Based on observations and resident and staff interviews, the facility failed to promote dignity for one of 14 residents (R) (R 6) who ate in the main dining room. Specifically, R6 was seated at a table with inappropriate height.Findings Include:1. Observation on 7/7/2025 at 12:43 pm, at the second table, two of six residents had meal trays and were eating. R6 was seated at that table, but R6 was upset about not having food and Certified Nursing Assistant (CNA) AA moved R6 to the third empty table that was also upper lip height. Observation on 7/7/2025 at 12:59 pm, R6 was observed sitting in a lowered seat wheelchair eating independently with her upper lip at table height. Observation on 7/7/2025 at 1:18 pm, R6 was seated at a single table at eye level. R6 introduced herself.Interview on 7/7/2025 at 1:33 pm, CNA AA said R6 eats all her food, but her upper lip is almost at table height. R6 should be seated at a smaller table so she can see her food.During an interview with the Director of Nursing (DON) on 7/10/2025 at 10:01 am, she said, We heard through the grapevine that this was a problem on Monday, so we started to fix it on Tuesday. We gave you the policies already for Dignity.During an interview with the Administrator on 7/10/2025 at 2:50 pm, she said R6 should be seated at an adjustable table height, a small table. It's harder for anyone to eat when they cannot see the plate. This is a dignity issue, as she should either be seated with other residents, or if at a table alone, she should be seated at a smaller table. We have adjustable table heights, and we should have adjusted it for her or put her at the smaller table if she was sitting alone.During an interview with the Regional Director of Operations on 7/10/2025 at 2:53 pm, stated, R6 should sit at a smaller table so she can see her food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and resident and staff interviews, the facility failed to provide bath linen in good condition on seven of nine hallways (C hall, 600 hall, 200 hall, 400 hall, 500 hall, 800 hall and 900 hall).Findings include:On 7/7/2025 beginning at 10:55 am, during a brief tour of C hall, one linen cart revealed no towels or washcloths, a second linen cart has a torn washcloth and a few hand towels in disrepair. On 7/7/2025 at 11:22 am, in the secured hall, a staff member came out of room [ROOM NUMBER] with an arm full of linens, some washcloths tattered, and said, they were not dirty, I promise and put them in soiled laundry bin. On 7/7/2025 at 11:26 am, on the 600-hall linen cart had 10 wash cloths, a few were tattered and 13 bath towels.During an interview on 7/7/2025 at 11:37 am, Resident R12 said, they tore up larger towels and made it into washcloths when the new company took over. I had a few yesterday that were torn.During an interview with R11, on 7/8/2025 at 10:14 am, R11 said, the facility cut up towels to washcloth size and showed four tattered washcloths taken from their drawer.During an observation on 7/9/2025 at 10:23 am, a Certified Nursing Assistant (CNA) on 200 hall had two ripped washcloths in her hand coming out of room [ROOM NUMBER].During an interview on 7/9/2025 at 10:37 am with CNA JJ, they said, on the 900 hall, we sometimes don't have linens, or they are torn and shredded. We only got new linens today because State is in the building. I can't change residents until after 11:00 am because all we have are rags, just torn washcloths and no towels. During an interview on 7/10/25 at 1:09 pm, R13 took 2 torn and shredded washcloths from her shelf and displayed them on her bed.During an interview on 7/10/2025 at 1:10 pm, R15 shared the Resident Council Minutes and June 2025 minutes revealed the facility still did not have enough towels and wash cloths.Review of the grievance log revealed a Resident Council Grievance filed on 4/30/2025 from R15 that area of concern: residents complained about linen shortage that happens daily and occurs on all units. Actions/approaches: the Administrator was present at the meeting and informed residents that extra linen has been ordered to address this issue.During a telephone interview on 7/10/2025 at 2:30 pm with the Environmental Service Supervisor (EVS), they said, We have tried to get the linen par up. Families have taken towels to cut up and making washcloths out of them.An interview on 7/10/2025 at 2:38 pm with the Administrator revealed that families had torn and shredded the bath towels. The families and residents were taking linen into their rooms and storing it, then the staff went in and took the linens out of the rooms. The laundry techs said the CNAs grab linens and they worked from back towards the front to divvy it up fairlyOn 7/10/2025 at 2:39 pm, the Surveyor shared with the EVS, the Administrator, and the Regional Director of Operations pictures of torn and shredded washcloths found in R13's room that day. The Administrator and Regional Director of Operations both said, We should never use anything that's cut up.

Based on observations, staff interviews, and review of the facility policy titled, Food Storage, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility had expired food in storage areas reserved for resident snacks. This practice affected two of three units (Middle Unit and the Nursing Unit) observed in the facility for resident food storage. Findings include:Review of the facility policy titled Food Storage with a date of January 2025 revealed under 5. Storage Guidelines. D. Perishable and Leftover Foods, Label with preparation date and discard date (typically within 3-7 days based on item type). Observation on 7/7/2025 at 11:30 am of the snack cabinet for residents on the Nursing Unit revealed the cabinet contained an unopened loaf of bread that had an expiration date of 4/24/2025. The bread was hard and had areas of green discoloration in several areas.An interview, on 7/7/2025 at 11:33 am with Certified Nursing Assistant (CNA) II revealed the bread should have been discarded back in April of 2025.Observation on 7/7/2025 at 11:45 am of the residents' refrigerator used for snacks on the Middle Unit revealed the refrigerator contained three wrapped turkey sandwiches with a use by date of 7/4/2025 and three cups of covered apples with a use by date of 7/4/2025.An interview on 7/7/2025 at 11:50 am with CNA HH revealed the sandwiches and apples should have been discarded on 7/4/2025. The CNA threw the sandwiches and apples in the trash.

Based on observations, staff interviews, and review of the facility policy titled, Hand Hygiene, the facility failed to ensure proper hand hygiene during the lunch meal in the Nursing Unit Main Dining Room for three of 14 residents (R) (R4, R5, and R6). The deficient practice had the potential to cause foodborne illnesses for residents eating in the Nursing Unit Main Dining room.Findings include:Review of the facility policy titled Hand Hygiene with an effective date of January 2025 revealed under Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Under Guidelines: . 5) Use an alcohol-based hand rub for the following situations: . o) Before and after assisting a resident with meals.On 7/7/2025 at 12:49 pm, Certified Nursing Assistant (CNA) AA entered the Nursing Unit Dining Room, sat down without performing hand hygiene and started to assist R4 to eat. CNA AA touched the spaghetti on R4s fork with her bare hands and then brought that fork up to R4s mouth for them to eat the now contaminated food. Using the same hand, CNA AA twirled her own hair and itched her own head, then continued to assist R4 to eat. At 12:51 pm, CNA AA took their cell phone out of their pocket and checked it, then went back to assisting R4 with their lunch meal. At 12:52 pm, CNA AA touched her face, did not use any method of handwashing, and continued assisting R4 to eat. At 12:53 pm, CNA AA got up and changed the tv station to cartoons, then sat down to assist R4 with meal with no handwashing. At 12:54 pm, CNA AA put salt and pepper on R4s spaghetti, then continued to assist R4 with his meal. At 12:55 pm, CNA AA touched her head again and scratched her head several times, then used the same dirty hand to feed R4 with no hand hygiene. At 12:58 pm, a CNA handed CNA AA a pair of gloves to wear while assisting R4 to eat, but instead of putting on the gloves, CNA AA walked away from the R4 to pass out another tray, with no hand hygiene, and CNA AA then proceeded to cut up R5's spaghetti.On 7/7/2025 at 1:02 pm, without hand hygiene, CNA AA moved to assist R5 to eat. At 1:09 pm, CNA AA left R5 and put their hands on their hips, walked to another table, and came back to R4 to assist them briefly, then went to assist R6 to eat with no hand hygiene in between. At 1:10 pm, CNA AA touched their own face with her right hand that she had been using to feed the residents. At 1:11 pm, CNA AA went back to R4 to assist with their drink. There was no observed hand hygiene between assisting R4, R5, or R6.On 7/7/2025 at 1:27 pm, CNA AA returned to the Nursing Unit dining room, and within seconds left the dining room to get another meal cart. At 1:29 pm, CNA AA returned to the dining room with the last meal cart. No hand hygiene was observed before passing out meal trays or between passing out meal trays.During an interview on 7/7/2025 at 1:33 pm with CNA AA, they revealed most of the feeders (dependent diners) eat in this dining room. CNA AA said, If I have an itch I scratch it, but that is not good infection control. I should use hand sanitizer in the dining room. With R5, I didn't use hand sanitizer, I did have gloves, but I didn't wear them.During an interview on 7/10/2025 at 9:49 am with the Manager of the Nursing Unit Licensed Practical Nurse (LPN) KK, LPN KK said, staff should wash hands, grab trays, set them up, open everything and offer bites and drinks in between. I would do handwashing when you stop and then wash hands before I start to feed someone again. I would wash again after I touched my face or hair. I would never touch food on a fork. Don't touch food with bare hands. Between residents, you need to wash your hands. If you did not have clean hands, you could contaminate food and make the residents sick.During an interview on 7/10/2025 at 10:01 am with the Director of Nursing (DON) regarding handwashing or hand hygiene, they said, The staff should use hand sanitizer before serving or feeding. During an interview on 7/10/2025 at 2:50 pm, the Administrator and the Regional Director of Operations both said there should have been handwashing between passing trays, and before you fed anyone, or it would be an infection control issue.

