by the expiration dates, and failed to properly cover opened food items. This deficient practice had the potential to affect 85 residents who received food orally. Findings included: Review of facility's policy titled, Food Storage dated 2021, revealed under section titled Procedure: 2. Food should be dated as it is placed on the shelves if required by state regulation. 3. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS food should be consumed, sold, or discarded. Refrigerated Food Storage: 2. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Frozen Foods: 3. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Review of facility's policy titled, Floor Stock dated 2021, revealed under section titled Procedure: 2.c. The food and nutrition services staff will: Rotate stock and remove outdated items. Record review of facility's policy titled, Accepting Food Deliveries dated 2021, revealed under section titled Procedure: 4. Perishable foods will be properly covered, labeled, and dated and promptly stored in the refrigerator or freezer as appropriate. Observation on 11/19/2024 at 9:24 am with the Food and Nutrition Manager (FNM) revealed and confirmed the following items in the walk-in cooler: Five clear boxes of cheddar cheese slices with no expiration date. One clear box of Swiss cheese slices with no expiration date. One container of [named brand] low fat cottage cheese with an expiration date of 11/15/2024. Observation on 11/19/2024 at 9:31 am with the FNM revealed and confirmed the following items in the freezer: Three bags of turkey burgers with no expiration date. Nine cups of milkshakes in clear containers with no expiration date. One opened bag of beef patties not properly sealed with no expiration date. One opened bag of French toast sticks not properly sealed with no expiration date. One opened bag of strawberries not properly sealed with no expiration date. One opened bag of biscuits not properly sealed with no expiration date. One opened bag of French fries not properly sealed with no expiration date. Nine loaves of bread with no expiration date. Observation on 11/19/2024 at 9:40 am with the FNM revealed and confirmed the following items in the pantry: One opened jug of [name brand] golden barbeque sauce that was opened and not refrigerated. Nine bags of mini marshmallow with an expiration date of 6/24/2024. Observation on 11/19/2024 at 10:06 am of the resident pantry located on the [NAME] Wing, with the FNM, revealed and confirmed the following expired foods items: One [name brand] prune juice with an expiration date of 6/18/2024. Three graham honey crackers with an expiration date of 7/22/2024 and 5/22/2024. Two original graham crackers with the expiration of 6/9/2023 and 7/10/2023. One sugar lemon cookie with an expiration date of 7/28/2024. Observation on 11/20/2024 at 10:33 am of the resident pantry located on [NAME] Wing with the FNM revealed and confirmed: 21 packages of [name brand] easy mix instant food thickener with an expiration date of 10/3/2024. The FNM discarded the expired packages. Interview on 11/20/2024 at 10:56 am the FNM revealed her expectation that everyone in the kitchen know that expired foods were a no and that they work as a team to oversee and label food items and throw out any expired food items before the expiration date. Interview on 11/20/2024 at 10:07 pm the FNM revealed she was not in charge of checking to see if the resident pantries had any expired food items. FNM further revealed the unit secretary assigned to that floor was normally responsible for checking the resident's pantry for any expired food items, but they currently don't have one. Interview on 11/20/2024 at 10:10 am the Licensed Practical Nurse (LPN) AA in charge of the [NAME] Wing revealed she had not looked in the drawers for expired items and she only checked the juices. Interview on 11/21/2024 at 10:18 am the Administrator revealed that everything should be labeled upon entry and should have an expiration date on it. He revealed there shouldn't be any expired items because the FNM did rounds every day to check food items. He further revealed his expectation that all food items would be properly closed. The Administrator further revealed the unit managers oversee verifying all expired items in the residents' pantries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interviews, the facility failed to accommodate the needs for one of 30 sampled residents (R) (#48) related to providing a wheelchair for mobility out of the room. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#48 had a Brief Interview of Mental Status (BIMS) score of 14 indicating cognitively intact. The resident required two person total dependance with transfer, one person limited assistance with locomotion on and off the unit and used a wheelchair for mobility device. The resident had a diagnosis of paraplegia. Review of the Progress Notes revealed on 1/19/2023 R#48 had a fall out of his wheelchair. Resident discussed in PAR (patient at risk) meeting on 1/20/2023 related to medication started for muscle spasms and the wheelchair would need to be repaired to include additional fall prevention measures of anti-tippers. Observations on 2/14/2023 at 10:31 a.m., 2/15/2023 at 9:33 a.m., and 2/16/2023 at 3:45 p.m. revealed resident in bed reading a book or watching a movie on his tablet. No wheelchair was observed in the resident's room. During interview on 2/14/2023 at 10:31 a.m., R#48 stated he would get out of the bed if he could, but he did not have a wheelchair. Resident #48 stated his wheelchair needed anti-tippers and has been with maintenance since 1/19/2023. Review of an invoice revealed anti-tippers were ordered on 1/20/2023. Observation and interview with the Maintenance Director on 2/15/2023 at 9:02 a.m. revealed resident equipment in need of repair is repaired and returned to the resident as soon as possible. The repaired wheelchair for R#48 was in an empty room across the hall from the resident's room. The Maintenance Director brought the wheelchair to R#48, and the resident confirmed that was his wheelchair and that he had