**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to ensure three of 34 sampled residents (R) (R59, R65, and R76) reviewed for residents' rights were able to exercise their right to vote in elections through absentee ballots or other authorized methods. Findings include: Review of the facility's policy titled, Exercise of Rights / Resident Rights F 550, dated 11/2024 revealed, . Our residents may exercise his or her rights as a resident of our community and as a citizen or resident of the United States . Residents will be encouraged to participate in activities of their choice, including community activities (e.g. voting, religious observances, etc.) . Transportation to community activities may be arranged through the Activity or Social Services Departments. 1. Review of R59's Profile Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed R59 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, rheumatoid arthritis, and hypertension. Review of R59's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, revealed R59 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of a spreadsheet titled Residents That Want To Vote, collected on [DATE] by Activity Director (AD), revealed that R59 wanted to vote and had no valid identification (ID). During an interview on [DATE] at 12:26 pm, R59 stated, I wanted to vote, but no one asked me or told me how to. 2. Review of R65's Profile Face Sheet, located in the EMR under the Profile tab, revealed R65 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, affecting right dominant side, metabolic encephalopathy, and memory deficit following cerebral infarction. Review of R65's quarterly MDS, with an ARD of [DATE] and located in the EMR under the MDS tab, revealed R65 was cognitively intact with a BIMS score of 14 out of 15. Review of a spreadsheet titled, Residents That Want To Vote, collected on [DATE] by the AD, revealed that R65 wanted to vote and had no valid ID, due to the ID being expired and from California (CA). During an interview on [DATE] at 12:24 pm, R65 stated, I wanted to vote, but they said I couldn't because I have a CA ID. 3. Review of R76's Profile Face Sheet, located in the EMR under the Profile tab, revealed R76 was admitted to the facility on [DATE] with diagnoses including dislocation of unspecified internal joint prosthesis, aftercare following joint replacement surgery, left hip joint osteoarthritis, and hypertension. Review of R76's quarterly MDS, with an ARD of [DATE] and located in the EMR under the MDS tab, revealed R76 was cognitively intact with a BIMS score of 15 out of 15. Review of R76's admission Inventory of Personal Effects, dated [DATE] and provided by the facility, revealed, R76 had a driver's license and social security card on his person. Review of R76's admission Recreation (Activities) admission Assessment, dated [DATE] and provided by the facility, revealed R76 was not a registered voter and was interested in voting. During an interview on [DATE] at 10:45 am, R76 stated, No one asked me [if I wanted to vote] when I got here in the beginning, and that was in [DATE]. I wanted to vote, though, because I think not voting has contributed to my depression, because they let that man in there. During an interview on [DATE] at 4:58 pm, the Social Services Director (SSD) stated, We went around to all the residents, I believe on [DATE], to ask who wanted to vote in the November election. We wrote all their names down on a list. Some residents did not have a valid Georgia (GA) ID or an ID at all. So, they can't vote. The families didn't come to take them to vote or to help the residents who needed to get an ID. We can't take residents to the Department of Motor Vehicles (DMV). Medical transport won't take them because it's not medically related. Our transport van wasn't working at the time, or needed to be registered. I don't know if the residents can use a ride-share to go vote. [R65] was on the list of wanting to vote, but she has a CA ID, not a GA one, so she can't vote. The daughter never came to help her get an ID so that she could vote. During an interview on [DATE] at 10:20 am, the SSD stated, I only address the voting if they come to me. No one came to me after we went through each resident who wanted to vote to see if they had a valid ID to vote. We had to register them by [DATE]th. When I talk to the residents about resident rights, I tell them voting is their right, but no one came to me about voting in November. If someone had come to me, then I would arrange for absentee ballot voting. During an interview on [DATE] at 12:16 pm, the Activities Director (AD) stated, On [DATE]th, I asked every resident who could talk and understand if they wanted to vote. Then I gave the list to the SSD because she is the one who asked me to go around and ask the residents. I don't know what happened after that. Asking them if they wanted to vote was the only part I was involved in. We couldn't take the residents who wanted to vote because our transportation van was getting fixed. [R76] wasn't a resident when I went around and asked everyone about voting. I didn't go back around and ask the new admissions between [DATE]th and [DATE]th if they wanted to vote because [SSD] didn't ask me to. I enter the information in the quarterly assessments. Anyone can see my assessments, but I don't think anyone pays attention to them to see if someone wants to vote. During an interview on [DATE] at 2:55 pm, the Administrator stated, There was a breakdown in communication regarding the voting. I always make sure everyone asks the resident because it is their right. I'm not sure why it happened, but there was a breakdown. We started a process where we upload all the IDs now because of the voting issue. We tried to ask all the residents the day prior to the registrations being due on [DATE], so we could arrange transport. Then the medical transport said they will only transport if medically related. We asked the county if they would come in, set up, and assist with voting, but they couldn't do that. Then we wanted to do absentee voting, and we couldn't make that happen in time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to ensure one of 34 sampled residents (R) (R4) was invited to participate in care plan meetings. This had the potential to cause R4's wishes and goals for her stay at the facility to be unmet. Findings include: Review of R4's Face Sheet tab of the electronic medical record (EMR) indicated R4 was admitted to the facility on [DATE] with diagnoses including dementia in other diseases classified elsewhere, psychotic disturbance, mood disturbance, and anxiety. Review of R4's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/30/2025 and located under the MDS tab of the EMR, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of R4's Care Plan, located under the Care Plan tab of the EMR and with a revision date of 5/21/2025, revealed no documented evidence that R4 had been invited to or participated in her care plan meetings. Review of the care plan revealed an initiation date of 3/26/2024 and revision dates including 12/20/2024, 3/24/2025, and 5/21/2025. During an interview on 6/9/2025 at 10:23 am, R4 indicated not knowing about any care meetings where staff from different departments, such as nursing, activities, dietary, and herself, talked about her care, plans, and goals. R4 stated she had not attended that type of meeting and indicated she had only been part of the resident council meeting. During an interview on 6/10/2025 at 3:10 pm, the Social Services (SSD) confirmed she was responsible for scheduling the care plan meetings. The SSD stated that she handed family members a letter when they came to the facility, notifying them of the care plan meeting times. She stated there was a sign-in sheet for each meeting, and the meetings were held quarterly. The SSD was asked to provide the sign-in sheets for R4's care plan meetings to show the residents' invitation and/or participation. The SSD stated she would look for them. During an interview on 6/11/2025 at 1:54 pm, the SSD was again asked to provide evidence that R4 had been invited to and/or participated in her care plan meetings. The SSD stated she was still looking for the information. No information had been provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to ensure one of five residents (R) (R64) reviewed for Advance Directives out of a total sample of 34 residents had the correct code status, which identified her wishes in the event of a medical emergency. The failure placed residents at risk of not having their end-of-life wishes honored. Findings include: A review of the facility policy titled Advance Directives, dated 5/2024, revealed, Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. Inquiries concerning advance directives should be referred to the Administrator, Director of Nursing Services [DON], and/or to the Social Services Director. Review of R64's electronic medical record (EMR) revealed R64 was readmitted to the facility on [DATE]. Review of the EMR banner revealed a code status of Full Code, all measures. Further review of the EMR under the Orders tab, which stated Full Code, all measures. Review of the Care Plan tab of the EMR revealed R64 had requested to be full code status initiated on [DATE] with a revision date of [DATE]. The goal was that staff would respect the wishes and rights of the resident regarding having CPR performed. Initiated on [DATE], revision on [DATE], and target date of [DATE]. Review of R64's Clinical Physician's Orders revealed an order dated [DATE] for Full Code, all measures. Further review revealed an order dated [DATE] for Hospice care. Review of the clinical record revealed a document titled Georgia Do Not Resuscitate Order dated [DATE] and completed with the resident's name and physician's signature. Interview on [DATE] at 10:57 am with Registered Nurse (RN) 1 (Hospice nurse) revealed that R64 was a Do Not Resuscitate (DNR), and that there were signed documents for the DNR that should be in the resident's chart. During an interview on [DATE] at 11:18 am, License Practical Nurse (LPN) 1, when asked about R64's code status, stated the resident was a full code and we would do everything possible to save her with compressions (CPR). LPN1 provided the code status book, which revealed R64's code status sheet was green, which meant she was a full code. During an interview on [DATE] at 11:39 am, LPN2 was asked what R64's code status was. LPN2 went to the EMR and stated R64 was a full code. LPN2 stated the resident's code status was on her profile page of the EMR and in the resident's physician orders, but she would also look in the code book. LPN2 stated she would start compressions on R64. During an interview on [DATE] at 11:41 am, the Staff Developer (SD) indicated that if a resident codes, staff would look in the code book and look in the EMR to determine a resident's code status to know what direction to take (whether to initiate CPR or not). The SD revealed that if the EMR and code book stated the resident was a full code, a code blue would be called, and chest compressions would be started. During an interview on [DATE] at 11:49 am, LPN3 stated that to determine a resident's code status, she would look at a resident's EMR and follow the physician's order. LPN 3 was asked to look at the EMR for R64's code status. LPN3 reviewed R64's EMR and stated the resident was a full code, so she would begin compressions. During an interview on [DATE] at 11:56 am, the MDS Coordinator stated that when assisting a resident who had coded, staff look in the EMR for the code status. Another nurse would check the code status book, and staff would follow the documented code status. In review of R64's EMR, the MDS Coordinator stated the resident was a full code, so compressions would begin. Interview on [DATE] at 12:42 pm, RN2 (Hospice nurse) revealed R64 was admitted to hospice while at home and was moved to the nursing facility. RN2 stated that since R64's admission to hospice on [DATE], the resident had always been DNR. During an interview on [DATE] at 12:02 pm, with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Nurse, all reviewed R64's chart together, the DON indicated that R64 was full code with all measures. The process would be to go to the EMR, and the banner would reveal Advance Directive wishes. The DON stated that staff could also refer to the code status book that was kept at the nursing station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the R29's Face Sheet, located in the Profile tab of the EMR, revealed R29 was admitted to the facility on [DATE]. Review of R29's most recent annual MDS with an ARD of 7/17/2024, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated R29 was cognitively intact for decision-making. This MDS assessment further indicated R29's vision was severely impaired and had no impairment in range of motion in the upper or lower extremities. Review of the MDS section titled Preferences for Customary Routine and Activities lists a series of questions about Activity Preferences. R29 provided the answer of Very Important for the following questions: How important is it to you to listen to music you like? How important is it to you to keep up with the news? How important is it to you to do things with groups of people? How important is it to you to go outside to get fresh air when the weather is good? Review of the most recent quarterly MDS with an ARD of 3/21/2025 revealed R29's Cognition was a score of 14, identifying this resident remained cognitively intact. Review of R29's current Care Plan under the Care Plan tab in the EMR revealed a 2/20/2024 initiation date. The Focus column on this care plan stated that R29 had little or no activity involvement. The goal initiated on 2/20/2024 was that R29 would express satisfaction with the type of activities and level of activity involvement when asked through the review date. The interventions included: Invite R29 to scheduled activities (Date initiated 6/12/2025), R29 needs assistance/escort activity functions; and monitor/document for the impact of medical problems on activity level. The Care Plan included a revision date on 5/21/2025; however, the only intervention dated 6/12/2025 was to invite (R29) to scheduled activities. An interview was conducted with R29 on 6/10/2025 at 12:20 pm. When asked what types of activities R29 liked to do, R29 expressed that she could not see and that she just sits there and listens to the TV. During all four days of the survey, 6/9/2025 to 6/12/2025, R29 was observed in her room sitting on the side of her bed. During an interview on 6/12/2025 at 11:50 am with the Minimum Data Set Coordinator (MDSC), it was explained that the 7/17/2024 annual MDS included R29's activity preferences; however, the current Care Plan with a revision date of 5/21/2025 did not include those likes. When the MDSC was asked if she would expect those likes to be a part of the R29's Care Plan to be sure R29's is provided the type of activities in the assessment, the MDSC stated Yes. Review of R29's EMR in the Orders tab revealed an order dated 1/15/2024 for TED (Thrombo-Embolic Deterrent) Hose stockings, on in am, off in pm, one time a day for Edema BLE (bilateral lower extremities). This order was active as of 11/16/2024, and there had been no order to discontinue. Review of R29's EMR in the Assessments tab revealed Nursing Weekly Skin Evaluations dating back to 3/6/2025 of R29 having edema in the lower extremities. An interview was conducted with R29 on 6/11/2025 at 7:51 am. R29 was sitting on the side of the bed with his/her feet in a dependent position. When R29 was asked about the swelling in his feet and legs, and if he/she had ever worn any socks or hose for his/her swelling. R29 stated that he/she had worn them in the hospital but has not worn them at the facility. During an interview on 6/11/2025 at 4:15 pm, LPN 1, the right-wing Unit Manager, was asked about the physician's orders for TED hose for R29. LPN1 reviewed the order and stated that the order was written by a nurse practitioner who no longer worked at the facility. LPN1 stated she could reach out to R29's cardiologist to see if he would like the resident to wear the TED hose because that would require measurement. The surveyor followed up with LPN1 on 6/12/2025 at 1:00 pm and stated that the Medical Doctor came in today and the TED hoses were not necessary. LPN1 stated that the TED hose had been discontinued and removed from the orders. During an interview on 6/12/2025 1:49 pm, the MDS Coordinator (MDSC) was notified that there were orders for TED hose for R29's edema. The MDSC was notified that the edema has been mentioned in the weekly assessments since 3/20/2025. When asked if this were an issue that should have come up in meetings where she would be notified, the MDSC stated yes. The MDSC verified by looking at the most recent weekly assessment that edema was mentioned. When the MDSC was asked if the resident with edema should have had a care plan, she stated yes. 3. Review of R27's admission Record located in the EMR under the Profile tab, revealed an admission date of 2/7/2014 with diagnoses including dysphagia following an unspecified cerebrovascular disease, aphasia, hemiplegia, and hemiparesis following cerebral infarction affecting the left dominant side. Review of R27's most recent annual MDS located in the EMR under the MDS tab with an ARD of 8/17/2024, revealed the resident had severely impaired cognitive skills for daily decision making. R27 had limitations in range of motion, had impairment on both sides in the upper and lower extremities, and was dependent on staff for all functional abilities to include bathing, dressing, personal hygiene, and mobility. R27 was also assessed as being incontinent of bowel and bladder and as having pressure ulcers. On 6/10/2025 at 12:33 pm, R27 was observed positioned on the left side. There was a foam wedge under the left knee. There did not appear to be any devices between the residents' knees. On 6/11/2025 at 7:57 am, two staff were observed entering R27's room to provide care. The surveyor asked the staff to observe R27's position. The staff uncovered the resident. The resident was observed to have bilateral leg contractures with the legs drawn up tightly toward the buttocks. The residents' knees were together with no pressure-relieving device between the knees. On 6/11/2025 at 9:30 am, the surveyor entered R27's room with the Wound Care (WC) Nurse. R27 was positioned to the right side with a wedge underneath or below the right knee between the mattress and the resident's right outer leg. A folded flat sheet was observed between the resident's knees. When asked if there had been any pressure-relieving device used between the resident's knees, the WC said that she was not aware of one. During an interview with the MDSC on 6/12/2025 at 11:45 am, the MDSC was asked about the residents' contractures. The MDSC confirmed there was no care plan specifically addressing the contractures and pressure relief. When asked if there should be a care plan addressing the contractures and pressure relief, the MDSC stated yes. Cross-Reference F679 and F686 Based on record review, staff interview, and policy review, the facility failed to develop a comprehensive care plan for three of 34 sampled residents (R) (R8, R29, and R27). These failures placed R8, R29, and R27 at risk for unmet physical and psychosocial care needs and the inability to meet their maximum practicable level of functioning. Findings include: 1. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had diagnoses including muscle weakness, seizures, absence of right leg above knee, aphasia, and deaf nonspeaking. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/13/2025 and located under the MDS tab of the EMR, revealed he scored zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R8 did not exhibit any behavioral symptoms and was dependent on staff with mobility and all activities of daily living. Review of R8's annual MDS, with an ARD of 8/12/2025 and located under the MDS tab of the EMR, revealed it was very important for him to participate in reading, music, current events, group activities, favorite activities, outside activities, and religious services. It was somewhat important for him to be around pets. Review of R8's Recreation (Activities: Admission/Annual/COC [change of condition]) Assessment, dated 8/11/2024 and located under the Assessment tab of the EMR, revealed it was very important for R8 to attend religious services. He also enjoyed pets, arts and crafts, bingo, games, outings, cooking, writing, cultural activities, current events, gardening, movies, music, resident council, socials, and sports. R8 was interested in activity participation and was cooperative. Review of R8's Care Plan, dated 2/27/2025 and located under the Care Plan tab of the EMR, revealed it did not address R8's activity needs or participation. In an interview on 6/12/2025 at 11:39 am, the MDS Coordinator (MDSC) stated she and the Activity Director (AD) worked together on developing activities Care Plans. She stated that if a resident had concerns with low participation, a Care Plan should be implemented. The MDSC stated she needed to check with the AD on the creation of an activity Care Plan for R52. In an interview on 6/12/2025 at 12:10 pm, the Activity Director (AD) stated the MDSC was responsible for creating activities Care Plans, and she would expect one to address activities for R8.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R27's admission Record located in the EMR under the Profile tab, revealed an admission date of 02/07/14 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left dominant side. Review of R27's most recent annual MDS located in the EMR under the MDS tab with an ARD of 8/17/24, revealed the resident had severely impaired cognitive skills for daily decision making. R27 had limitations in range of motion, had impairment on both sides in the upper and lower extremities, and was dependent on staff for all functional abilities. Review of the EMR under the Orders tab revealed that there was no current physician's order for the use of heel protectors. Review of the EMR under the Care Plan tab revealed a care plan initiated on 02/10/22 with a focus stating: [R27] has skin impairment/pressure injury r/t [related to] decreased mobility . One of the care plan interventions revealed R27 was to wear heel protectors while in bed. This intervention was initiated on 02/12/22. Observations of the R27 were made on 06/11/25 at 7:57 AM, 06/11/25 at 9:30 AM, 06/11/25 and at 4:30 PM while in bed. There were no heel protectors in place. During an interview with LPN 1 on 06/11/25 at 4:50 PM, LPN 1 was asked about the care plan intervention for heel protectors for R27. LPN 1 stated that she was not aware of an order for heel protectors for R27. R27's care plan was reviewed with LPN 1 that included the intervention to wear heel protectors with the date of initiation being 02/12/22. LPN 1 stated that the intervention would need to be reviewed to see if it is still what the wound care doctor wants. During an interview with the MDSC on 06/12/25 at 11:45 AM, the MDSC was asked about the resident's care plan for pressure injuries and the use of heel protectors. The MDSC stated she was made aware on the prior day of the heel protectors not being ordered and stated the heel protectors have been removed from the care plan. 3. Review of the EMR Face Sheet tab, indicated R4 was admitted to the facility on [DATE] with diagnosis including but not limited to dementia in other diseases classified elsewhere, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mild intellectual disabilities, other seizures. Review of R4's EMR, annual MDS with an ARD of 03/30/25, revealed a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Review of R4'4 EMR Care Plan tab, indicated R4 care plan history dates were as follows: 12/20/24 and 03/24/25. In the Care Plan under Nursing, R4 was a long-term nursing home placement. The goal was for R4 to remain at this facility for long-term nursing home placement. Date initiated 03/36/24, revision on 05/21/25, and target date 09/19/25. During an interview on 06/11/25 at 1:54 PM, the Social Service Director (SSD) reviewed the Care Plan history which indicated R4 had been back in the facility since 03/26/24, and there were only two completed care plans showing. The SSD verified the information but was not able to explain. Based on interview, record review, and review of facility policy, the facility failed to ensure quarterly care plan conferences were being completed in order to assess, review, and revise the care plan as needed five of 34 sampled residents (Resident (R)8, R27, R29, and R4) reviewed for care plan conferences and care plan revisions. This had the potential for the residents to have unmet care needs. Findings include: 1. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had diagnoses including muscle weakness, lack of coordination, seizures, absence of right leg above knee, aphasia, and deaf nonspeaking. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/25 and located under the MDS tab of the EMR, revealed he was dependent on staff with activities of daily living including toilet hygiene and dependent on staff for bed mobility and transfers from bed to chair. R8 did not use the toilet and was always incontinent of bladder and bowel. a. Review of R8's Care Plan, dated 02/27/25 and located under the Care Plan tab of the EMR, revealed R8 required staff participation with activities of daily living such as personal hygiene, bathing, and oral care. The Care Plan did not address R8's incontinence and need for a check and change program. Review of R8's Kardex, provided on paper by the facility and dated 06/12/25, revealed, Bladder continence and Bowel movement/continence were documented with no further information included. In an interview on 06/12/25 at 8:39 AM, Licensed Practical Nurse (LPN)3 stated R8 was incontinent of bowel and bladder and used incontinence briefs. She stated he should be checked and changed if needed at least every two hours if not more often. In an interview on 06/12/25 at 9:06 AM, LPN4 (who served as the left side unit manager) stated R8 should be checked and changed if needed at least every two hours. She stated she was not aware he was going longer than two hours without incontinence care. In an interview on 06/12/25 at 12:31 PM, Certified Nursing Assistant (CNA)2 stated R8 was incontinent and used incontinence briefs. In an interview on 06/12/25 at 11:39 AM, the Minimum Data Set Coordinator (MDSC) stated R8's Care Plan did not address incontinence or a check and change program, but this information should have been included. Review of the facility policy titled, Quality of Life - Activities of Daily Living, dated April 2025, revealed, Residents are provided with appropriate care and services including . [assistance with] elimination . Update Care Plan appropriately and interventions as needed. b. Review of R8's Care Plan, dated 02/27/25 and located under the Care Plan tab of the EMR, revealed R8 required staff participation with transfers. The Care Plan did not address R8's specific assistance needs with transferring. In an interview on 06/11/25 at 10:35 AM, CNA11 stated he did a two-person transfer for R8, and added he would have used his gait belt if he was transferring R8 by himself, but since CNA12 was assisting, it was not needed. CNA11 stated he preferred to do R8's transfers with two CNAs assisting rather than alone. In an interview on 06/12/25 at 8:39 AM, CNA12 stated R8 transferred with the assistance of two staff and could pivot on his leg to assist. LPN 3 added during a two-person transfer, a gait belt should be used. In an interview on 06/12/25 at 11:39 AM, the MDSC stated R8's Care Plan did not address R8's specific needs regarding transfers, but this information should have been included. Review of the facility's policy titled, Safe Lifting and Movement of Residents, dated October 2024 revealed, Staff will document resident transferring and lifting needs in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and policy review, the facility failed to ensure one of six residents (R) (R8) reviewed for assistance with Activities of Daily Living (ADLs), out of a total of 34 sampled residents, received assistance with ADLs. This failure had the potential to cause skin breakdown, urinary tract infection, or discomfort for R8. Findings include: Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] and had diagnoses including muscle weakness, seizures, absence of right leg above the knee, aphasia, and deaf nonspeaking. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/13/2025 and located under the MDS tab of the EMR, revealed he scored zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R8 did not exhibit any behavioral symptoms and was dependent on staff with activities of daily living, including toilet hygiene. R8 did not use the toilet and was always incontinent of bladder and bowel. Review of R8's most recent Bladder Incontinence Evaluation, dated 11/9/2024 and located under the Assessments tab of the EMR, revealed he was incontinent and used incontinence briefs at all times. The assessment documented, Proceed with a check and change program. Review of R8's Care Plan, dated 2/27/2025 and located under the Care Plan tab of the EMR, revealed R8 required staff participation with activities of daily living such as personal hygiene, bathing, and oral care. The Care Plan did not address R8's incontinence and need for a check and change program. Review of R8's POC [Point of Care] Response History, dated 5/12/2025 through 6/10/2025 and located under the Tasks tab of the EMR, revealed he was always incontinent. Review of R8's Kardex, provided on paper by the facility and dated 6/12/2025, revealed, Bladder continence and Bowel movement/continence were documented with no further information included. During an observation on 6/9/2025 beginning at 10:03 am, R8 was seated in a geriatric chair in the left side day room. R8 was unable to understand or respond to questions. He remained in the geriatric chair in the day room without any incontinence checks by staff. At 12:18 pm, R8 was wheeled to a table in the left side day room, without an incontinence check, by Certified Nurse Aide (CNA) 2. He remained in the geriatric chair at the dining table until 1:15 pm, when he was wheeled away from the table but left in the left side day room, without an incontinence check, by CNA2. R8 was observed yelling out periodically during this time. At 1:45 pm, R8 was taken to the bingo activity in the main dining room in his geriatric chair by the Activity Director (AD). He remained in bingo until 2:22 pm, when he was brought back to the left side day room. R8 remained in his geriatric chair in the day room, exhibiting periodic yelling out at staff and squirming in his chair, without an incontinence check until he was taken to his room at 3:25 pm by CNA2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the R29's Face Sheet, located in the Profile tab of the EMR, revealed R29 was admitted to the facility on [DATE]. Review of R29's most recent annual MDS with an ARD of 7/17/2024, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated R29 was cognitively intact for decision-making. This MDS assessment further indicated R29's vision was severely impaired and had no impairment in range of motion in the upper or lower extremities. Review of the MDS section titled Preferences for Customary Routine and Activities lists a series of questions about Activity Preferences. R29 provided the answer of Very Important for the following questions: How important is it to you to listen to music you like? How important is it to you to keep up with the news? How important is it to you to do things with groups of people? How important is it to you to go outside to get fresh air when the weather is good? Review of the most recent quarterly MDS with an ARD of 3/21/2025 revealed R29's Cognition was a score of 14, identifying this resident remained cognitively intact. Review of R29's current Care Plan under the Care Plan tab in the EMR revealed a 2/20/2024 initiation date. The Focus column on this care plan stated that R29 had little or no activity involvement. The goal initiated on 2/20/2024 was that R29 would express satisfaction with the type of activities and level of activity involvement when asked through the review date. The interventions included: Invite R29 to scheduled activities (Date initiated06/12/2025); R29 needs assistance/escort activity functions; and monitor/document for the impact of medical problems on activity level. The Care Plan included a revision date on 5/21/2025; however, the only intervention dated 6/12/2025 was to invite (R29) to scheduled activities. An interview was conducted with R29 on 6/10/2025 at 12:20 pm. When asked what types of activities R29 liked to do, R29 expressed that she could not see and that she just sits there and listens to the TV. During all four days of the survey, 6/09/2025 to 6/12/2025, R29 was observed in her room sitting on the side of her bed. An interview was conducted with the Activities Director (AD) on 6/10/2025 at 1:00 pm. The Activities Director was asked if she could provide activity participation records for R29. The AD reviewed her records, both for group activities and one-to-one participation records, from April to June 2025. The AD stated she has tried to invite R29, but she won't come. When asked if she could show me where it is documented that the resident has been invited, the AD verified that there are no activity participation records or documentation where R29 has attended or has been invited to activities. Based on observation, resident interview, resident family interview, staff interviews, record review, and policy review, the facility failed to ensure three of four residents (R) (R8, R52, and R29) reviewed for activities, out of a total sample of 34 sampled residents, received sufficient activity engagement to meet their needs. Findings include: Review of the facility's policy titled, Activities and Social Events, dated October 2024, revealed, When developing the resident's activity and social care plan, the resident should be given an opportunity to choose when, where, and how he or she will participate in activities and social events . The staff will evaluate a resident's physical and mental capacity to participate in various levels of activities. They will note any significant physical and cognitive limitations or behavior issues that would influence the level of a resident's participation or type of activities that are relevant to that individual. They will also note in the medical record any restrictions or needs that might be relevant to participation in activities. 1. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had diagnoses including muscle weakness, seizures, absence of right leg above knee, aphasia, and deaf nonspeaking. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/13/2025 and located under the MDS tab of the EMR, revealed he scored zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R8 did not exhibit any behavioral symptoms and was dependent on staff with mobility and all activities of daily living. Review of R8's annual MDS, with an ARD of 8/12/2024 and located under the MDS tab of the EMR, revealed it was very important for him to participate in reading, music, current events, group activities, favorite activities, outside activities, and religious services. It was somewhat important for him to be around pets. Review of R8's Recreation (Activities: Admission/Annual/COC [change of condition] Assessment, dated 8/11/2024 and located under the Assessment tab of the EMR, revealed it was very important for R8 to attend religious services. He also enjoyed pets, arts and crafts, Bingo, games, outings, cooking, writing, cultural activities, current events, gardening, movies, music, resident council, socials, and sports. R8 was interested in activity participation and was cooperative. Review of R8's Care Plan, dated 2/27/2025 and located under the Care Plan tab of the EMR, revealed it did not address R8's activity needs or participation. Review of R8's Activity for the Day participation records for May 2025 and June 2025, provided by the facility on paper, revealed R8 participated in: -5/27/2025: Bingo -6/9/2025: Bingo -6/10/2025: Outside and Popsicles During an observation on 6/9/2025 beginning at 10:03 am, R8 was seated in a geriatric chair in the left side day room with the TV on. R8 was unable to understand or respond to questions. He remained in the geriatric chair without any activity or staff engagement until 12:18 pm, when R8 was wheeled to a table in the left side day room for lunch. He remained in the geriatric chair at the dining table until 1:15 pm, when he was wheeled away from the table but left in the left side day room. R8 was observed yelling out periodically during this time. At 1:45 pm, R8 was taken to the Bingo activity in the main dining room in his geriatric chair by the Activity Director (AD). During the activity, R8 did not participate or receive assistance to engage in the activity. The AD sat at a different table playing his Bingo card. R8 remained in Bingo until 2:22 pm, when he was brought back to the left side day room. R8 remained in his geriatric chair in the day room, exhibiting periodic yelling out at staff and squirming in his chair, without any activity or staff engagement until 3:25 pm. During an observation on 6/10/2025 beginning at 1:02 pm, R8 was observed seated in his geriatric chair in the left side day room without any activity or engagement. At 2:08 pm, the AD was observed inviting residents to participate in a Bean Bag Toss activity. However, R8 was not invited to attend. R8 remained seated in the day room until 2:27 pm, when he was taken to his room to prepare for his wound treatment. During an observation on 6/11/2025 beginning at 7:27 am, R8 was observed seated in his geriatric chair in the left side day room with the TV on. He remained seated without any activity or engagement until 10:31 am, when he was taken to his room During a telephone interview on 6/11/2025 at 1:43 pm with R8's family member (F)1, she stated she believed R8 could use more engagement in activities. F1 stated, I just see him sitting there in the common area. F1 stated R8 was very social and was very involved in his community and his favorite activities, especially arts and crafts. F1 stated that the hardest thing for R8 has been the loss of freedom that came with his leg amputation, and he was now not getting exposure to social events or activities. F1 stated she felt R8 could benefit from more activity engagement, particularly in hands-on sensory stimulation types of activities. In an interview on 6/12/2025 at 12:10 pm, the AD stated R8 was deaf but communicated with sign language and gestures, and he could also read lips. She stated R8 enjoyed Bingo, though he typically needed the staff to play his board for him. The AD stated he also went out to smoke periodically or attended outside activities. The AD stated R8 was not provided with one-to-one visits, and his only programming was occasional attendance at group activities like Bingo. She stated that based on a review of R8's attendance records, he should be receiving one-to-one visits for additional engagement and interaction, but she had not yet implemented this. 2. Review of R52's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE]with diagnoses including depression, stroke with hemiplegia, encephalopathy, dementia, and blindness in one eye. Review of R52's annual MDS, with an ARD of 3/19/2025, revealed he scored 15 out of 15 on the BIMS, indicating intact cognition. He did not exhibit mood or behavioral symptoms. R52 was dependent on staff for transfers from bed to wheelchair and for wheelchair mobility. He felt it was very important to participate in reading and outdoor activities, and somewhat important to participate in music, current events, group activities, favorite activities, and religious services. Review of R52's Care Plan, dated 5/21/2025 and located under the Care Plan tab of the EMR, revealed, The resident is dependent on staff for activities, cognitive stimulation, social interaction r/t cognitive deficits. The approaches included: The resident . needs 1 to 1 bedside/in-room visits and activities if unable to attend out of room events . Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility . [and] Provide with activities calendar. Notify resident of any changes to the calendar of activities. Review of R52's Recreation (Activities: Admission/Annual/COC Assessment, dated 1/15/2025 and located under the Assessment tab of the EMR, revealed he enjoyed arts and crafts, pets, Bingo, games, outings, cooking, cultural activities, current events, movies, music, religious services, resident council, socials, and sports. He was very interested in participating in activities and was cooperative and motivated. Review of R52's Activity for the Day participation records for May 2025 and June 2025, provided by the facility on paper, revealed R52 participated in: -5/12/2025: Bowling There were no records of participation for June 2025. In an observation in R52's on 6/9/2025 at 10:04 am, he was lying in bed with the TV on. R52 stated he did not attend a lot of activities and spent most of his time lying in bed. R52 stated he especially liked to play Bingo, but added he only attended Bingo every now and then because the staff did not always let him know when it was going on or get him out of bed in time to attend. R52 stated he would like to attend Bingo more often. During observations on 6/9/2025 from 12:28 pm to 2:00 pm, R52 was lying in bed. At 1:45 pm, the AD was observed inviting and escorting residents to play Bingo. However, R52 was not invited to get out of bed to attend Bingo. The Bingo activity took place in the dining room. In an interview on 6/9/2025 at 2:00 pm, R52 stated he did not know Bingo was taking place but would have liked to attend. He stated he needed help getting cleaned up and getting out of bed before he could attend the activity. During observations on 6/10/2025 from 8:23 am to 9:28 am and from 1:02 pm to 2:08 pm, R52 was observed lying in bed with his TV on. At 2:08 pm, the AD was observed inviting residents to participate in a Bean Bag Toss activity. However, R52 was not invited to attend. R52 remained in bed. In an interview on 06/12/2025 at 12:05 PM, the AD stated R52 sometimes attended group activities and did not receive one-to-one visits. The AD stated his activity participation was low, but this was because the nursing staff did not always assist in getting R52 out of bed and to activities. The AD stated R52 was not specifically invited to activities, but groups were announced over the intercom, and that should alert the nursing staff to start helping get residents to the activity. The AD stated she had never done training with the nursing staff on preferred activities and times of day or strategies to help get residents to participate in activities. The AD stated she needed the nursing staff to help get R52 to activities because she could not get all the residents there by herself.

Based on observations, staff interviews, and record review, the facility failed to ensure that one of three residents (R) (R27) reviewed for pressure ulcers out of a total sample of 34 sampled residents was provided with a pressure-relieving device to relieve pressure between bony prominences. This failure had the potential to place R27 at risk for pressure ulcer development. Findings include: Review of R27's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 2/7/2014 with diagnoses including dysphagia following an unspecified cerebrovascular disease, aphasia, hemiplegia, and hemiparesis following cerebral infarction affecting the left dominant side. Review of R27's most recent Annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 8/17/2024, revealed the resident had severely impaired cognitive skills for daily decision making. R27 had limitations in range of motion, had impairment on both sides in the upper and lower extremities, and was dependent on staff for all functional abilities, including bathing, dressing, personal hygiene, and mobility. R27 was also assessed as being incontinent of bowel and bladder and as having pressure ulcers. On 6/9/2025 at 3:10 pm, staff were observed in R27's room to provide care. During this observation, R27's legs were observed to be severely contracted and bent up to the lower torso. On 6/10/2025 at 12:33 pm, R27 was observed positioned on the left side. There was a foam wedge under the left knee. There were no devices between the resident's knees. On 6/11/2025 at 7:57 am, two staff were observed entering R27's room to provide care. The surveyor asked the staff to observe R27's position. The staff uncovered the resident. The resident was observed to have bilateral leg contractures with the legs drawn up tightly toward the buttocks. The resident's knees were together with no pressure-relieving device between the knees. On 6/11/2025 at 9:30 am, the surveyor entered R27's room with the Wound Care (WC) Nurse. R27 was positioned to the right side with a wedge underneath or below the right knee between the mattress and the resident's right outer leg. A folded flat sheet was observed between the resident's knees. When asked if there had been any pressure-relieving device used between the resident's knees, the WC Nurse said not that she was aware of.

2. Review of R8's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility with diagnoses that included seizures, aphasia, and deaf non-speaking. Review of R8's quarterly MDS, with an ARD of 3/13/2025 and located under the MDS tab of the EMR for Section C (Cognitive Patterns) revealed, he scored zero out of 15 on the BIMS, indicating severely impaired cognition; Section D (Mood) revealed, R8 did not exhibit any mood or behavioral symptoms, and Section N (Medications) revealed, he used antianxiety medication. Review of R8's Care Plan, dated 4/27/2025 and located under the Care Plan tab of the EMR, revealed, [R8] uses anti-anxiety medications r/t [related to] anxiety disorder. The approaches included Give anti-anxiety medications ordered by physician. Review of R8's Medication Administration Record (MAR), located under the Orders tab of the EMR and dated May 202025, revealed a physician's order, which originated on 4/17/2025, for lorazepam (an antianxiety medication), 0.5 milligrams (mg) three times daily for anxiety. Further review of the MAR revealed that the lorazepam was not administered on: -5/16/2025, 6:00 am - The comment code indicated supply reordered. -5/17/2025, 6:00 am and 2:00 pm - The comment code indicated supply reordered. -5/18/2025, 6:00 am, 2:00 pm, and 10:00 pm: - The comment code indicated supply reordered; and -5/19/2025, 6:00 am and 2:00 pm - The comment code indicated supply reordered. Review of R8's EMR under the Notes tab revealed corresponding notes regarding the missing doses of lorazepam: -5/15/2025, 11:30 pm: Reordered. -5/17/2025, 5:44 am: Waiting on pharmacy. -5/18/2025, 5:58 am: Waiting on pharmacy. -5/18/2025, 10:49 pm: Waiting for pharmacy. -5/19/2025, 5:25 am: Waiting on pharmacy. Review of R8's MAR, dated June 2025 and located under the Orders tab of the EMR, revealed that the lorazepam was not administered on: -6/6/2025, 6:00 am - The comment code indicated supply reordered. -6/6/2025, 10:00 pm - The comment code indicated, Other. -6/7/2025, 6:00 am - There was no documentation, and -6/7/2025, 2:00 pm - The comment code indicated, supply reordered. Review of R8's EMR under the Notes tab revealed corresponding notes regarding the missing doses of lorazepam: -6/6/2025, 6:13 am: Waiting for pharmacy. -6/6/2025, 11:49 pm: Medication not on cart, need new Rx [prescription]. There were no notes on 6/7/2025. In an interview on 6/12/2025 at 8:39 am, Licensed Practical Nurse (LPN) 3 stated R8 did not refuse medications and should receive medications as ordered. She stated that when a new order for a controlled medication was sent to the pharmacy, the nurse also had to call the doctor to authorize and sign the prescription. She stated most likely, the above instances where the medication was not administered was because there was a delay in getting the order signed by the physician. LPN3 did not know why the medication was not taken from the facility's emergency medication supply to ensure R8 did not miss doses. In an interview on 6/12/2025 at 8:59 am, LPN4, who served as the left side unit manager, stated she was not aware of the above instances of lorazepam not being available for R8. She stated she relied on the nurses to reorder medications when necessary and follow up when medications are not delivered timely. LPN4 added that lorazepam was available in the facility's emergency medication supply, so there was no reason for the dose not to be given. LPN4 stated there were no issues with getting orders signed by the physician, and the process typically went very smoothly and quickly. Based on observation, interview, record review, and review of the facility's policy titled 5.1 Delivery and Receipt of Routine Deliveries, the facility failed to provide controlled medications for two of three residents (R) (R76 and R8) reviewed for medications out of a total sample of 34. This failure had the potential to place R76 and R8 at risk of uncontrolled pain and anxiety. Findings include: Review of the facility's policy titled, 5.1 Delivery and Receipt of Routine Deliveries, revised 8/1/2024, revealed, . if any item ordered by the facility is not received in the delivery, facility staff should check for a pharmacy communication slip indicating: 2.1.1 medications that are back ordered. 2.1.3 medications that are too soon to be refilled. 2.1.5. other communications explaining the reason a medication or item was not delivered . Facility should contact pharmacy if facility requires an explanation for the missing items of medications . 1. Review of R76's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R76 was admitted to the facility with diagnoses that included dislocation of unspecified internal joint prosthesis, aftercare following joint replacement surgery, left hip joint osteoarthritis, and hypertension. Review of R76's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 3/25/2025 and located under the MDS tab of the EMR for Section C (Cognitive Patterns) revealed, R76 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R76 was cognitively intact. Review of R76's Order Summary, located under the Orders tab of the EMR, revealed R76 had physician orders, dated 5/19/2025, for tramadol, a narcotic pain medication, fifty (50) milligrams (MG), one tablet every eight hours for pain. During an observation on 6/11/2025 at 8:16 am, R76 asked Licensed Practical Nurse (LPN) 3 about his tramadol pain medicine and stated that it should have come in last night. LPN3 lets R76 know that it was not delivered, but she double-checks the narcotic box to be sure, and if not, she would call the pharmacy on it today. During an interview on 6/11/2025 at 8:18 am, R76 stated, I've been out of my pain med since Monday night at 10:00 pm. They haven't given me anything for two and a half days. During an interview on 6/11/2025 at 8:31 am, the Assistant Director of Nursing (ADON) stated, The nurses are supposed to reorder meds when the blister pack gets down to the last row. But if they run out of meds, then they're supposed to call the pharmacy and get a code and permission to access the Pyxis machine. The resident should not be out of their pain meds. The only time they wouldn't have a narcotic is if they were a new admission. At this point, we shouldn't ever run out. This is a valid concern, because I wasn't aware he was out. We can call the pharmacy and pull it from the Pyxis if needed. So, if he's asking for it, then we can call the doctor and get an order to change the med administration time also. During an interview on 6/11/2025 at 8:50 am, LPN4, also Unit Manager for this unit, stated, [R76]'s tramadol isn't in yet. But when it comes in, I will let him know. He can't have any until 2:00 pm, though, because that's when it's scheduled. LPN4 was asked what was being done to manage the resident's pain during this time he was without pain medication. LPN4 answered, Well, he hasn't complained of pain, so we'll give it at 2:00 PM if it comes in. During an interview on 6/11/2025 10:03 am, the Administrator stated, We have the Pyxis to take care of those emergent meds needing to be pulled. That's what it is there for. Nursing must call the pharmacy and have two nurses access it together. So, there is no reason his pain wasn't addressed and no reason his meds weren't here on time, if they were ordered on time. During an interview on 6/12/2025 at 2:55 pm, the Administrator stated, I investigated the pharmacy not delivering [R76]'s tramadol. The pharmacy said it was ordered, but there was an issue with the courier not delivering it. So, it should have been gotten out of the Pyxis and given to R76 for his pain.