Based on interview and record review, the facility failed to revise their CLIA (Clinical Laboratory Improvement Amendments) certificate within 30 days after new ownership. The facility does not have a current CLIA certificate appropriate for the level of testing it conducts after approximately seven months of ownership.Findings include:Review of the CLIA Certificate of Waiver with Effective Date of 5/6/2024 and Expiration Date of 5/5/2026 is in the name of the previous owner hospital.Review of the CLIA Certificate of Compliance with Effective Date of 8/19/2023 and Expiration Date of 8/18/2025 is in the name of the previous laboratory service owner. In an interview on 7/8/2025 at 12:21 pm with the facility's Administrator, they stated, We are still operating under that (Previous Owner) waiver as part of the transition. The new owner purchased the facility from the hospital in January 2025.On 7/8/2025 the State CLIA Department was consulted, and they confirmed the following, The facility is out of compliance and should request a revised CLIA certificate using the attached CMS-116 application. Facilities are required to notify CLIA STATE agencies within 30 days of ownership changes. The facility was provided with CMS-116 application on 7/9/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the policy titled, Oxygen (O2) Administration, the facility failed to maintain a clean O2 concentrator filter consistent with professional standards of practice for two of 23 residents (R) (R56 and R119) who use O2. The deficient practice had the potential to cause respiratory distress for R56 and R119. Findings include: A review of the facility policy titled Oxygen Administration dated 5/12/2022 and revised on 11/16/2022 revealed in the section titled Care of Concentrator Equipment, number five revealed remove and wash the air filter every seven days, documenting on resident's Medication Administration Record (MAR), Change oxygen (O2) tubing every seven days, documenting on resident's MAR, Wash concentrator with WellStar approved cleaning solution, Change humidifying water bottle weekly, Replace facility approved storage bag once a month or (as needed) PRN, and Check connections and flow setting to assure resident oxygenation every shift and PRN. Review of the electronic medical record (EMR) revealed that R56 was admitted to the facility with diagnoses including, but not limited to chronic obstructive pulmonary disease (COPD), and emphysema. Review of R56's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicates R56 had moderate cognitive impairment with no physical or verbal behaviors exhibited, dependent with extensive assistance for activities of daily living (ADLs) with two-person assistance. Review of R56's care plan dated 4/11/2024 indicated a respiratory problem. Goals included but were not limited to exhibiting no shortness of breath during the next 90 days. Interventions included but were not limited to providing humidification, monitoring for changes in symptoms that may indicate worsening respiratory status, notifying provider of changes, ensuring that supply is available at all times, change tubing per protocol, change O2 Concentrator Set up (nasal cannula (NC) tubing and water) and clean O2 concentrator filter with soap and water weekly on Wednesday and PRN, and administer oxygen therapy as ordered: Oxygen at two liters via nasal cannula at all times. Review of the EMR revealed that the Physician's Orders for R56 included but were not limited to changing the oxygen concentrator setup (NC tubing and water) and cleaning the oxygen concentrator filter with soap and water weekly on Wednesday, as needed, and open back vented area, and wipe with WellStar approved wipes weekly. Review of the EMR for R56 medication orders revealed oxygen is administered at two liters via nasal cannula per physician orders. Observation on 5/21/2024 at 3:18 pm revealed R56's O2 concentrator filter (in rear of unit) was covered with a thick, white substance. Observation on 5/22/2024 at 12:30 pm revealed that R56's O2 concentrator filter was covered with a thick, white substance. Observation on 5/22/2024 at 5:00 pm revealed that R56's O2 concentrator filter was covered with a thick, white substance. Observation and interview on 5/22/2024 at 5:05 pm with the Dementia Unit Manager (UM) HH confirmed the O2 concentrator filter for R56 was covered with a thick, white substance. The Dementia Unit Manager HH revealed that the O2 concentrator maintenance was conducted on the third shift (11:00 pm to 7:00 am), every Wednesday, and as needed per the physician order. However, R56's MAR revealed the O2 concentrator was clean as ordered. She verified and confirmed that the filter was covered with a thick, white substance. She stated that in her professional opinion the filter did not appear to have been cleaned during the previous third shift as indicated on the MAR. Review of the EMR revealed R119 was admitted to the facility with diagnoses including, but not limited to acute respiratory failure with hypoxia. Review of R119's MDS assessment dated [DATE] revealed a BIMS score of six, which indicated R119 had a severe cognitive impairment. R119 requires partial and moderate assistance with ADLs with one or two-person assistance. Review of the care plan dated03/21/2024 for R119 indicated a problem with receiving oxygen therapy. Goals included but were not limited to exhibiting no shortness of breath during the next 90 days. Interventions included but were not limited to providing humidification, monitoring for changes in symptoms that may indicate worsening respiratory status, notifying the provider of changes, ensuring that supply is always available, changing tubing per protocol, and administer oxygen therapy as ordered. Review of the the Physician's Orders for R119 included but were not limited to changing the oxygen concentrator setup (NC tubing and water) and cleaning the oxygen concentrator filter with soap and water weekly on Wednesday, as needed, and open back vented area, and wipe with WellStar approved wipes weekly. Review of the medication orders for R119 were listed but not limited to oxygen is administered at two liters via nasal cannula per physician orders. Observation on 5/21/2024 at 3:24 pm revealed R119's O2 concentrator filter (rear of unit) covered with a thick, white substance. Observation on 5/22/2024 at 12:28 pm revealed that R119's O2 concentrator filter was covered with a thick, white substance. Observation on 5/22/2024 at 5:05 pm revealed that R119's O2 concentrator filter was covered with a thick, white substance. Observation and interview on 5/22/2024 at 5:17 pm with Dementia Unit Manager HH revealed the O2 concentrator filter for R119 was covered with a thick, white substance. Dementia Unit Manager HH revealed that the O2 concentrator maintenance was conducted on the third shift, every Wednesday, and as needed per the physician order. She verified and confirmed that the filter on R119's O2 concentrator was covered with a thick, white substance. She stated that in her professional opinion that this filter did not appear to have been cleaned on the previous third shift as indicated on the treatment administration record (TAR). Interview on 5/22/2024 at 2:36 pm with a Certified Nursing Assistant (CNA) CC, she stated that the Licensed Practical Nurse (LPN) was responsible for assisting residents with their respiratory care needs, which included cleaning the oxygen concentrator filters. Interview on 5/22/2024 at 3:06 pm with LPN JJ verified that the nurse assigned to that resident's hall was responsible for maintaining and cleaning the O2 machine filter, ensuring the nebulizer machine was stored properly when not in use, and keeping the O2 tubing in a bag when not in use. Interview on 5/23/2024 at 9:43 am with the Director of Nursing (DON), she revealed that her expectations of staff caring for residents who receive O2 therapy was that the nurses assigned to these residents were to ensure the O2 concentrators were thoroughly cleaned and the filters were cleaned each week and as needed. She stated that the third shift nurse was responsible for cleaning the O2 concentrator and filters weekly and documenting their activities, but all nursing was responsible to check and make sure the equipment was clean and free of debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to individualize and/or implement a resident-centered care plan for six of 41 sampled residents (R) (R#97, R#45, R#70, R#117, R#20, and R#486) related to: activities for R#97; Activities of Daily Living (ADL) for R#45; and related to the restorative services for (R#70) (R#117) (R#20) and (R#486). Findings include: 1. Review of R#97's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the staff did not assess his activity preferences. Review of R#97's care plan revealed a care plan description for a need for customary routine choices to be met with the goal that the resident will have preferences for customary routine offered by staff. The approaches listed in the care plan included participating in favorite activities, participating in religious activities or practices, reading books, newspapers, or magazines, and that the resident enjoys listening to music that he likes. It further noted that he likes to be around animals and enjoys his favorite activities. During an observation on 10/18/22 at 11:12 a.m. and 2:29 p.m.; and 10/19/22 at 9:38 a.m., 11:15 a.m. and 3:11 p.m., R#97 was observed in bed, lights off and privacy curtain closed. Further observation revealed that the television was on at each of these times, but no provision of activities by staff were noted. During an interview and observation on 10/18/22 at 11:12 a.m. with R#97, he stated that he was bored. R#97 if he ever left the room for activities or had activities in the room. R#97 stated that he did not know that the facility had activities. Observation of the room revealed resident did not have an activity calendar on his side of the room. During interview with Certified Nursing Assistant (CNA) NN on 10/19/22 at 12:46 p.m., she stated that R#97 gets up out of bed into a Geri-chair but only stays up for a short period of time because he screams to go back to bed. CNA further stated that other than watching television, R#97 does not engage in any activities. During interview with the Activity Director (AD) on 10/19/22 at 2:26 p.m., she stated that she had two activity assistants and that they are responsible for ensuring that each resident has a current activity calendar. She stated that the assistants are responsible for informing and inviting resident to the group activity on each unit. The AD also stated that the activity assistants were responsible for providing 1:1 activities for residents who do not attend the group. After reviewing R#97's record, the AD further stated the resident has not had an initial or follow up activity assessment completed since admission. During