not seen it since his accident on 1/19/2023. Interview with Certified Nursing Assistant (CNA) KK on 2/15/2023 at 9:16 a.m. revealed she had not seen R#48 in his wheelchair since they took it after he fell about a month ago. CNA KK stated R#48 was out of bed to activities once in the Geri-chair but did not enjoy it due to the lack of mobility the Geri-chair provided. Interview with Registered Nurse (RN) HH on 2/15/2023 at 9:19 a.m. revealed the resident had not been up out of bed since his wheelchair accident due to a part that was needed for the wheelchair. She stated maintenance is scheduled to complete the repair. Interview with Licensed Practical Nurse (LPN) AA on 2/15/2023 at 9:21 a.m. revealed she cannot recall the last time she seen R#48 out of bed since his wheelchair accident. Interview with CNA JJ on 2/15/2023 at 9:37 a.m. revealed she is very familiar with R#48. She stated that due to a part needing to be ordered for his wheelchair, the resident has not had a wheelchair at bedside to accommodate his needs. CNA JJ had not assisted the resident out of bed since 1/19/2023. Review of Nurse's Note dated 2/15/2023 revealed resident up to recliner wheelchair with anti-tippers in front and back. Resident does not look positioned right in chair. Writer requested OT (occupational therapy) to assess for positioning of resident in chair . Seemed to be a problem with mechanism in letting the recliner part of wheelchair. Writer and OT explained that ordering another wheelchair would probably be best due to safety concerns. Interview with the Rehab Director on 2/16/2023 at 10:06 a.m. revealed a request was made for her to evaluate the positioning of the resident in the wheelchair. She stated this was the first time since 1/19/2023 a request or concern had been made regarding resident in the wheelchair. Due to the resident having concerns related to his positioning in the wheelchair, the rehab department requested a new wheelchair for safety measures. Review of the undated Purchase Order revealed a tentative order request for a Tracer Sx5 Reclining Wheelchair with elevated leg rest, which will allow for the same locomotion as the previous wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, staff interviews, and review of the policy titled, Medication Storage in The Care Center the facility failed to ensure that three of eight medication carts and one of three treatment carts were locked when the carts were out of view of the nurse. Additionally, one bottle of eye drops requiring refrigeration was unrefrigerated and an inhaler was not stored properly. Findings include: A review of the Policy titled, Medication Storage in The Care Center (Reviewed and Updated 2012) revealed: Intent: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedural Guidelines: 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 11. Medications requiring refrigeration or temperatures between 2 degrees C (36 degrees F) And 8 degrees Celsius (46F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. An observation on 2/14/2023 at 10:51 a.m. on the South Wing revealed a medication cart labeled cart 3 positioned outside room [ROOM NUMBER] with drawers positioned toward the hallway. The cart was unlocked and unattended. Licensed Practical Nurse, (LPN) AA approached the cart at 10:53 a.m. and moved the cart to the next room and began preparing medication of another resident. Then upon seeing the surveyors observing the cart she yelled down the hallway, bring the keys at 10:53 a.m. Registered Nurse, (RN) BB handed the keys to LPN AA . LPN AA acknowledged the cart had been left unattended and unlocked. An observation 2/14/2023 at 10:58 a.m. revealed at the South Wing nurses station unlocked and unattended was cart 2. LPN CC revealed the cart was unlocked and should have been locked even though the cart was being shared by two nurses. The RN BB revealed cart 2 was being shared by two nurses and should be locked while unattended. RN BB revealed it is her expectation that the medication carts be locked when unattended. An observation 2/14/2023 at 11:10 a.m. on the [NAME] Wing (the locked Dementia unit) a treatment cart was observed unlocked and unattended. The treatment cart contained dressing supplies and treatment medications including. Medi- Honey, Bacitracin ointment, Neosporin ointment, wound cleaner, hydrogen peroxide, vitamin D ointment and Hibiclens liquid. An interview with the RN DD revealed the treatment cart does not have a key but should be secured by turning the knob to a locked position. An observation 2/14/2023 at 11:18 a.m. on the North Wing revealed positioned outside room [ROOM NUMBER] the medication cart was and unlocked and unattended. LPN EE acknowledged the cart was unlocked and unattended and should have been locked. Observation on 2/15/2023 at 8:37 a.m. On the [NAME] Wing medication Cart 1 The following storage issues were observed during medication pass with LPN LL. Symbicort 80/4.5 inhaler not labeled with resident name or in a box. LPN LL revealed it belonged to (R#37) and returned it to an empty box with her name on it and stated it should have been stored in the labeled box in the residents drawer. Additionally, Latanoprost .005% eye drops 2.5 Milliliters (ml) labeled with resident name (R# 37) was observed unopened. The product label revealed the eye drops should be kept refrigerated until opened. Eye drops were stored in med cart and were not refrigerated. LPN EE confirmed the Latanoprost eye drops should have been stored in the refrigerator until opened and she revealed she did not know why it was in the medication cart unopened or how long the eye drops had been unrefrigerated. An interview on 2/16/2023 at 8:55 a.m. with Unit Manager, LPN FF revealed when the medication cart is unattended it should be locked, and the screen shut off. An interview on 2/16/2023 at 8:59 a.m. with RN GG revealed when a nurse is not at the Medication Cart administering medications the cart should be locked. An interview on 2/16/2023 at 9:02 a.m. with the Director of Nurses (DON) revealed her expectation is for Medication Carts to be locked when unattended and all medications should be stored per manufactures' recommendations. Further interview revealed medications should be stored in the container from the pharmacy labeled with the resident's name. An interview 2/16/2023 at 9:10 a.m. with the Administrator revealed medication carts should be locked when a nurse is not with it or when medication cart is not in view.