Based on observations, interviews, and review of the facility's policies titled Storage of Medications F 761 and 5.3 Storage and Expiration Dating of Medications and Biologicals, the facility failed to remove expired medications from one of two medication carts located on the Left Wing. This deficient practice had the potential to place the residents at risk of receiving medications with altered effectiveness. Findings include: Review of the facility's policy titled, Storage of Medications F 761, reviewed 3/2025, indicated, . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed per state regulation . Review of the facility's policy titled, 5.3 Storage and Expiration Dating of Medications and Biologicals, reviewed 8/1/2024, indicated, . Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has shortened expiration date once opened or opened . Observation on 6/11/2025 at 10:20 am with Licensed Practical Nurse (LPN) 4, (also Unit Manager) of the medication cart at the nurses' station on Left Wing revealed one open bottle of Pro-Stat Nutricia 30 fluid ounces with an expiration date of 5/16/2025 and one unopened box of blood glucose control solution with the expiration date of 12/7/2024 in the first drawer of medication cart. LPN4 confirmed that both items were expired. There was also an open bottle of extra-strength antacids, with an expiration date of 3/2025. LPN4 confirmed all findings. During an interview on 6/11/2025 at 10:30 am, LPN4 stated, All the nursing staff are supposed to go through the medication carts and check expiration dates. We don't really have a system because someone is always checking them. During an interview on 6/12/2025 2:55 pm, the Administrator stated, I'm aware there were some expired medications found in the medication cart that shouldn't have occurred. Staff will need to be reeducated, so this doesn't happen again in the future.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility's policy titled Evaluations, the facility failed to ensure one of one resident (R) (R184) reviewed for rehabilitation out of a sample of 34 residents received timely speech therapy services when ordered to address a swallowing problem. This failure had the potential to place R184 at risk of a decline in swallowing function and dissatisfaction with pureed meals, which could contribute to weight loss or malnutrition. Findings include: Review of the facility's policy titled Evaluations, dated 10/4/2024, revealed, Evaluations will be initiated within a reasonable amount of time following receipt of a physician's order, authorization, or according to facility policy. Review of R184's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses that included dysphagia, anxiety, depression, and failure to thrive. Review of R184's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/10/2025 for Section C (Cognitive Patterns) revealed, she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition and Section K (Swallowing/Nutritional status) revealed, she received a mechanically altered diet. Review of R184's Care Plan, dated 6/5/2025 and located under the Care Plan tab of the EMR, revealed she was on a mechanically altered diet. Review of R184's EMR under the Orders tab revealed a physician's order, dated 5/28/2025, for the Speech Therapist (ST) to evaluate and treat as indicated. There was also a physician's order, dated 5/28/2025, for a pureed texture diet. During an interview on 6/9/2025 at 12:00 pm, R184 stated she was admitted to the facility specifically for speech therapy, as she had trouble eating and had to eat pureed foods. She stated she had not yet seen the ST, and this made her angry, as she wanted to work on getting back to eating regular foods. She stated she did not like eating pureed foods and typically did not eat very much at meals. She stated the pureed food looked like baby food. During the interview, R184's speech was unclear, and statements had to be repeated several times. She was drooling and was unable to control the loss of saliva from her mouth. In an interview on 6/11/2025 at 2:48 pm, the Rehab Director (RHD) stated he was just alerted on 6/9/2025 that R184 needed a speech therapy screening. He stated the screening was completed on 6/11/2025, and typically, screenings had to be completed within 48 hours of notification of the order. The RHD stated he was not aware of the order for a speech therapy evaluation on 5/28/2025, as nursing entered the orders into the EMR, then communicated any new orders to therapy via a screening request form. The RHD stated he received a screening request form for R184 on 6/9/2025. In an interview on 6/11/2025 at 3:34 pm, the ST stated she was unaware R184 had a speech therapy evaluation ordered on 5/28/2025, as it was never communicated to her. She stated she received a request for screening from nursing on 6/9/2025 because R184 was upset with her food texture. She stated R8 was screened on 6/11/2025 and was unsafe with any texture other than puree due to problems with swallowing and a risk for aspiration. The ST stated she would need to conduct an evaluation to determine if R184 could benefit from speech therapy treatment. The ST stated that the screening determined if an evaluation was warranted, and an evaluation was a more thorough, hands-on assessment to determine if further treatment was warranted. The ST stated she would have evaluated R184 on 5/28/2025 if she had known about the order. In an interview on 6/12/2025 at 9:07 am, Licensed Practical Nurse (LPN) 4, who served as the left side Unit Manager, stated she did not know how R184's 5/28/2025 order for ST was missed, and it should have been communicated via a screening request form to the therapy department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of the facility policy titled Guidelines for Charting and Documentation, the facility failed to ensure the clinical record accurately reflected the status of one of 34 residents (R) (R8) related to use of a wander guard (departure alert system). This failure created a misrepresentation of care being provided. Findings include: Review of the facility policy titled Guidelines for Charting and Documentation, dated June 2024, revealed, Be concise, accurate, and complete and use objective terms . Document only the facts. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had diagnoses including muscle weakness, seizures, absence of right leg above the knee, aphasia, and deaf nonspeaking. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/13/2025 and located under the MDS tab of the EMR, revealed he scored zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R8 did not exhibit any behavioral symptoms, including wandering, and was dependent on staff with mobility and all activities of daily living. Review of R8's Wandering and Elopement Evaluation, dated 4/16/2025 and located under the Assessments tab of the EMR, revealed he was unable to ambulate or to self-propel his wheelchair, and he had no wandering or exit-seeking behaviors and no risk factors for elopement. The evaluation documented, Resident no longer self-propels and is not a wander risk at this time, wander [guard] removed. Review of R8's EMR under the Care Plan tab revealed it did not address the potential for wandering or eloping. Review of R8's May 2025 and June 2025 Medication Administration Records (MARS), located under the Orders tab of the EMR, revealed a physician's order, dated 11/8/2024, to check the function of the wander guard every day. The nursing staff initialed that this was completed daily. During an observation on 6/11/2025 at 1:03 pm, R8 was seated in his geriatric chair in the day room. He did not have a wander guard device on. In a concurrent interview, Certified Nurse Aide (CNA) 2 stated R8 did not have a wander guard and was no longer able to get around on his own, so it was not necessary. CNA11 confirmed R8 did not have a wander guard. During an interview on 06/11/25 at 4:40 PM, Licensed Practical Nurse (LPN) 3 and LPN4, who served as the left side Unit Manager, stated R8 did not use a wander guard as he was dependent on staff for mobility. LPN3 and LPN4 confirmed they removed his wander guard and the order for the device when his mobility status changed, as he no longer needed it. LPN3 and LPN4 stated they were unaware that the order to check for placement was still active and reflected as implemented on the MAR. LPN3 stated this was due to staff not reading what they were signing off, and it was inaccurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility's policy titled Infection Control Program - Antibiotic Stewardship, the facility failed to ensure that antibiotics were not used without the presence of a diagnosed infection for one of three residents (R) (R53) reviewed for antibiotic stewardship out of a total sample of 34 residents. The failure had the potential to lead to increased antibiotic resistance or adverse side effects related to unnecessary antibiotic usage. Findings include: Review of the facility's policy titled Infection Control Program - Antibiotic Stewardship, dated October 2024, revealed, After order has been received, the Infection Control Coordinator or designee should complete the surveillance document, utilizing the McGeer criteria, noting evidence for the infection. If the antibiotic does not fit the criteria, the physician will be contacted. Review of the facility's Infection Control Log, used to track infections and antibiotic usage, revealed R53 was listed with a urinary infection with an onset date of 5/10/2025. The log documented that R53 was taking the antibiotic doxycycline, and this was a facility-acquired infection. The area to document the organism, the x-ray result, and/or the lab/culture result was left blank. There was no place to document symptoms on the log and no place to document whether the infection met criteria. The log documented one urinary tract infection and no upper respiratory infections for the month. Review of R53's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE]. Review of R53's Medication Administration Record (MAR), dated May 2025 and located under the Orders tab of the EMR, revealed a physician's order dated 5/6/2025 for doxycycline (antibiotic), 100 milligram tablet twice daily for URI [upper respiratory infection]. Review of R53's EMR under the Notes tab revealed an eInteract SBAR Summary for Providers, dated 5/6/2025, which documented that R53 experienced a cough and had new orders for a chest x-ray, antibiotic, and cough syrup. Subsequent Nursing Infection Notes, dated 5/9/2025, 5/10/2025, and 5/11/2025 documented, ABT[antibiotic]/URI in progress. Review of R53's Radiology Report, dated 5/7/2025 and located under the Miscellaneous tab of the EMR, revealed his chest x-ray indicated, No active disease. No evidence of pneumonia. Review of R53's EMR revealed no communication with or rationale from the physician regarding continued use of an antibiotic in the absence of any active infection. During an interview on 6/12/2025 at 2:56 pm, the Infection Preventionist (IP) stated she started working in her current position in April 2025. She stated her antibiotic stewardship program included determining whether an infection met criteria to require treatment and determining whether an antibiotic was effective. The IP stated that the Infection Control Log listed the onset date, site, infection diagnosis, antibiotic, and date resolved. The IP stated she did not have access to lab results yet, so she had not yet been reviewing labs and/or x-rays as part of her antibiotic stewardship program. The IP stated she would determine whether an antibiotic was effective by reading nurses' notes to determine if symptoms had improved. The IP stated she did not have a way to determine if an organism is susceptible to the antibiotic prescribed, as she did not have access to lab results. She stated she would just alert the physician if there was no improvement in symptoms with the current antibiotic. The IP stated she had not reviewed R53's use of doxycycline to determine if the infection met criteria and whether the antibiotic was appropriate. She stated she had not seen the chest x-ray results from 5/7/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain proper ventilation in six resident rooms and on the main hall of the facility to ensure adequate air circulation and environmental hygiene. This failure had the potential to contribute to residents' discomfort and poor air quality for all 80 residents currently residing in the facility. Findings include: 1. Observations made beginning on 6/9/2025 at 9:09 am on the right wing of the facility identified bathroom ventilation fans were found not operational in rooms 125, 131, 133, and 137. On 6/12/2025 at 12:45 pm, the Maintenance Director Assistant (MDA), the Housekeeping Director (HKD), the Administrator, Director of Nursing (DON), and Corporate staff accompanied the surveyors on a tour of the building and confirmed identified concerns, including rooms where the ventilation fans were not working. The MDA verified that the ventilation fan was not working in room [ROOM NUMBER], with tissue paper, as there was no updraft of the paper. During an observation on 6/9/2025 at 2:32 pm in the shared bathroom for the four residents in rooms [ROOM NUMBERS], there was a heavy urine odor in the bathroom. The exhaust vent in the bathroom was not working and would not draw up a piece of toilet tissue. During an observation with the Maintenance Director Assistant (MDA) on 6/12/2025 at 12:50 pm, the shared bathroom between rooms [ROOM NUMBERS], the MDA confirmed a heavy urine odor in the bathroom. The MDA checked the function of the exhaust vent and stated it was not drawing air. During an observation on 6/9/2025 at 12:48 pm, the hallway ceiling vent and grate outside of the Administrator's office were observed to be covered in excessive dirt and debris consisting of a blackened substance with visible thick, white, and gray furry matter. During an observation and interview on 6/12/2025 at 1:00 PM while completing a walk-through of the left wing of the facility with Maintenance Director Assistant (MDA), he stated, We change out the filters every month. This one is pretty dirty, and it's caked with dirt. To clean them, we would replace all three vents and clear off the grate that is covered with dirt and the loose strings of dirt and lint hanging from the grate. During an interview on 6/12/2025 at 1:30 pm, the Administrator stated, We were down to one maintenance person for a while. The previous maintenance person worked here for one year but has been gone for three to four weeks. It's been difficult to keep up with all the maintenance. Review of the facility's maintenance records for the past 12 months revealed that the filters were changed monthly, but no other details were provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to maintain a safe, functional, and sanitary environment in 16 of 47 resident rooms (rooms 101, 104, 105, 106, 125, 128, 129, 131, 132, 133, 137, 138, 139, 142, 143, 147), the main dining room, and the right and left wing day rooms. These failures had the potential to lead to injury or accidents, the spread of infection, or feelings of discomfort and dissatisfaction among residents. Findings include: Review of the facility policy titled Other Environmental Conditions, dated October 2024, revealed, The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and public. Observations of the Left Wing of the facility during resident screening/initial pool on 6/9/2025 and again during an environmental tour of the facility with the Administrator, Director of Nursing (DON), Maintenance Director Assistant (MDA), Housekeeping Director (HKD), Regional Director of Clinical Services (RDCO), and Regional [NAME] President of Operations (RVPO) on 6/12/2025 revealed: 1. On 6/9/2025 at 9:11 am in room [ROOM NUMBER], bed A was at its lowest setting, exposing a hole in the wall next to the bed where an electrical outlet once was. During the environmental tour on 6/12/2025 at 1:10 pm, the MDA stated he planned on putting a cover over the hole so that it could be used as an outlet later if needed. He stated the hole had been uncovered for a couple of weeks. 