an interview on 10/19/22 at 2:43 p.m. with Activity Assistant SS she revealed that she provides 1:1 activity with residents on the unit who are bedbound and does that attend group activities. She stated that the facility has group activities daily at 10:00 a.m. and 2:00 p.m. She stated that she goes to the resident's room and invites them to the activities and the CNAs on the unit assist resident to group activities. She stated that the scheduled activities are not announced because the residents have a calendar in their rooms and there is a big activity calendar near the dining room. Activity Assistant SS verified that R#97 did not have an activity calendar on his side of the room and agreed that calendar posted on resident's roommates' side of the room is not visible to R#97. Activity Assistant SS stated that the only interaction that she has with R#97 is going by his room from time to time and socializing with him. She confirmed that the resident does not attend group activities. Review of Activity Log Reports printed from the computerized system revealed that R#97 had not attended a group activity after 8/3/22 and did not have any one-to-one activities documented since admission. This was verified with the AD on 10/19/22 at 2:26 p.m. A review of the facility's policy titled Activities with a revision date of 7/8/21 Policy: A. Residents have the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility. B. To provide an activities program with services which are suited to the resident's needs, abilities, and interests. Activities provided to residents are appropriate to their needs and capacity to participate. Residents benefit from the activities which are in accordance with their interests. Appropriateness of activities is determined by a consideration of needs. C. Activities are provided in individual and group settings for both ambulatory and nonambulatory residents. 2. Review to the clinical record for R#45 revealed the most recent quarterly MDS assessment dated [DATE] revealed she required total assistance for baths and extensive assistance for personal hygiene. Review of the care plan dated 5/6/21 indicated that R#45 requires assistance with ADLs. Approaches include resident needs extensive assist with bed mobility, dressing, and personal care. Observation and interview with R#45 on 10/18/22 at 11:00 a.m., 10/19/22 at 9:46 a.m. and 4/11/18 at 9:33 a.m. and 11:03 a.m. after a.m. care was provided, revealed that fingernails on both hands are long and untrimmed. She asked surveyor to cut them for her. R#45 told surveyor that she does not desire her fingernails to be that long. She further stated that a girl once came around to trim and polish her nails, but no one comes around to do that anymore. On 10/19/22 at 12:36 p.m. during an interview with CNA NN, she stated the activity department is responsible to trim and polish resident fingernails and confirmed that they do not provide care for residents nails. During an interview with Director of Nursing (DON) on 10/19/22 at 3:01 p.m. she stated that the CNAs are responsible to ensure that all residents nails are cleaned, trimmed, and filed when they are providing showers. She further stated that the activity departments staff assists the CNAs, at times, with polishing nails but the responsibility of nail care is the responsibility of the CNAs. 3. Review of R#70's clinical record revealed that he had diagnoses including cerebral infarction due to embolism of left post cerebral artery and Hemiplegia affecting left nondominant side. Review of his Quarterly MDS assessment dated [DATE] revealed that he had had functional limitation in (Range of Motion) ROM on one side of the upper and lower extremities. Review of the care plan, initiated 5/27/22, revealed an intervention of Resident is on Restorative Nursing Program (RNP) for Passive Range of Motion (PROM) and Splint. Observations on 10/18/22 at 9:14 a.m., 10/19/22 at 9:53 a.m., 11:38 a.m. and 12:26 p.m. revealed R#70 was not able to completely extend his fingers on his left hand and he did not have any splint or orthotic device in place. Observation of R#70's room revealed signage above his bed with pictures of orthotic devices that read: Daytime left-hand splint ON: after breakfast, OFF after lunch, On (2:00 p.m.), Off after dinner. Passive (ROM) before putting on. Nighttime: Left hand palm protector on at bedtime. Check skin daily for irritation, clean hand splint daily with Sani-cloth, wash palm protector with soap and water and air dry, wash hand with mild soap and water and dry well, Contact Occupational Therapist (OT) with any questions or concerns. Review of nursing notes dated 8/23/22 at 7:05 p.m. revealed that R#70 had a history of cerebrovascular accident (CVA) and Hemiplegia, left side; and ROM was working with resident for Passive ROM and splint. A review of the Restorative Task revealed the following restorative plan of care - Passive ROM: Passive ROM for knees, ankles and hip flexing and extension. Active range of motion seated in (wheelchair) marches, kicks. Active ROM with (Right Lower Extremities) and (Left Lower Extremities). Active ROM and Active ROM with (Left Lower Extremities) as tolerated . (Physical Therapy) to improve (Left Lower Extremities) function. Splint/Brace: Monitor (Left Lower Extremities) positioning device with application per schedule. During an Interview with Registered Nurse (RN) Unit Manager FF on 10/19/22 at 10:27 a.m. she stated that the restorative CNA was pulled to work another hall today and there was not another restorative CNA scheduled to work. She further stated that the CNAs on the floor were responsible for following the restorative plan of care when the restorative CNA was not available. During an interview on 10/19/22 at 10:40 a.m. with CNA NN, she stated that the CNAs are responsible for doing ROM with ADL care for all residents. She stated that if residents have splints or braces that the CNAs are responsible to ensure that they are applied. She further stated that she was trained by the therapy department to apply the devices. The facility staff put a note in the closet to let us know about the resident's care. She stated that she does not think there are any resident on the hall who require splints at this time. During an interview on 10/19/22 at 10:53 a.m. with LPN OO, he stated that that the restorative and Physical Therapy aides are responsible to perform ROM and apply splints for resident requiring them. He further stated that if the restorative aide is pulled to another floor, the nurses or the CNA is responsible for following the restorative plan of care. He stated that activities and the CNA is responsible to perform the nail care for residents. During an interview with Therapy Manager PP on 10/19/22 at 11:13 a.m. revealed that resident has been on therapy case load and was discharged from skilled services with a restorative plan of care. He further stated that R#70 is not currently receiving skilled services and that the restorative aide should be following the plan of care outline by the therapist. During an interview with DON on 10/19/22 at 3:07 p.m. She stated that the restorative plan of care is developed by the therapy department and the Unit Managers are responsible for inputting the plan of care into the electronic record for the restorative aide to follow. DON stated that currently the facility has 52 residents on the restorative program and has 1 full time restorative aide during the week and 1 restorative aide on the weekend. She further stated that not all the resident receives restorative every day. During an interview with Occupational Therapist on 10/20/22 at 10:20 a.m. she stated and verified that R#70 should be wearing the left-hand splint during the day, every day. She went into the R#70's room and stated that resident does not have the splint on. Splint observed lying in the room on the bedside table. She stated that the nursing staff should apply the splint after breakfast, and it should have already been on at the time of the observation. 4. Review of R#117's clinical record revealed that she had diagnoses including arthritis and generalized muscle weakness. Review of her Quarterly MDS dated [DATE] revealed that she required extensive assistance with Bed Mobility, Dressing, Toileting, Personal Hygiene and Bathing. Review of her care plan, initiated 4/14/22 revealed a care plan description titled Active Assist Range of Motion (AAROM) program/ Restorative with a goal to prevent further ROM loss and an intervention, please see resident for AAROM to bilateral LE for ankle pumps, knee flex/ext, hip flex/ext, hip abd /add x 15 reps each. BUE to tolerance for shoulder flex, elbow flex/ext, finger flex/ext x 10 - 15 reps. Observation and interview with R#117 on 10/18/22 at 11:30 a.m. Resident stated that she no longer receives skilled therapy but is supposed to receive exercises to her arms and legs by therapy, but she is not receiving the services. Resident further stated that her arms and legs are getting stiffer and weaker due to not having the exercises. R#117 stated that her daughter was at the facility earlier today and exercised her legs because the staff at the facility will not do it. Interview with R#117 10/19/22 at 10:07 a.m. resident stated that the staff did not exercise her legs or hands on 10/18/22. She further stated that she is getting so weak. She further stated that her daughter is going to New York and will be away for a week so she will not probably receive any exercises until her daughter returns. R#117 stated I don't know why they don't do what they are supposed to do. Interview with r on 10/19/22 at 2:56 p.m. Resident lying in bed. Resident does not have splints in place. Resident stated that no one has been in her room to perform exercises today. During an interview with Therapy PP, on 10/19/22 at 11:13 a.m. revealed that R#117 has been on therapy case load and was discharged from skilled services with a restorative plan of care. He further stated that resident is not currently receiving skilled services and that the restorative aide should be following the plan of care outline by the therapist. Therapist stated that resident is a long-term resident at the facility and has been on the therapy caseload but is not currently receiving skilled services. He further stated that resident was discharged from therapy with a restorative plan of care that should be followed. A review of the Restorative Roster revealed R#117 that from 8/1/22 through 10/18/22 R#117 had her restorative plan of care documented as the service being provided only 11 days in that period. 