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review and review of the facility policy titled, Male/Female Catherization the facility failed to promote, maintain, and protect a resident's dignity for two of nine residents (R#35, R#56) with an indwelling urinary catheter. Findings include: Review of the facility policy titled, Male/Female Catherization dated 11/28/16 documented a resident has a right to respect and dignity. 1. R#35 was admitted to the facility in 3/22/16 with diagnoses that included (partial list) vascular dementia, hypertension, major depression, pressure ulcers and peripheral vascular disease. Review of R#35's significant change Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of zero (0) indicating very poor cognition; Section G-Functional Status: resident requires total assistance with all Activities of Daily Living (ADL's); Section H-Bowel and Bladder: resident has indwelling urinary catheter and is always incontinent of bowel; Section M-Skin: resident is at risk for pressure ulcers and has facility acquired unstageable pressure ulcer. Review of R#35's the May 2021's Physician's orders for R#35 revealed an order for: Insert 16 FR Foley catheter for wound management, record total every shift. Apply catheter strap daily. Change catheter every month on the 10th 3-11 shift. Daily catheter care-clean each shift Change catheter as needed for wound management. Review of R#35's Care Plans revealed a plan in place dated 5/13/21 Resident has an indwelling catheter inserted for management of unstageable wound to buttocks. Approaches include place urine bag in a privacy bag. An observation of R#35 on 5/10/21 at 3:28 p.m. revealed resident had an indwelling urinary catheter attached to a urinary catheter bag. The catheter bag was not in a privacy bag and the catheter bag was visible from the door. An observation of R#35 on 5/11/21 at 11:35 a.m. revealed resident had an indwelling urinary catheter attached to a urinary catheter bag attached to the side of the bed. The catheter bag was not in a privacy bag and the catheter bag was visible from the door. An interview on 5/12/21 at 11:26 a.m. with Registered Nurse (RN) Unit Manager (UM) RN CC of [NAME] Wing revealed her expectations are to make sure a resident who has a catheter should always have on a catheter strap, urine bag kept below the bladder, bag kept off the floor and the bag kept in a privacy bag. An interview on 5/13/21 at 3:03 p.m. with the Director of Nursing (DON) revealed she would expect the nurses and Certified Nursing Assistants (CNA's) to place the resident's catheter bag in a privacy bag to maintain the resident's dignity. 2. Review of the 2/3/2021 Quarterly MDS for R#56 revealed in Section (C) Cognition a BIMS was not done because the resident is never or rarely understood. Section (G) Functional Status revealed the resident is totally dependent upon staff for ADLs. Section (H) Bowel and Bladder revealed the resident has an indwelling foley catheter. Review of the care plan for R#56 revealed resident has an indwelling catheter in place. Approaches include place urine bag in a privacy bag. During an observation on 5/10/2021 at 12:32 p.m. revealed R#56 had an indwelling urinary catheter attached to a urinary catheter bag, urine was straw in color and attached to the side of the bed. The catheter bag was not in a privacy bag and it was visible from the door. During an observation on 5/11/2021 at 9:33 a.m. revealed R #56 catheter bag remained without a privacy bag and was visible from the door. During an observation and interview on 5/12/2021 at 8:15 a.m. with LPN BBB she observed the catheter bag for R #56 uncovered and visible from the door. During this time, she revealed the catheter bag does not have a privacy cover and added the catheter bag should always be covered. She revealed it is the nurse and CNAs responsibility to ensure the catheter bags are covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure a clean, comfortable, and homelike environment for one of four halls that had a build-up of dust in the heating/AC vents, holes in the walls in two resident bathrooms and one of two shower rooms on the South Wing on one of four halls. Findings include: During the initial tour on 5/10/21 at 2:41 p.m. revealed the heating/AC vents on the South Wing hall for rooms 47-86 had a thick layer of dust in the vents. During the initial tour on 5/10/21 at 2:51 p.m. revealed one of two shower rooms had a hole in the lower portion of the wall with three tiles missing. The three tiles were located behind the toilet in the shower room with a black dry substance on them. During the initial tour on 5/10/21 at 3:02 p.m. revealed the shared bathroom between rooms [ROOM NUMBERS] had a hole in the wall with several tiles missing. The tiles were laying on the floor behind the toilet. During the initial tour on 5/10/21 at 3:04 p.m. revealed the shared bathroom between rooms [ROOM NUMBERS] had a hole in the wall. During walking rounds on 5/12/21 at 12:15 p.m. with Maintenance Director (MD) revealed he was aware of the maintenance issues observed on the South Wing. MD Stated he had not received permission from corporate to start working on South Wing of the building. MD Confirmed all the above findings. MD Stated the heating/AC units are cleaned every three months and were last cleaned in March. States he does not keep a tracking log of when they are cleaned. Revealed he has a 'monthly checks and services list but it does not have heating/AC units listed as one of the items.