2. On 6/9/2025 at 9:12 am in room [ROOM NUMBER], the nightstand next to Bed B had veneer peeled off with the veneer's jagged edges sticking up. Additionally, there were two long pieces of wood that had been taken off the wall next to Bed B and were lying on top of the air conditioner unit. The wood had several nails sticking straight up. Also, the tile of the windowsill on the left corner was broken and crumbling. During the environmental tour on 6/12/2025 at 1:12 pm, the MDA stated the nightstand needed to be replaced as the veneer was peeling off. The MDA and HKD stated they were not aware of how the pieces of wood came off the wall or why they were on top of the air conditioner (AC) unit. The MDS stated the nails posed an accident hazard, and they needed to be removed from the room. The HKD stated that the crumbling tile on the windowsill needed to be replaced. 3. On 6/9/2025 at 9:17 am in room [ROOM NUMBER], the tiles on the floor near the sink were water-damaged and were pulling up off the floor and sticking up jaggedly. Next to the sink was a large black stain on the wall above the water-damaged tiles. The four nightstands in the room had missing or peeling veneer. In the bathroom, there were black stains on the ceiling tile around the sprinkler head and black stains around the edges of the floor under the sprinkler. The toilet paper holder was missing, and a plunger was on the floor, not stored in a bag or covered. The toilet was unsecured on the left side, leaving it loose and wobbly and able to be moved approximately three inches side to side. During the environmental tour on 6/12/2025 at 1:13 pm, the MDA stated there was water damage on the wall and the floor next to the sink. He stated the black stains were mildew and not mold, although he stated he had not tested for mold. The MDA stated the leak in the wall had been fixed, but nothing had been done to clean up the damage. The MDA added that this needed to be cleaned as mildew can affect resident health. The HKD confirmed the nightstands were in disrepair and needed to be replaced. The MDA stated that the ceiling tiles and floor in the bathroom were stained from dirty water that sprayed when the sprinkler head was replaced. He stated this was just dirt, not mildew or mold, but confirmed he had not tested for mold. The MDA confirmed there was no toilet paper holder in the bathroom and stated he was not aware it was missing. The HKD stated the plunger should be stored in a bag, not directly on the floor, to prevent the spread of infection. The MDA stated the toilet was loose and needed to be secured. He stated he was not aware of this condition. 4. On 6/9/2025 at 9:25 am in room [ROOM NUMBER], the cove base was missing under the AC unit, exposing a peeling wall under the unit. During the environmental tour on 6/12/2025 at 1:00 pm, the MDA confirmed the missing cove base in room [ROOM NUMBER], stated he was not aware of the missing cove base, and stated it needed to be repaired. 5. On 6/9/2025 at 10:13 am, the Left-Wing day room had numerous areas of scratched or peeling paint on the walls and on the railings surrounding the TV areas. There were multiple stains and areas of dried debris on the walls. The countertops holding the TVs and other supplies had multiple sticky areas of red and brown substances, dust, dirt, and dried debris. During the environmental tour on 6/12/2025 at 12:56 pm, the HKD stated the housekeeping staff was expected to wipe down the walls, countertops, and other surfaces in the common areas, and added that he audited the housekeeper's work twice daily. He stated the countertops and walls should have been clean. The Administrator added that the facility had been without a Maintenance Director and had just recently hired someone to take the position, which would help with getting projects and repairs done. Observations on 6/9/2025, beginning at 9:09 am, on the Right Wing identified the following maintenance and environmental concerns: 1. The main dining room was observed with an accumulation of more than a day's worth of dust on top of the piano, the chair in front of the piano had cobwebs on the back leg/left, and the tiles on the side near the kitchen were broken with missing pieces. There was also an area where quarter-round trim was missing at the dining room entry, along the wall under the wall display. 2. room [ROOM NUMBER] - A buildup of dust and grime was observed around the baseboards, the cabinet under the sink was observed with a drawer off track, and underneath the cabinet, dirt and crumbs were observed in the right corner. 3. The exit door in the hallway near rooms [ROOM NUMBERS] was observed with a gap at the bottom and sides of the door, allowing light to come through. The gaps were large enough for pests to enter. At the sides of the door, along the baseboards, there was more than one day's accumulation of dirt and dust buildup and cobwebs. 4. room [ROOM NUMBER] - The chair rail above the head of the bed was observed to be cracked. In the bathroom, there was a buildup of dirt and grime in the corners and behind the toilet, and a urine odor was present. 5. room [ROOM NUMBER] - There was no light covering to light above the sink in the bedroom. The corners and along the baseboards were observed to have a buildup of dirt and dust. The ceiling tiles near the bathroom door and above the sink had watermarks around a pipe going into the ceiling. The toilet lid was observed broken and lying on the floor of the bathroom. The floor in the bathroom was observed with a buildup of more than a day's worth of dirt and grime in all four corners. The toilet tank did not have any water in the tank, and the ceiling's light cover was hanging down, not covering the light bulb. 6. room [ROOM NUMBER] - The faucet to the sink located at the entrance to the room was observed loose and not secured to the sink. The ceiling tiles above the sink were discolored with brown spots, and the sheetrock outside the bathroom had areas of missing sheetrock in need of repair. The floors along the baseboards had more than a day's worth of accumulation of dirt and grime. In the bathroom, the commode seat was observed to have brownish colored stains on it. The plunger in the bathroom was observed without a cover and sitting on the floor of the bathroom. The light cover was observed with an accumulation of black debris on the inside. 7. In front of room [ROOM NUMBER], along the Therapy Department wall, there was brownish colored spillage on the column and baseboard. 8. room [ROOM NUMBER] - There was dust buildup on the vent fan, and the light cover had a buildup on the inside. The flooring behind the door had a buildup of an accumulation of dust and dirt, more than a day's worth. 9. 139 B- The head and foot boards were observed not fully attached, with each having one side making contact with the floor. A heavy buildup of dust and dirt was observed on the inside of the AC vent of the AC unit. A gap in the sheetrock was observed along and between the top of the AC unit and the wall. Two tiles on the windowsill were observed to be broken and loose. The bathroom door was also observed to have paint scuffed off at the bottom, as well as paint missing from the door frame. 10. room [ROOM NUMBER] - The privacy curtain for Bed A was soiled with a brown substance, and the privacy curtain track in the middle of the room was not secured to the ceiling. There was a drawer underneath the sink that was observed off track, and the baseboard between the closet and the sink was observed missing. The wall area where the baseboard was missing was observed to be black. 11. Outside the door of room [ROOM NUMBER], in the hallway, there was an accumulation of dirt and dust in the corners and along the baseboards. There were two broken tiles at the door of the room. 12. room [ROOM NUMBER] was observed with a newer laid gray plank-type flooring. At Bed B, the flooring was not secured, with portions of the flooring having loose, raised edges, the wall behind the headboard was scuffed, and paint was removed from the wall in the scuffed areas. The top of the bedside table for Bed B had veneer missing from all four edges. At the entry to the room, the tile flooring from the hallway to the new plank flooring in the bedroom was higher than the hallway tile. There was no transition between the two different types of flooring. 13. room [ROOM NUMBER] - The attached headboard of Bed B was observed broken, with a portion missing. The bedside table was observed with all three drawers off track, and pieces of veneer were missing or loose from the bottom, sides, and back edges. 15. 138 - The faucet was observed with a continuous drip of water, and the right-side water nozzle was observed to be broken with a piece missing. 16. During an observation on 6/9/2025 at 9:34 am, tiles were noted to be missing from the floor of the right-wing day room. 17. room [ROOM NUMBER] had an open area under the sink, and a wash pan was under the sink to catch dripping water. Tiles were missing on the floor as you entered the bathroom. 18. The hallway walls had missing paint, and wheelchair marks were noted on the walls. 19. room [ROOM NUMBER] had a leak in the room, and the dresser was warped. On 6/12/2025 12:45 pm, the HKD, MDA, Corporate Staff, the Administrator, and the DON accompanied the surveyors on a tour of the Right Wing to observe the identified housekeeping and maintenance issues. As issues were confirmed by staff, notes were taken to address them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to maintain an effective pest control program for seven of 34 sampled residents' rooms (R) (R71, R15, R70, R59, R52, R184, and R20). This failure had the potential to lead to further pest infestation in the facility and feelings of discomfort or spread of infection among the residents. Findings include: Review of the facility's policy titled, Pest Control, dated October 2024, revealed, The community maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Review of the facility's Resident Council Minutes for the past year, provided by the facility on paper, revealed: -On 6/26/2024, several residents complained of roaches in the facility. The facility's response was to schedule an exterminator on a monthly basis. -On 5/28/2025, several residents complained of water bugs in the facility. The facility's response was to schedule an exterminator. Review of the facility's pest control logs, provided on paper, revealed pest control services were provided on: -1/8/2024 - full exterior and interior service. Pest activity was noted. -4/1/2024 - fly machine maintenance, rodent monitoring, and full interior treatment for general pests. Pest activity was noted. -12/10/2024 - bait station inspection, exterior treatment for general pests, and fly trap service. -6/6/2025 - pest elimination services, fly control service, rodent control service, and roach clean outs of rooms 114, 115, 116, 117, 118, 142, and 146. There was no evidence of monthly extermination services as outlined in the facility's resolution to the Resident Council's grievance, and there were no records of services between December 2024 and June 2025. 1. Review of R71's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/27/2025, revealed he was admitted to the facility on [DATE]. R71 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During an interview on 6/9/2025 at 9:54 am, R71 stated he has seen water bugs or roaches throughout the facility. R71 stated he tried to step on the bugs, but they were too fast and usually got away. 2. Review of R15's annual MDS, with an ARD of 3/213/2025 and located under the MDS tab of the EMR, revealed he was admitted to the facility on [DATE]. R15 scored 15 out of 15 on the BIMS, indicating intact cognition. During an interview on 6/9/2025 at 9:53 am, R15 stated that the trash bins were kept in the hall right outside his room door, and this attracted bugs to his room. 3. Review of R70's quarterly MDS, with an ARD of 5/7/2025 and located under the MDS tab of the EMR, revealed she was admitted to the facility on [DATE]. R70 scored 15 out of 15 on the BIMS, indicating intact cognition. During an interview on 6/9/2025 at 9:25 am, R70 stated there were roaches in her room and she saw them every day. R70 stated her roommate often put food on the floor, and this attracted the bugs. 4. Review of R59's quarterly MDS, with an ARD of 3/21/2025 and located under the MDS tab of the EMR, revealed he was admitted to the facility 12/21/2021. R59 scored 13 out of 15 on the BIMS, indicating moderately impaired cognition. During an interview on 6/9/2025 at 2:34 pm, R59 stated there were roaches or water bugs in her room. She stated she was afraid to go to sleep and have the bugs crawl on her, so she had her family member spray the room for bugs. R59 stated, I had a good night's sleep after that. 5. Review of R52's annual MDS, with an ARD of 3/19/2025 and located under the MDS tab of the EMR, revealed he was admitted to the facility on [DATE]. R52 scored 15 out of 15 on the BIMS, indicating intact cognition. During an interview on 6/9/2025 at 10:04 am, R52 stated there were small flying bugs in the facility, and he had seen roaches now and then. 6. Review of R184's admission MDS, with an ARD of 6/10/2025 and located under the MDS tab of the EMR, revealed she was admitted to the facility on [DATE]. R184 scored 15 out of 15 on the BIMS, indicating intact cognition. During an interview on 6/9/2025 at 12:00 pm, R184 stated there were gnats in the bathroom and shower room, and she had seen roaches in her room. 7. Review of R20's quarterly MDS, with an ARD of 4/4/2025 and located under the MDS tab of the EMR, revealed he was admitted to the facility on [DATE]. R20 scored 15 out of 15 on the BIMS, indicating intact cognition. During an interview on 6/11/2025 at 4:00 pm, R20 stated the shower room was full of roaches and gnats. He stated there were roaches in resident rooms as well, especially inside the closets. During an interview on 6/12/2025 at 1:27 pm, the Administrator stated a new extermination company was hired recently and serviced the facility on 6/6/2025. She stated the previous extermination company was not completing services in a timely manner, so she had reached out to sister facilities to hire a more reliable company. The Administrator stated the new company would be completing regular visits. The Maintenance Director Assistant (MDS) stated that to address resident concerns when pest control services did not come in, he bought approved insecticides and treated rooms as they were brought to his attention.