5. Observations on 10/18/22 at 11:10 a.m., 10/18/22 at 3:20 p.m., and 10/19/22 at 10:15 a.m. revealed R#20 dressed and sitting in a wheelchair. Resident's right upper extremity (RUE) was positioned closed to body and right hand was clinched into a fist. Resident's right lower extremity (RLE) was positioned in a bent sitting position. Observations revealed two signs posted on the wall above the head of the bed with instructions to apply RUE splint in the morning and remove at bedtime and to apply right knee brace when out of bed. Observations revealed one splint and one knee brace lying on the bedside table. A review of the Restorative Nursing Treatment Plans dated 2/10/22 and signed by the OT, the PT and CNA GG revealed a treatment plan of: Frequency five to seven times per week 1: PROM to RUE 2: RUE weight bearing on rail in hallway with trunk flexion and extension from wheelchair focusing on RUE elongation 3: RUE splint on and clean. Goals: maintain RUE PROM and prevent contractures. Frequency five to seven times per week 1: Please stretch RLE into extension 20-30 second holds for three to five repetitions 2: Place orthotic on for tolerance for maximum of nine hours Goals: Maintain RLE ROM, maintain right knee orthotic four to nine hours per day A review of the care plan included: Description: PROM lower extremity Goal: Maintain ROM and maintain right knee orthotic for four to nine hours a day. Interventions: Stretch RLE into extension 20-30 seconds hold three to five repetitions and place orthotic on for minimum of four hours and maximum of nine hours Description: PROM weight bearing and splint Goal: Maintain RUE PROM and contractures. Interventions: PROM to RUE weight bearing on rail in hallway with trunk flexion/extension on RUE elongation hold on rail by restorative aid and RUE splint on. A record review of the Restorative Roster with date range of 7/19/22 through 10/19/22 revealed restorative nursing services were not provided for a minimum of five days a week every week. An interview on 10/19/22 at 1:20 p.m. CNA GG revealed she is scheduled Monday through Friday to provide restorative nursing services. She revealed she was reassigned on this date to cover CNA duties on 200 Hall. She further revealed she is reassigned to cover CNA hall duties as often as three days a week. She reveals there is one weekday CNA and one weekend CNA trained to provide restorative nursing services in her absences. She further reveals there are days that the CNA assigned to the residents are responsible for providing restorative nursing services due to all restorative CNAs being unavailable. She further revealed any staff that provides restorative nursing services charts in the EMR as completed, refused or other if not provided. She revealed she feels that she is unable to adequately provide ordered restorative services to all residents and she revealed there are currently 53 residents with restorative nursing plans. She revealed she feels that all residents do not receive restorative nursing services in her absences due to the CNAs do not have time to provide restorative services in addition to all other cares. An interview on 10/19/22 at 1:40 p.m. with the DON revealed there are two CNAs trained to provide restorative nursing services and one CNA that is cross trained to provide restorative nursing services if needed. She revealed it is her expectation that the CNAs assigned to the floor provide restorative nursing services if a restorative CNA is unavailable. She revealed it is her expectation for all staff providing restorative nursing services should document services provided every shift in the EMR. Record review of the care plan for R#20 with the DON verified care plan goals and interventions were not followed. Record review of Restorative Roster with date range of 7/19/22 through 10/19/22 with the DON verified that restorative nursing services were not provided for a minimum of 5 days a week every week for R#20. 6. Observations on 10/18/22 at 10:40 a.m., 10/18/22 at 3:10 p.m., and 10/19/22 at 9:15 a.m. revealed R#486 lying in bed on left side. Observations revealed left upper extremity (LUE) positioned close to body in a bent position with hand clenched. Observations revealed one splint lying on the bedside table. Observations revealed a sign on the wall above the head of the bed with instructions to apply splint on left forearm (LFA) in the morning and remove at bedtime. Resident's speech is unclear. A review of the Restorative Nursing Treatment Plans dated 4/20/22 and signed by the OT, the PT and CNA GG revealed a treatment plan of: Frequency five times per week Plan: 1: PROM to LUE as tolerated 2: Monitor LUE resting hand splint as tolerated to wearing schedule Goals: Maintain PROM of LUE A review of the care plan revealed Description: PROM Goal: Will maintain PROM LUE Interventions: PROM to LUE as tolerated (restorative nursing) Hand splints as tolerated (restorative nursing) A record review of the Restorative Roster with date range of 7/19/22 through 10/19/22 revealed restorative nursing services were not provided for a minimum of five days a week every week. An interview on 10/19/22 at 1:20 p.m. CNA GG revealed she is scheduled Monday through Friday to provide restorative nursing services. She revealed she was reassigned on this date to cover CNA duties on 200 Hall. She further revealed she is reassigned to cover CNA hall duties as often as three days a week. She reveals there is one weekday CNA and one weekend CNA trained to provide restorative nursing services in her absences. She further reveals there are days that the CNA assigned to the residents are responsible for providing restorative nursing services due to all restorative CNAs being unavailable. She further revealed any staff that provides restorative nursing services charts in the EMR as completed, refused or other if not provided. She revealed she feels that she is unable to adequately provide ordered restorative services to all residents and she revealed there are currently 53 residents with restorative nursing plans. She revealed she feels that all residents do not receive restorative nursing services in her absences due to the CNAs do not have time to provide restorative services in addition to all other cares. An interview on 10/19/22 at 1:40 p.m. with the DON revealed there are two CNAs trained to provide restorative nursing services and one CNA that is cross trained to provide restorative nursing services if needed. She revealed it is her expectation that the CNAs assigned to the floor provide restorative nursing services if a restorative CNA is unavailable. She revealed it is her expectation for all staff providing restorative nursing services should document services provided every shift in the EMR. Record review of the care plan for R#486 with the DON verified care plan goals and interventions were not followed. Record review of Restorative Roster with date range of 7/19/22 through 10/19/22 with the DON verified that restorative nursing services were not provided for a minimum of five days a week every week for R#486.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) were provided for two of 41 sampled residents (R) (R#45 and R#68) related to nail and hair care. Findings include: 1. Review to the clinical record for Resident R#45 revealed the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she required total assistance for baths and extensive assistance for personal hygiene. Review of the care plan dated 5/6/21 indicated that R #45 requires assistance with ADLs. Approaches include resident needs extensive assist with bed mobility, dressing, and personal care. Observation and interview with R#45 on 10/18/22 at 11:00 a.m., 10/19/22 at 9:46 a.m. and 4/11/18 at 9:33 a.m. and 11:03 a.m. after a.m. care was provided, revealed that fingernails on both hands are long and untrimmed. She asked surveyor to cut them for her. R#45 told surveyor that she does not desire her fingernails to be that long. She further stated that a girl once came around to trim and polish her nails, but no one comes around to do that anymore. On 10/19/22 at 12:36 p.m. during an interview with Certified Nursing Assistant (CNA) NN She stated the activity department is responsible to trim and polish resident fingernails we don't do it. During an interview with Director of Nursing (DON) on 10/19/22 at 3:01 p.m. she stated that the CNAs on the floor are responsible to ensure that all residents nails are cleaned, trimmed and filed when they are given their showers. She further stated that the activity departments staff assist the CNAs at time with polishing nails but the responsibility of nail care is the responsibility of the floor staff. A review of the facility's policy titled Shower/Tub Bath, Sub-Category - Personal Care with an effective date August 2007 revealed a required action 1.5 - Trim the resident's toenails or fingernails as instructed by your supervisor. 2. A review of the policy titled, Shower/Tub Bath under Purpose, stated to define a process to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. On 10/18/22 at 10:36 a.m. R#68 observed lying in bed with eyes closed, hair noted to be oily with pimples on forehead. Observation on 10/19/22 at 1:39 p.m. of R#68 who was in bed awake with television on. R#68 hair remains oily and greasy to touch. On 10/19/22 at 11:24 a.m. Staff JJ stated that the resident receives a bath Mondays and Thursdays on the evening shift (3: 00 p.m.-11:00 p.m.), a bath schedule was observed hanging on the wall in the breakroom, the bath schedule did not indicate shampoos to be included during bath/showers. Review of quarterly MDS assessment dated [DATE] Section G revealed that R#68 is totally dependent on staff for all aspects of her personal hygiene which includes combing hair. During an observation on 10/20/22 at 10:15 a.m., R#68 was in bed awake with television on. R#68 hair continued to look oily and greasy. An interview on 10/19/22 at 11:25 a.m. with Unit Manager (UM) II, revealed a bath system in the electronic medical record was labeled Bath Roster where the resident has received bed baths on 10/3/22, 10/6/22, 10/10/22, 10/13/22, 10/14/22 and 10/17/22. UM II further reveals that R#68 did not go to beauty shop for hair shampoos, and that they use a shampoo cap for her hair, however she was not sure when the last time she had received a shampoo of her hair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide an ongoing program of activities for one resident (R) (R #97), who needed extensive to total assistance by staff for provision of all care. The sample size was 42 residents. Findings include: Review of R #97's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that the staff did not assess his activity preferences and required extensive to total assistance with activity of daily living (ADL) care. Review of his care plan revealed a care plan description for a need for customary routine choices to be met with the goal resident will have preferences for customary routine offered by staff. The approaches listed n the care plan includes participating in favorite activities, participating in religious activities or practices, reading books, newspapers or magazines, Resident enjoys listening to music that he likes. Likes to be