Based on observations, staff interviews, and review of the facility policy titled, Medication Storage in the Care Center the facility failed to discard expired biologicals prior to the expiration dates in two of four medication storage rooms. Findings Include: Review of the facility policy titled, Medication Storage in the Care Center, copyrighted 2019, revealed: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. An observation on 5/13/21 at 8:28 a.m. of the [NAME] Wing medication room revealed three unopened bottles of aspirin 325mg with an expiration date printed on the bottles of April 2021. Expired medications verified by the Licensed Practical Nurse (LPN) LPN BB. An interview on 5/13/21 at 8:28 a.m. with LPN BB revealed she checks the medication room for need to order more floor stock and looks for expired medications. She also indicated the Unit Manager (UM) checks the room for need and expired medications. An interview held 5/13/21 at 10:07 a.m. with the [NAME] Wing Registered Nurse (RN) RN UM revealed 11p.m. to 7 a.m. shift is responsible for checking the medication carts two times a week for expired medications and the need to order any medications. An observation on 5/13/21 at 8:46 a.m. of the South Wing medication room revealed: One (1) expired vial of Tuberculin Purified Protein Derivative labeled expires 30 days after opening; vial was labeled opened on 3/25/21 and expired 4/24/21. 1 bottle of Multivitamin with Minerals with an expiration date printed on the bottle of April 2021. 1 bottle of Magnesium Citrate with an expiration date printed on the bottle of April 2021. 2 Control Solutions for testing Glucometers with an expiration date printed on the bottle of 1/31/21 and 2/15/21. 1 bottle of Antiseptic Wound Cleanser with an expiration date printed on the bottle of January 2021. 3 BD Vacutainer UA preservative tubes with an expiration date printed on the tubes of 4/30/21. 4 Tracheostomy Care Trays with an expiration date printed on the trays of 4/16/21. 5 Clorox Germicidal Bleach Wipes with an expiration date printed on the wipes of 4/24/21. An interview on 5/13/21 at 9:10 a.m. with the Licensed Practical Nurse (LPN) LPN OO confirmed the above items were expired. She indicated she was not sure who is responsible for checking the cabinets for expired medications or supplies. An interview on 5/13/21 at 9:12 a.m. with the South Wing RN UM confirmed the above items were expired. She indicated the Central Supply Clerk rotates the floor stock medications when she refills the cabinets. She further indicated all charge nurses are responsible to check for any expired items in the medication room. An interview on 5/13/21 at 9:23 a.m. with the Director of Nursing (DON) indicated it is her expectation for all nurses to check the medication rooms for expired medications and supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and Resident interviews, and review of the Facility's Assessment the facility failed to provide sufficient nursing staff on four of four wings; North Wing, [NAME] Wing, South Wing, and [NAME] Wing; f to achieve the highest practicable level of well-being for all Residents. The facility census was 114 Residents. Findings include: Review of the Facility Assessment revised 4/2021 revealed a staffing plan as follows: In order to achieve personal care centered, foster excellence in the nursing services and promote continuity of care we take and look at the needs of our residents. We believe in consistent staffing for the benefit of the resident. This provides them with a sense of comfort along with the ability to make friendships and get to know the staff, plus staff will know slight changes in the resident. To develop the assignments, we look at the acuity of the residents. By checking their AD looking into behaviors and diagnosis we are able to determine acuity level. During an interview on 5/10/2021 at 12:41 p.m. with Resident (R) #4 on North Wing, he revealed he has waited as long as an entire shift to get help when he was incontinent. He stated the facility does not have enough staff to take care of everyone. During an interview on 5/10/2021 at 1:27 p.m. with R#92 on South Wing she revealed she does not feel there is enough staff in the building and stated she often must wait for long periods of time before she can get assistance and added she has had to wait up to 3 hours. During an interview on 5/10/2021 at 2:24 p.m. R#2 on South Wing she revealed there is not enough staff and added that she is able to do most things herself but needs assistance at times and no one shows up. During an interview on 5/10/2021 at 2:59 p.m. with R#27 on South Wing he revealed there is not enough staff and has to wait for long periods of times before he can get assistance but added he knows the staff are busy and are doing the best they can. During an interview on 5/10/2021 at 3:59 p.m. with R#7 on North Wing he revealed he is supposed to get a bath on Tuesday, Thursday, and Saturday but is told by staff that they do not have enough staff to get him into the shower because he requires a lift and there are not enough people to safely take him to the shower. He stated she does get a bed bath but would like, at some point, to have a shower. During an interview on 5/10/2021 with Licensed Practical Nurse (LPN) QQ for North Wing, she revealed there was a Certified Nursing Assistant (CNA) out on North Wing for today. She stated when someone calls out, they call out to the Supervisor on duty, and it is that Supervisor's responsibility to get coverage for that call out. She stated, according to the schedule, the CNA who was supposed to work today was actually off and added it would be the Staffing Coordinators responsibility to get that position filled. LPN QQ revealed that the Staffing Coordinator was stationed in their sister facility and is responsible for staffing two locations. LPN revealed for today on North Wing there are two LPN's and two CNA's but there should be three CNA's. During an interview on 5/11/2021 at 7:15 a.m. with LPN RR, revealed she is staffed by the facility through Agency and has been working in the facility regularly since February 2021. She revealed she works in different areas of the facility when on the schedule and was on North Wing from 11:00 p.m. to 7:00 a.m. last night. She stated for North