Based on observations, staff interview, and review of the facility's policy titled, Ice Machines and Ice Storage Chests F880, the facility failed to ensure food items in the walk-in cooler were labeled and dated, maintain the kitchen in a clean and sanitary manner, and keep the ice scoop clean and covered. The deficient practices had the potential to place the 77 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: Review of the facility's policy titled, Ice Machines and Ice Storage Chests F880, reviewed 10/2024, revealed, . Ice machines and ice storage distribution containers will be used and maintained and to assure safe and sanitary supply of ice . To help prevent contamination of . ice storage chests/containers or ice, staff should follow these precautions. e. Keep the ice scoop/bin in a covered container when not in use. f. Clean and sanitize the tray and scoop daily . 1. During the initial tour of the kitchen with the Dietary Manager (DM) on 6/9/2025 at 8:43 am, the following observations were made: a. An undated bag of shredded lettuce and an undated container of English peas were found on shelves in the walk-in cooler. The DM verified that the two items were undated at the time of the observation and discarded them. b. A portable air conditioning unit was observed sitting on top of the counter where dishes exited the dishwasher. The unit was vented through the ceiling. The portable air conditioning unit had an accumulation of dust and grease buildup on the air intake or the back side of the unit. The vent was observed with an accumulation of dust along the tubing. The portable unit's air vent on the front side was held open by paper towels so the vent would stay open for air flow. c. Two vents below the clock on the wall at the three-compartment sink and the dishwasher counter were observed with an accumulation of grease and dust buildup. The DM explained that one was an exhaust vent and one was for airflow coming into the building. d. The back of the oven, cooktop, and fryers were observed with an accumulation of grease and dust. e. The ceiling tiles throughout the kitchen were observed with brownish discoloration and areas of splatter. Above the vent hood, there was one ceiling tile that was observed sagging. During an observation and interview on 6/9/2025 at 1:11 pm, after the meal service and during dishwashing, the DM was asked to show where staff monitoring logs of temperatures taken from the dish machine to ensure the temperatures for sanitizing dishes were in the correct range. The temperature log was retrieved, and there were no temperatures logged for 6/8/2025 and 6/9/2025 before washing dishes. The DM stated the temperatures should have been checked and logged. During an observation and interview on 6/10/2025 at 2:31 pm, the following observations were made: a. A large fan was blowing air into the kitchen. The fan was found with an accumulation of sticky dust. The DM stated that the air conditioning had been out for a long time, and when asked how long, she did not say. When asked if it had been since the last survey, she stated yes. The thermostat above the three-compartment sink read 84 degrees. b. A ceiling vent over the food serving table/steam table was observed not fully covering the area in the ceiling that it is intended to cover. There were gaps between the ceiling and the edges of the vent. c. The portable air conditioning unit remained in the dishwashing area, with the accumulation of dust and grease still noted. The DM was asked about reporting maintenance issues in the kitchen. The Dietary Manager stated that any maintenance needs were entered through the computerized communication tool for maintenance needs and that communication went to maintenance, then to the Administrator, and then to Corporate, depending on the amount of the needed repair. During an interview on 6/12/202025 at 9:30 am, the Administrator was asked to provide any maintenance requests sent through the computerized communication system for the last year. The Administrator and Regional [NAME] President of Operations (RVPO) were notified that the DM reported that the air conditioner in the kitchen had not been working. The Corporate consultant stated she was not aware of the air conditioner being out until this survey. On 6/12/2025 at 11:08 am, the computerized communication reports were received via email from the Administrator. There were no entries of kitchen maintenance requests in the report. 2. During an observation and interview on 6/9/2025 at 12:48 pm with the Assistant Director of Nursing (ADON), an uncovered ice scoop was noted inside a clear plastic container on the ice chest cart. The scoop and container were visibly dirty, the container was cracked, and the lid was broken off. The ADON stated, This all needs to be changed out. The container has a large crack, and the lid is broken off. The ice scoop should be covered and left open to the air. I don't know how long it's been like this, but I'm going to replace it right now. The ADON returned at 12:52 pm and stated, We have to order some because we don't have any in stock right now. We're going to put it in a baggie for now since it should be covered until the new ones come in. During an interview on 6/12/2025 at 8:20 am, the Administrator stated, The ADON did show me the dirty, broken ice scoop and container. The scoops should always be covered, and the entire ice chest and cart should be cleaned regularly, and staff should know this. I ordered new ice scoops and containers for both halls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy titled, F 625 Bed Hold, the facility failed to ensure a bed-hold policy upon transfer to the hospital for one of 35 sampled residents (R) (R79). Findings include: Review of the facility policy titled F 625 Bed Hold revised May 2023 indicated the following: 1. Upon admission and when a resident is transferred for a non-emergency hospitalization or for therapeutic leave, a representative of the business office will provide information concerning our bed-hold policy. 2. When emergency transfers are necessary, the facility will provide the resident and the resident representative with information concerning our bed-hold policy per state law as applicable. R79 was admitted to the facility with diagnosis including but not limited to encounter for surgical aftercare following surgery on the digestive system, diabetes mellitus, cocaine dependence with intoxication delirium, major depressive disorder, and insomnia. Review of R79's Physician orders revealed an order of buspirone hydrochloride (HCL) 7.5 milligrams (mg), duloxetine HCL 40 mg, and apixaban 5 mg. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] documented R79 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had intact cognition. Interview on 1/25/2024 at 9:30 am with Regional Director of Clinical Services AA indicated they did not do a bed hold on resident when he went to the hospital. Interview on 1/25/2024 at 9:49 am with Social Services Director (SSD) revealed they did not do a bed hold on the resident when he went to the hospital due to the resident's behaviors. The SSD indicated they 1013'd (the purpose of this certificate (1013) is to authorize transportation to an emergency receiving facility) the resident and the police were called and the nurse who the resident touched inappropriately pressed charges against the resident. The SSD mentioned R79 was discharged to a personal care facility after leaving the hospital. The SSD indicated they did not give him 30 days' notice but would not take him back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, F 656, F 657, F 658 Comprehensive Care Plan, the facility failed to develop and implement a care plan for activities of daily living (ADL) for one of 35 sampled residents (R) (R8). The deficient practice had the potential for decline in R8's functional abilities. Findings include: Review of the facility's policy titled F 656, F 657, F 658 Comprehensive Care Plan revised August 2022 documented under Policy: An individualized comprehensive resident centered care plan that includes measurables objectives and time frames to meet the residents medical, nursing, mental, cultural and psychological needs is developed for each resident. Procedure: 8. Each resident's comprehensive care plan is designed to: . f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. 1. Review of the electronic medical record (EMR) for R8 revealed diagnoses that included but not limited to syncope and collapse, repeated falls, presence of cardiac pacemaker, and hypertensive heart disease with heart failure. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] documented R8 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Further review revealed R8 has no impairment with upper extremity/lower extremity and partial/moderate assistance with wheelchair, eating, toileting, shower/bathe-self. Review of the care plan revealed R8 had no care plan developed for ADLs. Observation on 1/24/2024 at 8:10 am, R8 was in bed resting. R8 was clean and odor free. R8 was asked if she received a shower. R8 stated that she could not say if she did or not. R8 stated she does not remember when she came to the facility. Interview on 1/25/2024 at 9:15 am with the Social Services Director (SSD), the SSD acknowledged that an ADL care plan was not developed for R8. She stated that she created and developed care plans for residents as well as the MDS Coordinator, who was also a participant in the care plan meetings. Interview on 1/25/2024 at 9:30 am with the MDS Coordinator, she acknowledged that R8 does not have a care plan for ADLs. She stated that she could not answer why R8 did not have a care plan for ADLs. Interview on 1/25/2024 at 2:21 pm with the Director of Nursing (DON) revealed her expectation of the SSD and the MDS Coordinator was for them to develop a base line care plan/comprehensive assessment that included ADL upon admission.

Based on observations, staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to have an order for oxygen (O2) therapy for one of three residents (R) (R72) on oxygen therapy. The deficient practice had the potential to cause delayed treatment. Findings include: A review of the facility policy titled Oxygen Administration last revised June 2021 revealed under Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Under Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident. Review of the electronic medical record (EMR) for R72 including the Minimum Data Set (MDS) section C-Cognition revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates that cognition is intact. Under section J-Health Conditions revealed R72 has shortness of breath or trouble breathing with exertion, shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. Under Section GG-Functional Abilities and Goals revealed R72 is dependent on staff for toileting hygiene, shower/bath, and personal hygiene. The Resident needs substantial/maximal assistance with upper and lower body dressing. Review of section O-Special Treatments indicates the Resident receives O2 Therapy. Review of the Physician's Orders revealed an order dated 1/14/2024 to change nebulizer tubing weekly, clean the concentrator filter weekly, Sunday night; change oxygen tubing and mask/cannula weekly on Sunday. There is no order for O2 by nasal cannula (NC). Review of the medical diagnoses include chronic respiratory failure and chronic obstructive pulmonary disease (COPD). The care plan revealed O2 therapy related to COPD, respiratory failure with hypoxia, noncompliant with keeping on oxygen which cause saturation to decrease, respiratory failure with hypoxia /difficulty breathing related to COPD, R72 has a diagnosis of chronic respiratory failure with hypoxia, she is on continuous oxygen, and she is non-compliant with supplemental oxygen, she remains at risk for complication due to low oxygen hypoxia resulting in previous hospitalization. *Noncompliant with keeping oxygen on; O2 via nasal cannula @6L [liters] continuous. Observation on 1/23/2024 at 10:00 am of R72 revealed O2 was on at 2L via NC. Observation on 1/24/2024 at 9:00 am of R72 revealed O2 was on at 2L via NC. Interview on 1/24/2024 at 12:35 pm with Certified Medical Tech (CMT) DD, CMT DD stated the O2 for R72 was on at 4L via NC today. Interview on 1/24/2024 at 1:00 pm with Licensed Practical Nurse (LPN) CC she indicated R72 was on 4L O2 via NC. R72 takes O2 off and doesn't always take treatment. R72 has been doing good with O2 saturations (oxygen level via pulse oximeter). LPN CC confirmed there was no order in the physician's orders for O2 by NC. Interview on 1/24/2024 at 2:00 pm with the Interim Director of Nursing (DON), the Interim DON was informed there was not an order on the chart for O2 therapy by NC for R72. The Interim DON reviewed the orders and stated the order was listed in the summary of orders. She stated for some reason the order for O2 dropped off and it was not in the chart at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled, Vaccination of Residents, Including Influenza, Pneumococcal, Respiratory Syncytial Virus (RSV), and COVID-19, Reporting of, the facility failed to offer or provide documentation of consent or refusal of vaccinations for five of five residents (R) (R7, R14, R53, R66, and R72) reviewed for vaccination consents. Findings include: Review of the facility's policy titled Vaccination of Residents, Including Influenza, Pneumococcal, RSV, and COVID-19, Reporting of last revised September 2023, revealed Guidelines, General Immunization: 3. Evaluate new residents vaccination status upon admission. 4. The resident or resident's legal representative may refuse vaccinations for any reason. 5. Residents have the right to refuse, be free of interference, coercion, discrimination, and reprisal of the community staff for refusing to take any vaccines. 6. If vaccinations are refused, the refusal shall be documented in the resident's medical record. Review of the medical record for R7 revealed the resident was admitted to the facility with diagnoses including but not limited to schizophrenia, and major depressive disorder. There was no indication in the record that a consent for vaccinations given or declined was signed by the resident or their representative. This omission was verified by the Interim Director of Nursing (DON). Review of the medical record for R14 revealed the resident was admitted to the facility with diagnoses including but not limited to cerebral infarction and post traumatic seizures. There was no indication in the record that a consent for vaccinations given or declined was signed by the resident or their representative. This omission was verified by the Interim (DON). Review of the medical record for R53 revealed the resident was admitted to the facility with diagnoses including but not limited to dysphagia, hemiplegia and hemiparesis following cerebral infarction. There was no indication in the record that a consent for vaccinations given or declined was signed by the resident or their representative. This omission was verified by the Interim (DON). Review of the medical record for R66 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction and memory deficit. There was no indication in the record that a consent for vaccinations given or declined was signed by the resident or their representative. This omission was verified by the Interim (DON). Review of the medical record for R72 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to chronic renal failure, chronic obstructive pulmonary disease, and COVID-19. There was no indication in the record that a consent for vaccinations given or declined was signed by the resident or their representative. This omission was verified by the Interim (DON). Interview on 1/25/2024 at 4:15 pm the Interim DON confirmed the lack of consents for the five residents listed. She stated going forward she will get all requested information from the residents and offer RSV vaccines to all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the facility policy, the facility failed to maintain the dignity of a resident while in the dining area for one of two residents (Resident [R] #37) reviewed for dignity by not cutting their food or assisting during a meal and allowing the resident to eat with their fingers. Findings include: A review of the facility's policy, Respect and Dignity, reviewed on 05/2021, indicated under policy statement that residents have the right to be treated with respect and dignity. The policy also indicated, Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility admitted R #37 on 08/31/2012 with diagnoses that included cognitive communication deficit, need for assistance with personal care, generalized muscle weakness, dysphagia, cataracts, diabetes, depression, and a stroke affecting the dominant side. A review of the annual Minimum Data Set (MDS), dated [DATE], indicated R#37 was unable to complete the