around animals and enjoys his favorite activities. Review of his clinical record revealed that he had a diagnosis of cerebral infraction and dementia without behaviors/psych/mood/anxiety. During observations on 10/18/22 at 11:12 a.m. and 2:29 p.m.; and 10/19/22 at 9:38 a.m., 11:15 a.m. and 3:11 p.m. R #97 was observed in bed, lights off and privacy curtain closed. Further observation revealed that the television was on at each of these times, but no provision of activities by staff were noted. During an interview and observation on 10/18/22 at 11:12 a.m. with R# 97 revealed resident stated that he was bored. Surveyor asked R#97 if he ever left the room for activities or had activities in the room. R#97 responded, no, I didn't know we had any. Observation of the room revealed resident did not have an activity calendar on in view on his side of the room. During interview with Certified Nursing Assistant (CNA) NN on 10/19/22 at 12:46 p.m., she stated that they got R #97 gets up out of bed into a Gerichair but only stays up for a short period of time because he screams to go back to bed. CNA further stated that other than watching TV, R #97 does not engage in any activities. During interview with the Activity Director on 10/19/22 at 2:26 p.m., she stated that she had 2 activity assistants. She further stated that the activity assistants are responsible for ensuring that each resident has a current activity calendar and informing and inviting resident to the group activity on each unit. The Activity Director also stated that the activity assistants are responsible for providing 1:1 activities for residents who does not attend the group. After reviewing R#97's record, the AD further stated the resident has not had an initial or follow up activity assessment completed since admission. During an interview on 10/19/22 at 2:43 p.m. with Activity Assistant SS she revealed that she provides 1:1 activity with residents on the unit who are bedbound and does that attend group activities. She stated that the facility has group activities daily at 10 a.m. and 2 p.m. She stated that she goes to the resident's room and invites them to the activities and the CNAs on the unit assist resident to group activities. She stated that the scheduled activities are not announced because the residents have a calendar in their rooms and there is a big activity calendar near the dining room. Activity assistant SS verified that R#97 did not have an activity calendar on his side of the room and agreed that calendar posted on resident's roommates' side of the room is not visible to R# 97. Activity Assistant told surveyor that the only interaction that she has with resident is going by his room from time to time and socializing with him. She confirmed that resident does not attend group activities. Review of Activity Log Reports printed from the computerized system revealed that R#97 had not attended a group activity after 8/3/22 and did not have any one-to-one activities since admission documented. This was verified with the Activity Director on 10/19/22 at 2:26 p.m. A review of the facility's policy titled Activities with a revision date of 7/08/21 Policy: A. Residents have the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility. B. To provide an activities program with services which are suited to the resident's needs, abilities, and interests. Activities provided to residents are appropriate to their needs and capacity to participate. Residents benefit from the activities which are in accordance with their interests. Appropriateness of activities is determined by a consideration of needs. C. Activities are provided in individual and group settings for both ambulatory and nonambulatory residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and review of the policy titled Restorative Nursing, the facility failed to follow Occupational Therapy (OT) and Physical Therapy (PT) Restorative Nursing Treatment Plan recommendations for range of motion (ROM) and orthotic application for four residents (R), (R#20), (R#70), (R#117) and (R#486) reviewed for ROM and mobility. The sample size was 41. Review of the policy titled Restorative Nursing revised 9/29/22 revealed: Purpose: To establish uniform guidelines concerning restorative care. Definition: General rehabilitative/restorative nursing care is that which does not require the use of a qualified professional therapist to render such care. Policy: Rehabilitative nursing is provided for each resident admitted . Philosophy: WellStar [NAME] Nursing Center uses an integrated model where staff, resident, and family ar trained in the philosophy and concepts of restorative care. The facility's policy is that restorative nursing is integrated in all activities of daily living and that each individual member of the staff plays a part in achieving an optimal level of self-care and independence and contributing to the total car of the resident. For example: Active and passive ROM, splinting The activities of restorative nursing care are developed and coordinated using an interdisciplinary care team approach beginning with the assessment process and is carried through with the completion of the resident's plan of care. Certified Nursing Assistants (CNA), under the supervision of licensed personnel, will be responsible for executing restorative nursing and documenting such care. Unit managers will monitor for compliance of policy and procedure. Procedure: 1. The nurse rehabilitation/restorative care program will be under the direction of a nurse manager Registered Nurse (RN). 4. The rehabilitation/restorative aides and certified nursing assistants will document time actually spent providing the restorative activity. 5. The Rehab Department will develop the resident's rehabilitation/restorative plan of care to be carried out by the rehabilitation/restorative nursing assistant. The clinical record and plan of care documentation will include measurable objectives and interventions. 8. The nursing rehabilitation/restorative care program will include, but not be limited to: passive range of motion (PROM), active range of motion (AROM), splint or brace assist. 15. Recording of the Restorative Nursing Treatment Plan by initial of certified nursing assistant, nurse, or restorative aide will be done as well as recording in minutes of each treatment plan activity provided. 16. Days and minutes of rehabilitative/restorative care activities will be entered on the Minimum Data Set (MDS). Findings include: 1. Observation on 10/18/22 at 11:10 a.m., 10//18/22 at 3:20 p.m. and 10/1/9/22 at 10:15 a.m. revealed R#20 dressed and sitting in a wheelchair. Right upper extremity (RUE) was positioned closed to body and right hand was clinched into a fist. Right lower extremity (RLE) was positioned in a bent sitting position. Observation revealed two signs posted on the wall above the head of the bed with instructions to apply RUE splint in the morning and remove at bedtime and to apply right knee brace when out of bed. Observation revealed one splint and one knee brace lying on the bedside table. A review of the clinical record revealed an admission date of 1/11/22 with diagnosis including, but not limited to cerebral infarction, contracture right wrist, muscle weakness. A review of the Quarterly MDS dated [DATE] revealed resident required set up assistance for eating and required extensive to total assistance for other ADLs. A review of the care plan included: Description of PROM lower extremity with a goal of maintain ROM and maintain right knee orthotic for four to nine hours a day. Interventions included to stretch RLE into extension 20-30 seconds hold three to five repetitions and place orthotic on for minimum of four hours and maximum of nine hours Description of PROM weight baring and splint with a goal of maintain RUE PROM and contractures. Interventions included PROM to RUE weight bearing on rail in hallway with trunk flexion/extension on RUE elongation hold on rail by restorative aid and RUE splint on. A review of the Restorative Nursing Treatment Plans dated 2/10/22 and signed by the OT, the PT and CNA GG revealed a treatment plan of: Frequency five to seven times per week 1: PROM to RUE 2: RUE weight bearing on rail in hallway with trunk flexion and extension from wheelchair focusing on RUE elongation 3: RUE splint on and clean. Goals: maintain RUE PROM and prevent contractures. Frequency five to seven times per week 1: Please stretch RLE into extension 20-30 second holds for three to five repetitions 2: Place orthotic on for tolerance for maximum of nine hours Goals: Maintain RLE ROM, maintain right knee orthotic four to nine hours per day A record review of the Restorative Roster dated 7/19/22 through 10/19/22 revealed restorative nursing services were not provided for a minimum of 5 days a week every week. Interview on 10/19/22 at 10:20 a.m. with CNA EE revealed she provides ADL cares to her assigned residents and in the absence of the restorative CAN she is expected to provide restorative services. She revealed she has had some training in restorative services and does know how to apply splints and braces. She revealed she charts ADL cares, restorative nursing services and refusal of cares in the electronic medical record (EMR). Interview on 10/19/22 at 11:15 a.m. with RN FF revealed there is one restorative CNA that works Monday through Friday, eight hours per day and is often reassigned to cover other areas if needed. She revealed there is another CNA trained to provide restorative services and they try to have her cover restorative services if possible. She revealed the CNA assigned to the hall is responsible for providing restorative services as much as they can if both restorative CNAs not available. Interview on 10/19/22 at 1:20 p.m. CNA GG revealed she is scheduled five days a week to provide restorative nursing services and is reassigned to cover CNA hall duties as often as three days a week. She reveals there is one weekday CNA and one weekend CNA trained to provide restorative nursing services in her absences. She further reveals there are days that the CNA assigned to the residents are responsible for providing restorative nursing services due to all restorative CNAs being unavailable. She revealed staff that provides restorative nursing services charts in the EMR as completed, refused or other if not provided. She revealed she feels that she is unable to adequately provide ordered restorative services to all residents and there are currently 53 residents with restorative nursing plans. She revealed she feels that all residents do not receive restorative nursing services in her absences due to the CNAs do not have time to provide restorative services in addition to all other cares. Interview on 10/19/22 at 1:30p.m. with CNA HH revealed she is normally assigned to 200 Hall and if the restorative CNA is reassigned, she is responsible for providing restorative nursing services to the residents she is assigned to. She revealed she often does not have time to provide restorative services. She further revealed CNAs are required to document all services provided to residents in the EMR every shift to include restorative nursing services. Interview on 10/19/22 at 1:40p.m. with the Director of Nursing (DON) revealed there are two CNAs trained to provide restorative nursing services and one CNA that is cross trained to provide restorative nursing services if needed. She revealed it is her expectation that the CNAs assigned to the floor provide restorative nursing services if a restorative CNA is unavailable and staff providing restorative nursing services should document services provided every shift in the EMR. Record review of the care plan for R#20 with the DON verified care plan goals and interventions. Record review of Restorative Roster with date range of 7/19/22 through 10/19/22 with the DON verified that restorative nursing services were not provided for a minimum of 5 days a week every week for R#20. 