Wing there was one nurse, two CNA's, and one RN Supervisor for 33 residents. She revealed CNA's work a lot of split shifts and explained that some CNA's will agree to stay and work three or four hours on the next shift leaving only one CNA for all residents the remainder of that shift but sometimes they will have a CNA agree to come in early to help out the last couple of hours of a shift but added even when this happens the residents are lacking in turning, repositioning, and incontinent care. LPN RR revealed that the facility is painfully understaffed, and residents must wait long periods of time after using their call lights to get the help they need. She revealed residents are staying wet longer than they should and added this causes discomfort for the residents. She revealed weekends are especially understaffed and added the weekends are even worse related to wait times for the residents in receiving care. LPN RR stated she worked on South Wing a month ago with a Nurse Supervisor who would not even try to get a replacement for a call out and told them they would be ok but added that it is the residents who suffer from the lack of staffing. During an interview on 05/11/21 at 8:20 a.m. with RN SS on North Wing she revealed when someone calls out for the oncoming shift, and it is agency, she will call agency to get a replacement but if a staff member of the facility calls out, she will, if the employee has not worked a double already, she asks an off-going employee if they would be willing to stay. She stated the biggest problem with Agency staffing is that they are not open and will not answer their phone in the middle of the night or early morning so she must wait for the day shift RN Supervisor (RN AA) to come in and try to get someone to fill the vacancy. RN SS stated there is no definite process to get replacement staff for call outs. She stated there is an as needed (PRN) pool but no one will answer their phone. RN SS revealed the residents are not being turned and repositioned during the night. She stated the CNA's do dry rounds every two hours and there was no time for them to turn and reposition because they do not have enough staff. She stated she helps out with med pass and even with CNA duties when they are short but stated that the residents suffer related to, they are staying in one spot because they are not being turned and repositioned like they should be. She stated she has not seen any evidence of wounds or skin conditions related to this but added there is discomfort for the residents and if this shortage of staff continues there is the potential for skin breakdown and worsening pressure sores. RN SS stated Staffing Coordinator VV is responsible for staffing this facility and their sister facility and added she is located in the other facility. During an interview on 5/11/2021 at 10:23 a.m. with R#97 on South Wing revealed the nurse only comes by one time per week and stated it takes a long time for the staff to respond to her call light. She revealed she has not had a shower in 2 to 3 months. R#97 stated she was not getting changed in a timely matter when she was soiled. During an interview on 5/11/2021 at 10:25 a.m. with LPN YY on South Wing she revealed she feels resident care suffers because there are not enough staff members to provide the necessary care for the residents need. She stated they do the best they can to take care of the residents but there just are not enough people to help with the residents. During an interview on 5/11/2021 at 10:28 a.m. RN AAA on South Wing she revealed she does not feel the facility has sufficient staff to provide adequate resident care. She stated the Certified Nursing Assistants (CNAs) sometimes have between 15-20 residents to take care of on their assignment and added they do the best they can but sometimes the residents do have to wait for long periods of time before someone can get to them. During an interview on 5/12/2021 at 6:50 a.m. with LPN BB, Agency Nurse, on [NAME] Wing, she revealed she works 40 hours per week in the facility on the day shift Monday through Friday. She stated the facility has a shortage of both nurses and CNA's and added they had one CNA on Monday for 7:00 a.m. to 3:00 p.m., two CNA's Tuesday on 7:00 a.m. to 3:00 p.m., and today they have four CNA's for 7:00 a.m. to 3:00 p.m. LPN BB revealed Residents are not gotten out of bed or showered due to lack of staff to do so. During an interview on 05/12/2021 at 7:00 a.m. with CNA HH on North Wing she revealed she worked 3:00 p.m. to 11:00 p.m. the previous shift and volunteered to stay over and do night shift because there was only one CNA scheduled for that shift. She revealed there are 33 residents on the North Wing and most of them are incontinent and require changing every two hours and added that there is no way one CNA can manage that by themselves. She revealed that even with two CNA's sometimes they cannot get around again to everyone during the shift, but they do the best they can. CNA HH revealed not having the allotted number of staff for a shift is a frequent occurrence and the facility is constantly asking staff to stay over or work extra. She revealed what bothers her most is that the residents have to wait long periods of time and sometimes stay wet or soiled for a significant amount of time and stated at times it is over an hour but added thankfully there has been no major skin issues but only some redness and discomfort from laying in one place all the time. During an interview on 05/12/21 at 7:15 a.m. with CNA UU, from a staffing Agency, revealed she has been coming to this facility regularly for five years and works on the 7:00 a.m. to 3:00 p.m. shift. She stated she feels so bad for the residents because there is not enough staff to even be able to give them showers and they are being washed off while in the bed. CNA UU stated R #65 has been begging her for a shower for two weeks and there has not been enough staff, so she has not been able to give her a shower and has been washing her off for the last two weeks. She stated if enough staff show up today, she is