Brief Interview for Mental Status and had been assessed by staff to have short-term and long-term memory impairment. The MDS also indicated the resident was rarely/never understood and rarely/never was able to understand. R#37 required supervision with eating. The Care Plan for R#37, revised 02/03/2022, indicated the resident was at risk for further weight loss due to physical condition and an alteration in textures. An intervention that was added on 11/06/2021 included staff supervision at meals as needed. A review of R#37's Care Plan, reviewed 03/03/2020, indicated the resident had a deficit in activities of daily living (ADLs). Part of the goal indicated the resident would continue to eat independently after set-up. The Care Plan also indicated the resident was at nutritional risk. Interventions included providing supervision to R#37 during meals as needed. An observation was made on 03/23/2022 at 12:23 PM. R#37 was in the dining room waiting for the lunch meal that was served at 12:29 PM. The resident's meal consisted of spaghetti noodles with sauce, mixed vegetables, bread, thickened tea, and a small plastic container of thickened liquid flavored water with a foil lid. Staff completed the initial set up but failed to cut up the noodles for the resident and did not open the lemon-flavored water. R#37 was observed eating with a spoon. The resident was unable to get the noodles up to the mouth using the spoon, so the resident used their fingers to pick up the noodles for eating. Unit Manager (UM) EE and other staff were in the dining area and passed by the resident as the resident was trying to eat. No staff person stopped by the resident's table and offered to open the water or offered to cut the noodles. The resident wiped their mouth and then took the plate of food and dumped the contents into the plate warmer portion. R#37 consumed less than 25% of the lunch meal. UM EE was interviewed on 03/23/2022 at 3:51 PM. UM EE stated if a resident's care plan indicated supervision was required that meant cueing, set up of the meal or physically assisting the resident if needed. The UM added she expected all fluids on the tray to be opened. She added if a resident was observed eating with their fingers, she expected staff to assist that resident either by cueing the resident to use utensils or physically feeding the resident. The UM stated R#37 required minimal assistance with feeding and would physically pull away if staff attempted to help. UM EE stated even with a contracted hand, R#37 was able to pull the tin foil lid from the juice container. She stated the resident was unable to cut up food independently. When told she walked by the resident and had not assisted R#37, she stated she was distracted trying to get assistance for another resident. Certified Nursing Assistant (CNA) CC was interviewed on 03/24/2022 at 11:20 AM. CNA CC identified herself as agency staff. The CNA stated the nurse usually told her about the assigned residents. She stated R#37 fed themself with a spoon after staff set the meal up that included opening juice containers and cutting food. CNA CC added R#37 was unable to remove the foil lid on the juice container and was unable to cut food due to having a contracted hand. The CNA stated she had not been informed the resident required assistance with meals. The CNA added she could find information about R#37 in the assignment book. She opened the book and turned to R#37's room number and found information about two other residents but could not find information about R#37. The Director of Nursing (DON) was interviewed on 03/24/2022 at 1:19 PM. The DON stated to supervise a resident during meals meant the staff member was close enough to the resident to see how much they ate or to provide physical assistance if needed. The DON stated if a staff member were supervising a resident that would mean the resident was within eye contact. She added some residents only ate a small amount and required encouragement to eat more. The DON stated supervision also meant the staff member would open containers, cut up items and give the resident utensils. The DON stated she expected staff to either look at a resident's care plan or to ask another staff member how much assistance residents required for eating. She added she would have expected staff to remove the foil lid from R#37's juice and cut up food for the resident so R#37 could have eaten with the spoon and not their fingers. She stated staff was expected to encourage the resident to eat more and offer another choice if needed. On 03/25/2022 at 11:24 AM, CNA DD was interviewed. The CNA stated R#37 was unable to cut up food independently but could eat independently after meal set up. Licensed Practical Nurse (LPN) GG was interviewed on 03/25/2022 at 12:31 PM. The LPN stated R#37 was able to eat independently after staff set up the meal which included cutting up all food and opening fluid containers. LPN GG added R#37 was unable to open the juice containers independently due to a hand contracture. The LPN stated supervising a resident during meals meant that staff monitored the resident to make sure the resident did not choke or to help as needed. LPN GG stated she would have expected staff to cut the noodles up for R#37 and to open the juice container. The LPN stated she had a problem knowing R#37 had to eat the noodles with fingers and said she thought that was a dignity issue. The Administrator was interviewed on 03/25/2022 at 1:45 PM. She stated she expected staff to open containers and cut up food items so the resident could eat independently. The Administrator stated when staff saw R#37 struggling with the noodles, they should have intervened and tried to feed the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, document review, and review of policy and procedures, the facility failed to ensure a resident's right for a homelike environment that meets the resident's needs, including a wheelchair, and access to a bathroom for two of nineteen residents (Resident #18 and Resident #39) reviewed for resident rights. Findings include: A review of the facility's policy titled, Safe, Clean, Comfortable, Homelike Environment F584, revised 11/2017, revealed, Policy Statement: Residents have the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely Policy Interpretation and Implementation: 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 1. A review of Resident (R) #18's admission Record indicated the facility admitted R#18 with diagnoses including cerebral palsy, Lennox-Gastaut syndrome, and unspecified intellectual disability. A review of R#18's annual Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score was not assessed due to R#18 being rarely/never understood. The MDS indicated R#18 had a wheelchair. A review of R#18's care plan, revised 11/29/2021, indicated R#18 was dependent on staff for activities, cognitive stimulation, and social interaction related to cognitive deficits, disease process, immobility, and physical limitations. R#18's care plan, revised 05/15/2020, indicated R#18 has a safe positioning belt on their wheelchair for positioning related to the resident having very jerky body movements. A review of R#18's Order Summary Report, revealed orders for Activity Level as tolerated and May leave community with family or on staff-supervised activity. Both orders were dated 11/10/2017. Observation on 03/21/2022 at 10:15 AM in R#18's room revealed R#18 in a low bed with a large pad on the side of the bed on the floor and another on the side between the wall and the bed. R#18 was observed making a moaning sound and rocking in the bed. Continued observation revealed there was not a wheelchair (w/c) in the room. Several wheelchairs were observed in the dining room area across from R#18's room. An interview on 03/21/2022 at 10:19 AM with Certified Nursing Assistant (CNA) YY revealed CNA YY was not aware if R#18 had a wheelchair. CNA YY stated that the staff used the shower table to take the resident to the shower and did not think R#18 got up in a wheelchair during the day. An interview on 03/21/2022 at 6:35 PM with the Family of R#18 revealed R#18 did not have a wheelchair and was very upset about it. Family of R#18 stated there had been problems with the wheelchair for three years and three months ago they were told the wheelchair was not fixable and R#18 had not had one since. Family of R#18 stated R#18 was always in bed when they visited because the resident did not have a wheelchair. The facility wanted to use a facility geriatric chair, but the family did not feel that was safe. R#18 thrashed while in a geriatric chair and it did not prevent the resident from falling off. An interview on 03/22/2022 at 9:55 AM with Rehab Director (RD)/OT VV revealed they had assessed R#18 for a wheelchair the previous day (03/21/2022). A wheelchair was also ordered the previous day and was expected to be there in a week or two. RD/OT VV stated that the former chair was broken and the RD/OT was uncertain about the amount of time R#18 was without a wheelchair. An interview on 03/24/2022 at 9:04 AM with CNA UU revealed R#18 did not have a wheelchair. CNA UU stated in the month working at the facility they had only seen R#18 get out of bed to take a shower. CNA UU stated the mechanical lift was used to get R#18 on the shower table. An interview on 03/24/2022 at 2:20 PM with CNA WW revealed the CNA had worked at the facility for three years. CNA WW stated R#18 used to be on the other side of the building. R#18 used to get up every day because the wheelchair supported the resident. CNA WW stated that when R#18 moved to the current side of the building, the wheelchair had not been available for at last five months and R#18 was no longer getting up. An interview on 03/25/2022 at 12:26 PM with Administrator AA revealed when they started the position in October they were told about R#18 not having a wheelchair. Administrator AA stated it was thought that the staff were using a geriatric chair to get the resident up. Administrator AA stated the Nurse Manager and the Occupational Therapist were working on getting a wheelchair. 2. A review of Resident (R) #39's admission Record indicated the facility admitted R#39 with diagnoses including dementia, schizophrenia, and paranoid personality disorder. A review of R#39's annual Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score was not assessed due to R#39 being rarely/never understood. R#39 required extensive assistance of one staff for toileting. R #39 was always incontinent of bowel and bladder. A review of R#39's care plan, revised 09/25/2020, indicated there was not a care plan for R#39's incontinence status or a toileting program. Observation on 03/21/2022 at 10:04 AM of R#39's room revealed there was a nightstand with a television on it placed directly in front of the bathroom door. An interview on 03/21/2022 at 10:06 AM with CNA YY revealed the nightstand was in front of the bathroom door so R#39 did not go into the bathroom without help. Observations of R#39's room on 03/22/2022 at 3:47 PM and 03/23/2022 at 9:10 AM revealed the nightstand remained in front of the bathroom door. An interview on 03/24/2022 at 9:00 AM with LPN/Unit Manager (UM) EE revealed LPN/UM EE knew about the bathroom door being blocked. LPN/UM EE stated R#39 did not get up alone anymore but did at one time, and the door blocked was a protective measure to keep R#39 from falling. When asked about a toileting program, LVN/UM EE stated the facility did not do toileting programs. When asked if the blocked doorway was included in the care plan, LVN/UM EE stated they did not think so and that they would move the nightstand until it was included in the care plan. An interview on 03/24/2022 at 9:04 AM with CNA UU revealed R#39 had not asked for assistance to go to the bathroom while CNA UU had been working at the facility the last month. An interview on 03/24/2022 at 9:23 AM with CNA CC revealed the CNA had worked at the facility about nine days. CNA CC stated R #39 had asked for assistance going to the bathroom, and CNA CC assisted by moving the nightstand and helping the resident onto the toilet. An interview on 03/24/2022 at 10:57 AM with DON BB, who had worked at the facility that month, revealed they were not aware that a nightstand was placed in front of the bathroom in R#29's room. DON BB stated that would not be appropriate. An interview on 03/25/2022 at 12:26 PM with Administrator AA revealed Administrator AA did rounds in the morning to look at her patients. She made rounds at lunch time and in the evenings as well. No furniture should be in front of a bathroom door, and they did not know it was there.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record reviews, and review of a facility policy, the facility failed to provide showers as planned and desired for one of two residents (Resident [R]#9) who was reviewed for choices for showers. Findings included: A review of the facility's policy titled, Shower/Tub Bath, dated 05/2021, indicated the purpose of the policy was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Under Documentation, the policy indicated the information to be recorded included the date and time the shower/tub bath was performed. The policy instructed staff to notify the supervisor if the resident refuses the shower/tub bath. The facility admitted R#9 on 12/21/2021 with diagnoses that included end stage renal disease, diabetes, protein calorie malnutrition, pressure ulcer and depression. A review of the admission Minimum Data Set (MDS) dated [DATE] , indicated the Brief Interview for Mental Status score was 12 out of 15 which indicated R#9 had moderate cognitive impairment. Rejection of care was identified for one to three days during the assessment period. The MDS indicated R#9 required extensive care for activities of daily living (ADLs). A review of the Care Plan for R#9 reviewed 01/11/2022, indicated the resident had skin impairment. Interventions to assist in healing the resident's skin included keeping the resident's skin clean and dry. The review of the resident's Care Plan did not reveal R#9 had been care planned for rejection of showers or baths. On 03/22/2022 at 8:24 AM, R#9 was interviewed. The resident stated they had only received two showers since the December 2021 admission. The resident added they were not very happy about that. The resident stated bed baths had been consistently received. Unit Manager (UM) EE was interviewed on 03/23/2022 at 4:00 PM. The UM described R#9 as alert and oriented to person, place and time and was reliable in what the resident said. The UM added showers were given on the morning and evening shift. UM EE stated she expected the certified nursing assistant (CNA) to tell the nurse when a resident refused showers and if the resident continued to refuse after the nurse intervened then the nurse was expected to document the refusal in the progress notes. Certified Nursing Assistant (CNA) CC was interviewed on 3/24/22 at 11:20 AM. The CNA stated she was an agency CNA. On arrival to the facility, the CNA stated the nurse gave her report when the assignment was made. She stated the nurse told her who had appointments, what type of transfer the residents required and who had to be assisted with eating. The CNA also stated there was a book with resident information. The CNA looked at the book for another resident's information and did not find any information about the specific resident including when the shower was due. On 03/24/2022 at 11:47 AM, UM EE was interviewed a second time and stated R#9 was scheduled for showers on Monday, Wednesday, and Friday during the 3:00 PM to 11:00 PM shift. The UM reviewed the shower book for the month of March 2022 and stated she had not found shower sheets that showed R#9 had received a shower as scheduled. CNA DD was interviewed on 03/25/2022 at 11:28 AM. CNA DD stated he looked at the shower book to find out which residents received a shower. The CNA stated he was unsure what days R#9 was scheduled for a shower but added he had not showered the resident. He stated the resident probably refused most of the time. He stated if a resident refused, he had to notify the nurse. CNA DD stated he did not think R#9 was scheduled for a shower on the evening shift. He acknowledged he had worked with R#9 on both the previous Monday and Wednesday evening shift and did not think he had asked the resident about showering on Monday night. He was sure he had not asked the resident on Wednesday night. The CNA stated he did not ask the resident because he was unaware R#9 was scheduled for a shower on Wednesday night. Licensed Practical Nurse (LPN) GG was interviewed on 03/25/2022 at 12:42 PM. LPN GG stated R#9 was alert, oriented and dependable in the information given. The LPN stated the CNAs gave showers as assigned by the nurses. She added when showers were given, the shower was recorded on a shower sheet. If the resident refused the