2. Observation on 10/18/22 at 10:40 a.m., 10/18/22 at 3:10 p.m., and 10/19/22 at 9:15 a.m., revealed R#486 lying in bed on left side with left upper extremity (LUE) positioned close to body in a bent position with hand clenched. Observation revealed one splint lying on the bedside table. Observation revealed a sign on the wall above the head of the bed with instructions to apply splint on left forearm (LFA) in the morning and remove at bedtime. A review of the clinical record revealed an admission date of 3/24/22 with diagnosis including, but not limited to: contracture left hip, contracture left knee. A review of the MDS dated [DATE] revealed resident requires extensive assistance for ADLs. A review of the care plan included: Description of PROM with a goal to maintain PROM LUE. Interventions to include PROM to LUE as tolerated (restorative nursing) and hand splints as tolerated (restorative nursing) A review of the Restorative Nursing Treatment Plans dated 4/20/22 and signed by the OT, the PT and CNA GG revealed a treatment plan of: Frequency five times per week Plan: 1: PROM to LUE as tolerated 2: Monitor LUE resting hand splint as tolerated to wearing schedule Goals: Maintain PROM of LUE A record review of the Restorative Roster with date range of 7/19/22 through 10/19/22 revealed restorative nursing services were not provided for a minimum of 5 days a week every week. Interview on 10/19/22 at 10:20 a.m. with CNA EE revealed she provides ADL cares to her assigned residents and in the absence of the restorative CAN she is expected to provide restorative services. She revealed she has had some training in restorative services and does know how to apply splints and braces. She revealed she charts ADL cares, restorative nursing services and refusal of cares in the electronic medical record (EMR). Interview on 10/19/22 at 11:15 a.m. with RN FF revealed there is one restorative CNA that works Monday through Friday, eight hours per day and is often reassigned to cover other areas if needed. She revealed there is another CNA trained to provide restorative services and they try to have her cover restorative services if possible. She revealed the CNA assigned to the hall is responsible for providing restorative services as much as they can if both restorative CNAs not available. Interview on 10/19/22 at 1:20 p.m. CNA GG revealed she is scheduled five days a week to provide restorative nursing services and is reassigned to cover CNA hall duties as often as three days a week. She reveals there is one weekday CNA and one weekend CNA trained to provide restorative nursing services in her absences. She further reveals there are days that the CNA assigned to the residents are responsible for providing restorative nursing services due to all restorative CNAs being unavailable. She revealed staff that provides restorative nursing services charts in the EMR as completed, refused or other if not provided. She revealed she feels that she is unable to adequately provide ordered restorative services to all residents and there are currently 53 residents with restorative nursing plans. She revealed she feels that all residents do not receive restorative nursing services in her absences due to the CNAs do not have time to provide restorative services in addition to all other cares. Interview on 10/19/22 at 1:30p.m. with CNA HH revealed she is normally assigned to 200 Hall and if the restorative CNA is reassigned, she is responsible for providing restorative nursing services to the residents she is assigned to. She revealed she often does not have time to provide restorative services. She further revealed CNAs are required to document all services provided to residents in the EMR every shift to include restorative nursing services. Interview on 10/19/22 at 1:40p.m. with the Director of Nursing (DON) revealed there are two CNAs trained to provide restorative nursing services and one CNA that is cross trained to provide restorative nursing services if needed. She revealed it is her expectation that the CNAs assigned to the floor provide restorative nursing services if a restorative CNA is unavailable and staff providing restorative nursing services should document services provided every shift in the EMR. Record review of the care plan for R#20 with the DON verified care plan goals and interventions. Record review of Restorative Roster with date range of 7/19/22 through 10/19/22 with the DON verified that restorative nursing services were not provided for a minimum of 5 days a week every week for R#486. [NAME] Findings include: 1.Review of R#70's clinical record revealed that he had diagnoses including cerebral infarction due to embolism of left post cerebral artery and Hemiplegia affecting left nondominant side. Review of his Quarterly Minimum Data Set (MDS) dated [DATE] revealed that he had had functional limitation in ROM on one side of the upper and lower extremities. Review of his care plan, initiated 5/27/22 revealed an intervention, resident is on Restorative Nursing Program (RNP) for Passive Range of Motion(PROM) and Splint. An observation on 10/18/22 at 9:14 a.m., revealed R#70 revealed was not able to completely extend his fingers on his left hand. No splint or orthotic device was observed on him at this time, as well as observation on 10/19/22 at 9:53 a.m., 11:38 a.m. and 12:26 p.m. Observation of R#70's room revealed signage above his bed with pictures of orthotic devices that reads as follow: Daytime left-hand splint ON: after breakfast, OFF after lunch, On 2 pm, Off after dinner. Passive range of motion before putting on. Nighttime: Left hand palm protector on at bedtime. Check skin daily for irritation, clean hand splint daily with Sani-cloth, wash palm protector with soap and water and air dry, wash hand with mild soap and water and dry well, Contact OT with any questions or concerns. Review of record reveal a nurses note dated 8/23/22 at 7:05 pm reads resident has a history of CVA and Hemiplegia, left side. Restorative Nursing Program is working with resident for PROM and splint. A review of the Restorative Task revealed the following restorative plan of care - Passive Range of Motion: PROM for knees, ankles and hip flexing and extension. Active range of motion seated in WC marches, kicks. AROM with RLE and LLE. Active Range of Motion A/AA/PROM with LLE as tolerated bt Pt to improve LLE function. Splint/Brace: Monitor LLE positioning device with application per schedule. During an Interview with RN Unit Manager FF on 10/19/22 at 10:27 a.m. she stated that the restorative CNA was pulled to work another hall today. And there is not another restorative aide scheduled to work today. but the only one scheduled today was pulled to the Unit today. She further stated that the CNAs on the floor are responsible for following the restorative plan of care when the restorative aide is pulled to the floor. She further stated that all the restorative documentation is completed in AHT. During an interview on 10/19/22 at 10:40 a.m. with CNA NN. She stated that the CNAs are responsible for doing ROM with ADL care for all residents. She stated that if residents have splints or braces that the CNAs are responsible to ensure that they are applied. She further stated that she was trained by the therapy department to apply the devices. The facility staff put a note in the closet to let us know about the resident's care. She stated that she does not think there are any resident on the hall who require splints at this time. During an interview on 10/19/22 at 10:53 a.m. with LPN OO. He stated that that the restorative and Physical Therapy aides are responsible to perform ROM and apply splints for resident requiring them. He further stated that if the restorative aide is pulled to another floor, the nurses or the CNA is responsible for following the restorative plan of care. He stated that activities and the CAN is responsible to perform the nail care for resident. During an interview with Therapy Manager PP on 10/19/22 at 11:13 a.m. revealed that resident has been on therapy case load and was discharged from skilled services with a restorative plan of care. He further stated that R#70 is not currently receiving skilled services and that the restorative aide should be following the plan of care outline by the therapist. During an interview with DON on 10/19/22 at 3:07 p.m. She stated that the restorative plan of care is developed by the therapy department and the Unit Managers are responsible for inputting the plan of care into the electronic record for the restorative aide to follow. DON stated that currently the facility has 52 residents on the restorative program and has 1 full time restorative aide during the week and 1 restorative aide on the weekend. She further stated that not all the resident receives restorative every day. During an interview with Occupational Therapist on 10/20/22 at 10:20 a.m. she stated and verified that R#70 should be wearing the left-hand splint during the day, every day. She went into the R#70's room and stated that resident does not have the splint on. Splint observed lying in the room on the bedside table. She stated that the nursing staff should apply the splint after breakfast, and it should have already been on at the time of the observation. 