planning on getting some showers done today. She revealed there is not enough staff to get them up and certainly not enough staff to use a lift that requires two people for safety. CNA UU revealed the weekend schedule is mostly blank with maybe two positions filled for the whole facility and added it is very difficult to find staff to come in and work, so the bare minimum gets done on the weekend. She revealed that she has worked so much extra that if she is being honest, lately she has called in some due to being exhausted. CNA UU revealed the same people are volunteering to work and help and they are getting exhausted and burned out. During an interview on 5/12/2021 at 8:20 a.m. with LPN MM on South Wing she revealed there are not enough CNAs to give the residents the care they need and stated most residents on the South Wing are extensive to totally dependent with Activities of Daily Living (ADLs). CNAs do not have time to give the residents baths, feed them, get them dressed, or out of bed before it is time for them to leave for the day. During an interview on 5/12/2021 at 11:10 a.m. with CNA ZZ on South Wing she revealed she has a difficult time getting to all of her residents. She stated she has between 10-15 residents on her assignment and added that the resident care does suffer because she always feels rushed to get to them all. During an interview on 5/12/2021 at 11:26 a.m. with RN CC on [NAME] Wing, the behavior/dementia wing, she revealed the facility has a staffing problem. RN CC revealed they use agency staff to work a lot of their shifts, but stated agency does not usually work the weekend or holidays and added most of the regular facility staff left two months ago. RN CC revealed she is currently on workman's compensation and has limited duties but does work about every day including the weekends and stated she assists with feeding the residents. She revealed the residents are not getting their scheduled showers and added that they might get one shower a week, but they do get washed in the bed every day. RN CC revealed the residents are getting turned and changed but not getting out of bed and added that most residents require a lift to get up and added it is too unsafe to get them up with a lift without sufficient staff. She revealed she has asked repeatedly for more staff because the residents in this unit require more care as most need assistance with meals, take longer to feed, or feed themselves, are total care, have behaviors and require constant monitoring. RN CC did not feel residents were losing weight or getting more wounds due to the lack of staff at this time and stated the staff that are here work very hard to get things done. She revealed that she has two nurses and four CNAs today and stated today is a good day. During an observation on 5/10/2021 at 11:00 a.m. on North Wing revealed there was no residents observed to be up out of bed and there were no residents observed to be up in chairs. During an observation on 5/10/2021 at 4:00 p.m. on North Wing revealed residents remained in bed. During an observation on 5/11/2021 at 10:00 a.m. on North Wing revealed residents in bed. There were no residents observed up in chairs. During an observation on 5/11/2021 at 3:30 p.m. on North Wing revealed residents remained in bed. During an interview on 5/13/2021 at 9:30 a.m. with RN AA revealed on the Staffing Sheet P/U means shift was picked up by a regular staffed employee and that the others are agency staff who worked the shift. She revealed for North Wing there should be four CNA's, [NAME] Wing should have four CNA's, South Wing should have six CNA's, and [NAME] Wing should have two CNAs to provide adequate care to the residents. RN AA revealed recently, it is getting so bad, and staff are leaving or going to PRN status. She revealed, because she has very little staff, when she does get someone to agree to work, they beg not to be put in certain areas such as South Wing because there are 46 residents and not enough staff to help. She revealed her first concern about not having enough staff in the building is that residents are not getting good quality care and added staff are not able to get residents up out of bed every day because there are not enough staff to get them up safely. She stated she comes in, in the morning and does rounds to see if they have enough staff and will move staff around as necessary. She stated the Unit Secretary sets up appointments, arranges transportation, answers call lights, and is a CNA. RN AA revealed there is one CNA that strictly goes to doctor appointments with residents. She revealed her biggest concern is there is not enough staff, CNA's, to adequately provide care to the residents but stated they do the very best they can. Review of the staffing sheets revealed on Saturday 5/8/2021 7:00 a.m. to 3:00 p.m. North Wing had two LPN's and two CNAs for 33 residents but needed 4 CNAs. The [NAME] Wing had two LPN's and two CNAs for 27 residents but needed four CNAs. The South Wing had three LPN's and three CNAs for 47 residents but needed six CNAs, and [NAME] Wing (Rehab Wing) had one LPN and one CNA for seven residents but needed two CNAs. Review of the staffing sheets revealed on Saturday 5/8/2021 3:00 p.m. to 11:00 p.m. North Wing had two LPN's and one CNAs for 33 residents but needed four CNAs. The [NAME] Wing had one LPN's (needed three LPNs) and three CNAs for 27 residents but needed four CNAs. The South Wing had two LPN's and four CNAs for 47 residents but needed six CNAs, and [NAME] Wing (Rehab Wing) had one LPN and two CNA for seven residents. Review of the staffing sheets revealed on Saturday 5/8/2021 11:00 p.m. to 7:00 a.m. North Wing had one LPN's (Needed two) and two CNAs for 33 residents but needed three CNAs. The [NAME] Wing had one LPN (Needed two LPNs) and two CNAs for 27 residents but needed four CNAs. The South Wing had two LPN's and two CNAs for 47 residents but needed four CNAs, and [NAME] Wing (Rehab Wing) had one LPN and two CNAs for seven residents. Review of the staffing sheets revealed on Sunday 5/9/2021 7:00 a.m. to 3:00 p.m. North Wing had two