2.Review of R#117's clinical record revealed that she had diagnoses including arthritis and generalized muscle weakness. Review of her Quarterly Minimum Data Set (MDS) dated [DATE] revealed that she required extensive assistance with Bed Mobility, Dressing, Toileting, Personal Hygiene and Bathing. Review of her care plan, initiated 4/14/22 revealed a care plan description titled Active Assist Range of Motion (AAROM) program/ Restorative with a goal to prevent further ROM loss and an intervention, please see resident for AAROM to bilateral LE for ankle pumps, knee flex/ext, hip flex/ext, hip abd /add x 15 reps each. BUE to tolerance for shoulder flex, elbow flex/ext, finger flex/ext x 10 - 15 reps. Observation and interview with R#117 on 10/18/22 11:30 AM. Resident stated that she no longer receives skilled therapy but is supposed to receive exercises to her arms and legs by therapy, but she is not receiving the services. Resident further stated that her arms and legs are getting stiffer and weaker due to not having the exercises. R#117 stated that her daughter was at the facility earlier today and exercised her legs because the staff at the facility will not do it. Interview with R#117 10/19/22 at 10:07 a.m. resident stated that the staff did not exercise her legs or hands on 10/18/22. She further stated that she is getting so weak. She further stated that her daughter is going to New York and will be away for a week so she will not probably receive any exercises until her daughter returns. R#117 stated I don't know why they don't do what they are supposed to do. Interview with r on 10/19/22 at 2:56 p.m. Resident lying in bed. Resident does not have splints in place. Resident stated that no one has been in her room to perform exercises today. During an interview with Therapy PP, on 10/19/22 at 11:13 a.m. revealed that R#117 has been on therapy case load and was discharged from skilled services with a restorative plan of care. He further stated that resident is not currently receiving skilled services and that the restorative aide should be following the plan of care outline by the therapist. Therapist stated that resident is a long-term resident at the facility and has been on the therapy caseload but is not currently receiving skilled services. He further stated that resident was discharged from therapy with a restorative plan of care that should be followed. A review of the Restorative Roster revealed R#117 that from 8/1/22 through 10/18/22 R#117 had her restorative plan of care documented as the service being provided on 11 days in that period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, record review and review of policies titled Control of Medications and Medication Self Administration, the facility failed to provide an environment that was free from potential accidents and hazards for two of 41 sampled residents (R) (R#47 and R#437) related to properly storing medications which were located on the bedside tables in residents rooms. Findings include: 1. A review of the facility policy titled Control of Medications dated 7/8/21 revealed: Purpose: To define a process for maintaining the security and storage of medications on the nursing unit. Procedure: Never leave controlled or non-controlled medications unsecured or unattended. 1.2 Store non-controlled medications in the medication cart. A review of the policy titled Medication Self Administration dated 7/8/21 revealed: Policy statement: It is WellStar's policy that residents have the right to self-administer medications if the Interdisciplinary Team has determined that it is clinically appropriate and safe for the resident to do so. Purpose: To define a process to allow residents to self-administer medications in a safe and effective manner. Procedure: 1.1 Evaluate the resident using the rehabilitation Self-Administration Assessment form. 2.5 Place a locked medication box in the resident's room. Document the resident's self-administration in the Medication Administration Record (MAR). 3.1 Allow the resident to have a key to the medication box. Observation on 10/18/22 at 11:50 a.m. revealed one container of Vitamin D3 gummies (150 count) and one container of Vita-fusion Women's Multivitamins gummies (150 count) on the bedside table. Both containers were observed to be less than one fourth full. Interview on 10/18/22 at 11:50 a.m. with R#47 revealed she takes two of each medications every day. Observation on 10/18/22 at 3:00 p.m. revealed one container of Vitamin D3 gummies (150 count) and one container of Vita-fusion Women's Multivitamins gummies (150 count) on the bedside table. Interview with R#47 on 10/18/22 at 3:00 p.m. revealed she is not sure if staff is aware that she has the vitamins and stated the containers have sat on her bedside table since she received them from her niece more than two weeks ago. Observation on 10/19/22 at 9:25 a.m. revealed one container of Vitamin D3 gummies (150 count) and one container of Vita-fusion Women's Multivitamins gummies (150 count) on the bedside table. A clinical record review revealed R#47 was admitted on [DATE] with diagnosis including but not limited to adult failure to thrive, magnesium deficiency, hypokalemia, vitamin d deficiency. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident is cognitively intact. Section G revealed R#47 required extensive assistance for Activities of Daily Living (ADLs). Review of Physician Orders dated 8/1/22 through 10/18/22 revealed there were no orders for the Multivitamins or the Vitamin D3 and no order indicating resident may self-administer medications. Record review of the MAR for R#47 for 8/1/22 through 10/18/22 revealed the Multivitamins or Vitamin D3 were not documented as given by the nurse or as taken by R#47. Interview on 10/19/22 at 9:25 a.m. with Licensed Practical Nurse (LPN) DD revealed residents are allowed to keep medication at the bedside if there is a physician's order, a medication self-administration assessment completed, and resident is determined to be capable of properly taking the medication. LPN DD verified the containers of Multivitamins and Vitamin D3 present on R#47's bedside table. Interview on 10/19/22 at 9:50 a.m. with the Director of Nursing (DON) revealed her expectations are for the staff to follow the policies for medication storage and medication self-administration. She further revealed all medications should be secured and not openly available. 2. During an observation on 10/18/22 at 10:15 a.m. and 10/19/22 at 2:45 p.m., Chloraseptic spray was observed at the bedside of R#437. On 10/20/22 at 10:05 a.m., the third nurse, [NAME] Worthy, LPN, was pulled into room after it was observed that the Chloraseptic spray was at bedside. She instructed the resident that she needed to call the nurse when she needed it because it was a prn medication, and it could not be left at the bedside. R#437 stated that she needs it before meals. The nurse encouraged the resident to call before meals and request her spray. [NAME] told the resident that she would let the nurse know to expect the resident to call for the spray before meals and would place the information on the 24-hour report. Review of MDS, dated on 10/15/22, revealed that R# 437 had a BIMS of 14. Review of medication record revealed that sore throat 1.4% spray, two sprays in the throat as needed every two hours for scratchy throat was ordered on 10/12/22. An interview with the DON on 10/20/22 at 11:10 am, revealed that there are not to be any medication at the bedside. She stated that there is a self-administration assessment that can be completed. Review of medical record revealed that there is no self-administration assessment completed on this resident. Review of the policy titled Medication Self Administration, dated 5/22/17, revealed the steps needed for a resident to be able to self-administer medications. Step One- Evaluate the resident using the rehabilitation Self- Administration Assessment form. Step Two- Instruct the resident on each medication. Instruct the resident on administration techniques. Record on the self-medication teaching sheet. Perform a return demonstration of each medication administration, including understanding of reason for use and side effects. Document successful return demonstration on Self Medication Teaching Sheet. Place a locked medication box in the residents room. Document the residents self-administration on the Medication Administration Record. Step Three- Allow the resident to have a key to the medication box (once the resident has demonstrated the ability to accurately and safely self-medicate for three days). Check and count the medications daily for the first week. Request refills from the pharmacy as needed. 4. Reevaluate during quarterly minimum data set (MDS) reviews and any significant change in residents ability to continue to self-administer. Step Four- 1. Document all training in a separate nursing note. 2. File the packet in the Rehab/Restorative section of the residents chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews and review of policy titled Oxygen Administration, the facility failed to obtain a physician order to administer oxygen to one of 41 sampled residents (R) (R#437) that required oxygen. Findings include: During initial observation of R#437 on 10/18/22 at 1:29 p.m., revealed that resident was on oxygen 4 liters. No labels and not dated. Resident had blue lips. R#437 stated that she admitted on 4 liters and that is the amount that she uses all the time. On 10/19/22 at 8:35 a.m., observation of resident found her sitting on the bedside commode. Oxygen 4 liters on and lips were not blue at the time of observation. Tubing, and/or humidity bottle not dated or labeled. Observation of another resident on oxygen on the rehab side of 200 hall revealed that he was on 2 liters and had no date or label on tubing/humidity bottle. Per the care plan for R#437 dated 10/11/22, resident receiving oxygen therapy. The goals included: exhibits no shortness of breath, provide with humidification, monitor for changes in symptoms that may include worsening respiratory status and notify provider of changes, ensure that supply is available at all times, change tubing per protocol, administer oxygen therapy as ordered. Review of physician orders for R#437 on 10/18/22, revealed that there was no order for oxygen. Review of a nurse note for R#437 was admitted to the facility on [DATE], revealed that the resident is/was on 4 liters of oxygen. Review of the admission Minimum Data Set (MDS) Assessment, dated 10/15/22, revealed that resident received oxygen before and during admission to facility. An interview with License Practical Nurse (LPN) AA, on 10/18/22, at 1:30 p.m., revealed that when she received word that there is an incoming admission, she would write the orders and then enter them into AHT. She stated that when this resident was going to be admitted , the resident had a history of congestive heart failure (CHF), which would require the standard CHF protocol orders for oxygen at two liters via nasal cannula to maintain oxygen saturation greater than 89%. Review of medication record for the month of October, revealed that oxygen at four liters via nasal cannula was ordered in AHT on 10/19/22. It also revealed that orders to change humidifier on wall oxygen weekly or as needed (prn), was also ordered on 10/19/22. Review of the policy titled oxygen administration, dated 5/12/22, revealed that step one in the preparation section of the procedure, stated that verification that there is a physicians order for this procedure.