LPN's and three CNAs for 33 residents but needed four CNAs. [NAME] Wing had two LPN's and three CNAs for 27 residents but needed four CNAs. The South Wing had two LPN's the entire shift and one LPN until 1:00 p.m. and two CNAs, one CNA for the entire shift and one CNA until 2:00 p.m., for 47 residents but needed six CNAs. The [NAME] Wing (Rehab Wing) had one LPN and one CNA for seven residents but needed two CNAs. Review of the staffing sheets revealed on Sunday 5/9/2021 3:00 p.m. until 11:00 p.m. the North Wing had two LPN's and three CNAs for 33 residents but needed four CNAs. The [NAME] Wing had two LPN's (needed 3 LPNs) and three CNAs for 27 residents but needed four CNAs. The South Wing had two LPN's and two CNAs for 47 residents but needed six CNAs, and The [NAME] Wing (Rehab Wing) had one LPN and two CNA for seven residents. Review of the staffing sheets revealed on Sunday 5/9/2021 11:00 p.m. to 7:00 a.m. the North Wing had one LPN's (Needed two) and two CNAs for 33 residents but needed three CNAs. The [NAME] Wing had one LPN's (needed two) and one CNAs for 27 residents but needed four CNAs. The South Wing had two LPN's (a 3rd LPN came in early on day shift at 5:00 a.m.) and three CNAs for 47 residents but needed four CNAs. The [NAME] Wing (Rehab Wing) had one LPN and two CNA for seven residents. During a four hour long continuous observation on 5/13/2021 from 10:30 a.m. to 2:30 p.m. on the North Wing outside of the rooms for R#58, R#78, and R#51 revealed no one entered the resident's room during that time. Review of the 4/26/2021 Quarterly Minimum Data Set for R#58 in Section (C) Cognition revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. Section (G) Function Status revealed the resident is totally dependent upon staff for ADLs. Review of the 3/19/2021 Quarterly MDS for R #78 revealed in Section (C) Cognition that no assessment for cognition should be done because the resident was never or rarely understood. Section (G) Functional Status revealed the resident is totally dependent upon staff for ADLs. Review of the 3/2/2021 Quarterly MDS for R #51 revealed in Section (C) Cognition that no assessment for cognition should be done because the resident was never or rarely understood. Section (G) Functional Status revealed the resident is totally dependent upon staff for ADLs. During an interview on 5/12/2021 at 2:35 p.m. with RN AA on North Wing she revealed she was sitting behind the nurse station working on setting up appointments for residents and making arrangements for transportation because the Unit Secretary was out, and she normally makes those arrangements for the residents and she did not notice there had not been anyone in the rooms of R#51, R#58, and R #78 for four hours. She revealed all three residents are totally dependent upon staff for care and that someone should have gone in and turned the resident and checked them for incontinence twice in a four-hour period. During an interview on 05/12/2021 at 9:00 a.m. with the Director of Nursing (DON), Staffing Coordinator VV, and the HR Director, who revealed she is present because she is Staff Coordinator VVs direct Supervisor, Staff Coordinator VV revealed she has helped in the facility as a CNA and with staffing since December of 2020 but in February 2021 she stated she began the job of Staffing Coordinator for the facility and a sister facility. She revealed she is not stationed in this facility but stated when a staff member calls out on night shift it is the responsibility of the night Supervisor to try to get a replacement and added it is the same process for the other shifts. The DON stated if the Supervisor cannot get a replacement, she will stay over until the RN AA gets in around 9:00 a.m. so she can work on getting someone to fill the position for the shift. Staffing Coordinator VV explained that she has a program that she uses to do the facility schedule with and added she takes the full-time employees and places them on the schedule and then she tries to get agency or regular facility staff to fill in the vacant shifts on the schedule and then sends it down to the RN AA. Staffing Coordinator VV revealed it is very difficult, due to Covid-19, to get anyone to work. HR Director stated employee's calling out should call out to the Nurse Supervisor on duty two hours prior to their shift to give the facility time to find a replacement. DON revealed the night supervisor has a book with the names and numbers of staff, and agency numbers, to call to work on getting a replacement for the call out and added that she has not heard of problems related to a decline in resident care from staff. HR Director revealed the facility is using agency staff daily and that the facility must have two Licensed Practical Nurses for each shift for each Wing and one CNA per 10 residents and stated right now they staff a total of 59 CNA's but are grossly understaffed. Staffing Coordinator VV stated she currently does the schedule for one to two weeks at a time and gives it to the RN AA. During this time the staffing book was reviewed with the Staffing Coordinator and she revealed there was a lot of open shifts available for CNA's and LPNs on various dates and added that she tried to get them scheduled but no one wants to work especially on weekends so she fills what she can and sends the schedules to the RN AA. HR Director revealed she did a job fair last week and there was a total of 60 people come through but stated she has ads in the local newspaper that links the jobs available to online job sites. She stated she places job openings with various public sites. She stated all applications come to her and she sends them to the facility for the DON to call and set up interviews. HR Director stated they offer shift differentials for nights and weekends and recently gave a $750.00 bonus to all staff as well as, during Covid, gave them additional pay on the hour but added they are not offering any sign on bonuses or incentives at this time. DON stated a lot of times she will call and set up interviews and they will not show, and she will call again to try and set up another interview but most of the time they don't answer. HR Director stated up until last quarter, October 2020 to December 2020, they averaged 350 applications per quarter for four facilities for all departments, and this quarter January 2021 to March 2021 they received 77. DON stated she, RN AA, and the Administrator have come in on various weekends to help pass trays, feed residents, pass medications, assist with care, because of the lack of staff and added that the wound care nurse has come in and worked some Saturdays as well but when she isn't here the nurse taking care of the resident is responsible for the wound care and stated they have a Wound Care Agency Nurse who has been with them for six months that helps out with wound care through the week and on weekends. She revealed she was aware the residents were not being gotten up and that showers were not being done because there was not enough staff to get them up safely and verified most, if not all of the residents on North and South Wing, are totally dependent on staff for ADLs. HR Director revealed over 16 hours in a shift would be a safety issue and staff may not work over 16 hours at a time and cannot go beyond working a double shift. During an interview on 5/12/2021 at 9:55 a.m. with RN AA she revealed she has worked in the facility for 10 years. She revealed that the HR Director made the decision to change how staffing was done about two to three months ago and put Staffing Coordinator VV over staffing for two facilities including this facility. RN AA stated she was happy doing staffing and it was good because she works in the facility and has a good relationship with staff, and they would work well with her and pick up shifts when needed. She revealed when Covid hit a lot of staff left and it became more difficult to staff the facility because people were afraid. RN AA revealed even though it was more difficult, staffing was still better when she was doing it because she had a better relationship with staff and the agencies they utilized. She revealed she does not know why the decision was made to move a needed CNA for resident care into a Staffing Coordinator position but added Staffing Coordinator VV did staffing at the sister facility she came here from and she helped her with staffing when she came to the facility. RN AA stated Staffing Coordinator VV was sending her staffing sheets one day at a time and she told her that she needed a whole week at a time because one day at a time did not provide her with enough time to cover the available shift that she (Staffing Coordinator VV) did not get covered, so she just started sending her, this week, the schedules for 2 weeks at a time. RN AA confirmed that Staffing Coordinator VV is putting the staff on the schedule who are currently employed by the facility and leaving her (RN AA) with the responsibility to fill any vacant shift. She revealed she and the DON and others come out to the floor and help pass trays and with resident care when needed but only those who are trained to provide resident care may do so and added that she has and will come in on weekends when needed and stated they really are doing the best they can. During an interview on 5/12/21 at 12:35 p.m. with RN WW for North Wing she revealed she has worked in the facility for eight years. She stated she works Monday through Friday 7:00 a.m. to 3:00 p.m. and added there have been weekends that she has had to come in because there was no nurse to work and pass medications, especially on holidays. She stated they have some Agency nurses who are permanent staff, one being CNA UU on North Wing. RN WW revealed that they do their best to get the resident's showers and get them up out of bed but most of the time they only have two CNAs for 33 residents who reside on the North Wing and it takes two CNAs to get a resident up safely using a lift and most residents on North Wing require a lift. She revealed, even though most days they work with only two CNAs, there had not been any falls that have resulted in a major injury and no new or worsening pressure sores. She revealed the residents do have to wait longer times for assistance and some wait as long as an hour to be turned and repositioned or to receive incontinent care and added that the nurses help out as much as they can. RN WW revealed today there are three CNAs on the North Wing so some residents will receive showers today. She stated staffing was much better when RN AA, who is always in the facility, was doing staffing because she knows all the staff and is familiar with the residents and the facility needs but added that with staffing shortage everywhere she doesn't know that at this point if it mattered who was doing staffing because there is a problem in all facilities right now with staffing due to Covid.

Based on observations and staff interviews the facility failed to ensure the sanitary handling of garbage and refuse at the kitchen loading dock and dumpster area. The facility census was 116 residents. Findings include: During the initial observation of the facility dumpster area with the Food Service Director (FSD) on 5/10/2021 at 2:10 p.m., a moderate amount of trash was observed on the loading dock, the steps to the grounds, the gated hosing area on the loading dock for washing/storing housekeeping and maintenance equipment, and along the grounds from the loading dock to the trash compactor where trash and garbage spillage was noted, including used gloves. In an interview with the FSD on 05/10/21 at 2:15 p.m., revealed he stated kitchen and housekeeping shared the duty of keeping the trash compactor area clean. He stated there was no schedule to clean the trash compactor area, but they kept an eye on it regularly. During observation of the loading dock and dumpster area with Housekeeping Supervisor on 05/10/2021 at 4:31 p.m., he stated his staff did share responsibility for keeping the dumpster area clean, and he believed the trash spillage by his staff occurred because the trash receptacles were likely too heavy for many of his staff to lift and empty into the trash compactor.