Based on observation, staff interview, and review of facility documents titled Food Storage and Distribution and Department Policy and Procedure, the facility failed to ensure that the piping under one of one hood and over the stove was without rust and failed to ensure cleanliness of this area underneath the hood over the stove in the kitchen. Findings include: The initial kitchen tour began on 10/1/22 at 8:55 a.m. with the Certified Dietary Manager (CDM) and revealed the following: The pipes that were underneath the hood over the stove were with white sediment on them and with brown corrosion looking material observed on them and not maintained well. During an interview with the CDM on 10/14/22 at 10:10 a.m. it was reported that she expected the area to be cleaned with the hood cleaning that is done once a quarter. Dietary Manager, CDM acknowledged what was seen in the kitchen in regard to pipes over the hood in need of cleaning/repair, but was unable to identify who exactly was responsible for checking to assure that the pipes over the hood in the kitchen were clean and well maintained. A kitchen tour began on 10/20/22 at 9:34 a.m. with the Maintenance Director revealed that he had an email that stated they are changing out the pipes next summer, but the pipes will be addressed to see if they could get a company to put stainless steel in the pipes instead of what they had now, and he further mentioned that it was in next year budget to get all of the rusted pipes replaced. Review of document titled Food Storage and Distribution was dated 2/10/22 and revealed It is the facility policy to store and distribute food and food products in a manner that ensures maintenance of safety and potency while also reducing the likelihood of preventable injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the facility policy titled Care Plan - Person-Centered, Baseline Interim and Comprehensive, the facility failed to follow the care plan related to contact precautions for one resident (R) (#12) of six residents requiring isolation. Findings include: Review of the clinical record revealed R#12 was readmitted to the facility on [DATE] with diagnoses including cellulitis to the right lower extremity and a history of Methicillin Resistant Staph Aureus (MRSA) to the right lower extremity. Review of the care plan last revised 3/7/19 revealed R#12 with a history of MRSA wound on leg. Interventions included but were not limited to: orange dot to be placed on door, over bed, and daily care record, alert staff of infection, wear gown as needed, if soiling is likely, and notify all resident's visitors as to the importance of following contact precautions and guidelines at all times. Observation on 6/11/19 at 9:56 a.m. revealed an orange dot on the name tag on the door of R#12's room. There was no personal protective equipment (PPE) or sign indicating to check with the nurse before entering the resident's room. During an interview on 6/12/19 at 9:21 a.m., the Certified Infection Control Manager (CIC) BB stated there is no way for a visitor, family member, or other resident to know if a resident is on isolation. He stated the orange dot on the name sheet on the door only alerts staff that the resident is on isolation. CIC BB confirmed that there is nothing in the area or on the resident's door to indicate to a visitor or family member that they should speak to a nurse before entering R#12's room. He also stated that if the resident had something like a draining wound there would be PPE available to use. In the instance of R#12, because she does have a draining wound, he stated this resident should have all staff gowning and donning PPE if working with the wound. During an interview with the wound care Licensed Practical Nurse (LPN) CC on 6/12/19 at 9:45 a.m., she stated that she always comes in R#12's room without PPE and there has never been anything outside her room such as PPE. She stated the orange dot tells her to go check in the MAR where there is an orange Isolation Precautions form in front of the resident's MAR. She continued by saying if there is PPE at the room she will use it if she believes there is a risk of splatter or spills and that she will put on the gown, gloves and shield if necessary. LPN CC was unaware of how the facility alerts visitors or other residents when a resident is on isolation. During an interview on 6/12/19 at 10:30 a.m. the Director of Nursing (DON) stated when a resident is admitted with infectious types of concerns, the Infection Control Nurse BB is notified. An orange dot is then placed on the door that triggers them to go to the care plan. She stated there should be designated equipment for the staff to use outside of the resident room. She stated there is no way to educate all visitors and other residents per the facility policy. The DON confirmed that R#12 did not have PPE outside the room. Further interview with the DON on 6/12/2019 at 2:27 p.m. revealed that R#12's care plan should have been more specific related to the isolation precautions. Review of the facility policy titled Care Plan - Person-Centered, Baseline Interim and Comprehensive dated 11/22/16 revealed: Purpose: To define a process where person-centered baseline interim and/or individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed and implemented .Care plan developed and implemented by, but not necessarily limited to,: RN (Registered Nurse) who has responsibility for the resident, Director of Nursing (as applicable), and charge nurse responsible for resident care. Cross Refer F880

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the facility policies titled Control of Resistant Organisms and Documentation of Transmission-Based Precautions, the facility failed to implement contact precautions for one resident (R) (#12) of six residents requiring isolation. Findings include: Review of the clinical record revealed R#12 was readmitted to the facility on [DATE] with diagnoses including cellulitis to the right lower extremity and a history of Methicillin Resistant Staph Aureus (MRSA) to the right lower extremity. Observation on 6/11/19 at 9:56 a.m. revealed an orange dot on the name tag on the door of R#12's room. There was no personal protective equipment (PPE) or sign indicating to check with the nurse before entering the resident's room. Review of the care plan last revised 3/7/19 revealed R#12 with a history of MRSA wound on leg. Interventions included but were not limited to: orange dot to be placed on door, over bed, and daily care record, place orange precaution sheet on MAR (medication administration record), provide dedicated orange stethoscope and BP (blood pressure) cuff in room, alert staff of infection, wear gown as needed, if soiling is likely, and notify all resident's visitors as to the importance of following contact precautions and guidelines at all times. During an interview on 6/12/19 at 8:20 a.m., Unit Manager (UM) AA stated R#12 came into the facility with colonized MRSA and was taken off isolation in March 2019. She stated the orange dot on the door means precautions. However, when asked the difference between those precautions and standard precautions for those without the orange dot, UM AA stated she would let the Infection Control Manager provide that information. During an interview on 6/12/19 at 9:21 a.m., the Certified Infection Control Manager (CIC) BB stated there is no way for a visitor, family member, or other resident to know if a resident is on isolation. He stated the orange dot on the name sheet on the door only alerts staff that the resident is on isolation. He stated there is no way a visitor would know if any resident is on isolation. CIC BB confirmed that there is nothing in the area or on the resident's door to indicate to a visitor or family member that they should speak to a nurse before entering R#12's room. He also stated that if the resident had something like a draining wound there would be PPE available to use. In the instance of R#12, because she does have a draining wound, he stated this resident should have all staff gowning and donning PPE if working with the wound. He stated he did not know why some residents with orange dots on this hall had PPE available and others did not. During an interview with the wound care Licensed Practical Nurse (LPN) CC on 6/12/19 at 9:45 a.m., she stated that she always comes in R#12's room without PPE and there has never been anything outside her room such as PPE. She stated the orange dot tells her to go check in the MAR where there is an orange Isolation Precautions form in front of the resident's MAR. She continued by saying if there is PPE at the room she will use it if she believes there is a risk of splatter or spills and that she will put on the gown, gloves and shield if necessary. LPN CC was unaware of how the facility alerts visitors or other residents when a resident is on isolation. During an interview on 6/12/19 at 10:30 a.m. the Director of Nursing (DON) stated when a resident is admitted with infectious types of concerns, the Infection Control Nurse BB is notified. An orange dot is then placed on the door that triggers them to go to the care plan. She stated there should be designated equipment for the staff to use outside of the resident room. She stated there is no way to educate all visitors and other residents per the facility policy. The DON was unaware of why some residents having orange dots on their doors have PPE hanging on their doors and others do not. The DON confirmed that R#12 did not have PPE outside the room; and when the Infection Control Nurse BB became aware of the problem, he then placed the equipment on R#12's door. She stated she expects the staff to follow this concern closely to keep the residents, staff and family members safe. She agreed that it would be difficult for anyone to know the difference between those doors with orange dots that had PPE hanging and those that did not. The DON could not explain why this was happening. Review of the facility policy titled Control of Resistant Organisms last reviewed November 2016 revealed: Policy: Residents with identified resistant organisms, (e.g., MRSA .), will have additional precautions (in addition to Standard Precautions) instituted to prevent and control the spread/transmission to others. Procedure: 1) A color code will be used to identify residents with specific infections needing transmission-based precautions in addition to standard precautions. To alert facility staff, tangerine (orange) colored dot will be placed on the resident's door, over the bed, and in the daily care record. 6) Depending on the organism and whether it is known to colonize these individuals for prolonged periods, the resident may stay on extra precautions indefinitely. Review of the facility policy titled Documentation of Transmission-Based Precautions reviewed November 2016 revealed: Procedures: A. It is the responsibility of the charge nurse to institute the precautions indicated. 2) Provide education to resident/family and document on education form in medication record. There is no indication of how education to visitors and other residents will be provided or that any education was ever provided to visitors.