shower the nurse had to then ask the resident and if refusal continued the physician and resident representative were notified. The nurse was expected to record the resident's refusal in the nurse's notes. The LPN stated the only time she was aware R#9 had refused a shower was on return from the hospital when the resident had not felt well. The Administrator was interviewed on 03/25/2022 at 1:45 PM. The Administrator stated she expected residents to receive showers as scheduled. The Director of Nursing (DON) was interviewed on 03/25/2022 at 4:02 PM. The DON stated the CNAs had a shower schedule to follow. She added when a resident received a shower the CNA completed a shower sheet that documented the resident's skin condition. The DON stated residents should be showered as scheduled unless the resident refused. If the resident refused the shower, the CNA should tell the nurse and then the nurse should approach the resident. The DON added if the resident continued to refuse the shower the nurse was expected to document the refusal, notify the physician and the responsible party and the refusal should be care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, record review, and facility policy review, the facility failed to notify a resident representative of missed dialysis appointments, change in condition and transfer to the hospital for one of two residents (Resident (R) #22) that received hemodialysis services. Findings include: The facility policy titled, Change in a Resident's Condition or Status F580, with an effective date of 05/2021 indicated, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and consistent with the delegation, the resident's representative when there has been: b. a significant change in the resident's physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications, d. A need to transfer the resident to a hospital/treatment center. A review of the Face Sheet indicated the facility readmitted R#22 on 05/03/2021. Admitting diagnoses included but was not limited to end stage renal disease requiring hemodialysis. A review of the current Physician's Orders for March 2022 indicated R#22 attended dialysis on Tuesday, Thursday, and Saturday. The review of the quarterly Minimum Data Set (MDS) dated [DATE], indicated R#22 scored six out of 15 on the Brief Interview for Mental Status which indicated R#22 had severe cognitive impairment. The MDS identified end stage renal disease as an active diagnosis. A review of the Progress Notes dated 08/21/2021 at 11:35 AM , indicated R#22 had refused dialysis three times. There was no indication the resident's representative, or the dialysis center had been notified. A review of Progress Notes dated 09/23/2021 at 7:17 AM , indicated R#22 refused to go to dialysis. There was no indication the resident's representative was notified. The Progress Notes indicated at the end of the shift for 09/23/2021, the nurse indicated R#22's left arm was swollen. There was no evidence that indicated the resident's representative was made aware of the change in the resident's condition. Progress Notes dated 09/24/2021 indicated R#22 was discharged to the hospital. There was no evidence that indicated the resident's representative was notified about the resident's transfer to the hospital. A review of the Social Worker's (SW) MM Progress Note dated 10/05/2021, indicated the resident had refused medications the previous day. SW MM documented R#22 often refused dialysis. There was no indication the resident's representative had been made aware of the resident's refusal to go to dialysis or that R#22 refused medications. A review of Progress Notes dated 10/05/2021, revealed Unit Manager (UM) FF indicated R#22 refused medications and refused to allow staff to change their clothing. There was no indication the resident representative had been made aware of this. A review of notes for 10/07/2021 at 8:20 AM indicated R#22 left the facility for an appointment. There was no evidence indicating the resident's representative was made aware of the appointment. Unit Manager (UM) EE was interviewed on 03/24/2022 at 11:47 AM. She stated when a resident refused treatments or medications the nurse reported the refusal to the resident representative and was expected to record the refusals. Licensed Practical Nurse (LPN) GG was interviewed on 03/25/2022 at 12:42 PM. She stated if a resident refused treatments the resident representative was notified and was recorded in the Progress Notes. The MDS Coordinator was interviewed on 03/25/2022 at 8:42 AM. The MDS Coordinator stated she had no knowledge that R#22 refused dialysis. The Administrator was interviewed on 03/25/2022 at 1:45 PM. The Administrator stated she was unaware R#22 refused dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure a discharge summary was completed for one (Resident [R] #80) of one resident reviewed for discharge requirements. This had the potential to affect 11 residents with planned discharges from the facility. Findings include: A review of the facility's policy titled, Discharge Summary and Plan F660, F661, revised 11/2017, indicated, Policy Statement: When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her living environment. 7. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident. Review of the admission Record, dated 01/22/2022, revealed R#80 had diagnoses which included type two diabetes mellitus, osteoporosis, malignant neoplasm of upper respiratory tract, and history of falling. A review of the discharge (return not anticipated) Minimum Data Set (MDS) dated [DATE] revealed R#80 had modified independence in cognitive skills for daily decision-making per a staff assessment for mental status. The resident required extensive assistance with bed mobility, bathing, and toilet use, and supervision with eating. The MDS indicated R#80 was discharged on 01/17/2022 to another nursing home or swing bed. A review of the care plan, initiated on 11/03/2016 and revised on 02/06/2017, revealed R#80 was a readmission to the facility and had plans to return home. The approaches included encouraging the resident and family to be involved with planning care and discharge planning, ensuring all documents were completed and orders/prescriptions were available at the time of discharge. Review of Progress Notes dated 01/18/2022 at 11:46 AM and signed by the former Social Services Director (SSD), revealed the resident was discharged on 01/17/2022 to another skilled nursing facility. A review of R#80's medical record revealed no documentation that a discharge summary was completed. In an interview on 03/24/2022 at 12:28 PM, the Director of Nursing (DON) revealed she was not employed when the resident was discharged , but the medical record indicated the resident transferred to a facility where the previous Administrator was now working. The DON revealed it was her expectation that each departmental supervisor completed their individual section of the discharge summary and that social services provided the summary upon discharge. In an interview on 03/24/2022 at 2:19 PM, the SSD indicated she had just started employment at the facility at the beginning of March 2022 but could not find a discharge summary in the resident's medical record. The SSD indicated her expectations were that every department should input into the discharge summary, and she would oversee that the discharge summary was completed and sent when the resident was discharged . In an interview on 03/25/2022 at 1:38 PM, the Administrator indicated she did not know the discharge summary was not completed but was responsible for monitoring all departmental managers. The Administrator stated it was her expectation that all department heads had a meeting to discuss their part of the discharge summary and that social services and medical records were responsible for ensuring the discharge summary was completed. The Administrator stated the former SSD was no longer employed with the facility, and the medical records staff member was new to the position. The Administrator indicated no audits had been completed to ensure discharge summaries were provided since she began employment six months ago. In an interview on 03/25/2022 at 3:19 PM, Medical Records (MR) employee LL revealed she just started in the position at the end of December 2021. MR LL revealed she was not aware of the discharge summary requirements but found out on 03/25/2022 that she was responsible for ensuring the discharge summaries were completed and sent upon discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to consistently provide nail care and oral care for one of three dependent residents (Resident [R] #22) observed for activities of living. Findings include: The facility's policy titled, Mouth Care with an effective date of 05/2021, indicated the purpose of the policy was to keep the resident's lips and oral tissue moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth. A facility policy for nail care was not provided. A review of R#22's quarterly Minimum Data Set (MDS) dated [DATE] indicated R#22 was readmitted to the facility on [DATE] and had diagnoses which included non-Alzheimer's dementia, end stage renal disease, diabetes, malnutrition, and seizure disorder. The MDS indicated the resident scored 6 on the brief interview for mental status, indicating severe cognitive impairment. The resident was identified on the MDS as totally dependent on staff for personal hygiene and bathing. The resident was not identified as rejecting care. A review of R#22's care plan for activities of daily living self-care performance deficit related to weakness and non-ambulatory status, with a revision date of 03/21/2020, indicated the resident required assistance with activities of daily living. The goal was the resident's abilities would improve with continued therapy. Interventions included praising all efforts at self-care and staff to assist with oral care as needed. Daily bathing and nail care were not addressed on the care plan. An observation was made of the resident on 03/22/2022 at 9:04 AM. R#22 stated they had bowel movement on their hands and fingers due to scratching and requested help with cleaning up. Help was obtained for the resident. On 03/23/2022 at 8:22 AM, R#22 was observed lying in bed and stated they had not received a bath. The resident's fingernails had a black substance around the cuticles and underneath the nails. The resident's teeth had an egg-colored substance on them with specks of yellow on the lips. On 03/23/2022 at 8:45 AM, an observation was made of Certified Nursing Assistant (CNA) KK and CNA LL assisting R#22 with a bed bath. CNA KK wiped the resident's face and hands with a wet cloth. R#22 stated someone would be providing nail care. After conclusion of the bath, CNA KK and CNA LL started gathering the supplies to leave the resident's room without offering to remove the black matter from under the resident's nails or around the cuticles. Yellow food particles remained on the resident's lips and on the resident's teeth. When asked when R#22 received oral care, CNA LL replied, now. Nail care was still not provided. Unit Manager (UM) EE was interviewed on 03/23/2022 at 4:15 PM. The UM at this time observed and confirmed R #22's nails were long and had black matter under them. She stated she remembered the resident had bowel movement on their hands the previous day. The UM EE stated she would ask a CNA to clean the resident's fingernails at this time. An observation was made of the resident on 03/24/2022 at 9:00 AM. R#22 was lying in bed and stated they were waiting for someone to come bathe them since it was Thursday and they had to go to dialysis today. R#22's nails remained long with black matter under all of them. The resident stated no one came to the room yesterday to trim and clean their fingernails. On 03/24/2022 at 9:02 AM, UM EE was interviewed again. The UM remembered asking a staff member to clean the resident's nails the previous day. At this time, the UM observed R#22's nails and agreed the staff member had not cleaned the resident's nails as instructed and stated she was disappointed. The Director of Nursing (DON) was interviewed on 03/24/2022 at 1:35 PM. The DON stated oral care should be offered at least twice daily in the morning and at night and as the resident required. The DON stated she was disappointed in the lack of care for R#22 and that apparently, educational opportunities were needed.

Based on observations, interviews, and record review, the facility failed to document accurate intake of meals and percentage of nutritional supplement consumed for one of two residents (Resident #37) reviewed for nutrition. Findings include: The facility admitted R#37 on 08/31/2012 with diagnoses that included cognitive communication deficit, need for assistance with personal care, generalized muscle weakness, dysphagia, cataracts, diabetes, depression, and stroke affecting the dominant side. A review of the Order Summary Report indicated R#37 had a physician's order dated 04/03/2018 for a carbohydrate-controlled diet with no added salt. The consistency was mechanical soft with ground meat texture. A review of the Weights and Vitals Summary indicated on 12/10/2021, R#37's weight was recorded on the weight record as 107.7 pounds. A review of an RD Note dated 12/16/2021 documented staff reported the resident's average food intake as 58% to 83%. The RD indicated R#37 had sustained significant weight loss and recommended the resident start Med Pass (a liquid high calorie supplement) 120 milliliters (ml) four times a day for a total of 960 additional calories per day. Review of the Order Summary Report indicated Med Pass 2.0 was ordered for the resident on 02/01/2022. A review of an IDT [Interdisciplinary Team] Patient at Risk [PAR] form dated 02/03/2022 indicated a PAR meeting had been held, and R#37's weight was recorded as 107.7 pounds. The average meal intake for 7 days indicated 76 to 100%. Current dietary interventions included Medpass 2.0 and an appetite stimulant. The date assessed by RD indicated 12/16/2021. The current interventions effective item was marked, Yes, and no new interventions were checked. The form indicated the current goal of care was weight gain. A review of the care plan for R#37 with a revision date of 02/03/2022 indicated R#37 was a risk of further weight loss due to physical condition and eating deficit. An update on 02/11/2022 indicated the resident received a carbohydrate-controlled diet with no added salt and mechanical soft / ground meat texture. The care plan indicated supplements (Med Pass) had been added on 02/01/2022. Interventions included serving the resident's diet and supplements as ordered, monitoring intake and recording the amount consumed, and reporting significant weight loss to the physician. An intervention for staff supervision at meals had been added on 11/06/2021. A review of the Weights and Vitals Summary indicated R#37 weighed 90.5 pounds on 02/08/2022. A review of the Dietary Manager (DM) Quarterly/Annual Review dated 02/11/2022 revealed R#37's weight was 90.5 pounds. The DM documented R#37 had sustained significant weight loss. The review indicated R#37 consumed 75% to 100% of meals. The dietary manager did not document the resident received supplements. A review of the 02/11/2022 Nutrition Evaluation completed by the assistant dietary manager indicated a weight of 90.5 pounds for R#37. The evaluation also documented R#37 had experienced a weight loss of 5% or more in the past month and 10% or more in the past 6 months. The evaluation also documented R#37's intake was good, and the resident had consumed 75% to 100% of his meals. The evaluation indicated the resident currently had supplements ordered but had not listed what type of supplement or the amount of supplement offered. A review of an RD Note dated 02/25/2022 indicated R#37's current weight was 102.4 pounds. The RD documented Med Pass supplements, 120 ml four times a day had been added on 02/01/2022. The RD indicated the average intake of food for R#37 was reportedly 60% to 85%. The RD documented he would ask for weekly weights to monitor R#37 more closely since the supplement was new and the resident's weights were a bit erratic. A review of the Weights and Vitals Summary indicated R#37's weight on 03/03/2022 was 98.9 pounds. A review of an RD Note dated 03/17/2022 indicated R#37 weighted 98.9 pounds. The RD documented R#37's meal intake was generally very good and added that the resident took a diuretic which may account for some of the resident's weight loss. The RD documented the resident received Med Pass supplements, but did not accept them very often. The RD indicated he would continue the resident on weekly weights and follow up as needed. Review of the February and March 2022 Medication Administration Records (MARs) included the order for Med Pass 2.0 four times daily. The supplement was initialed as provided to the resident as ordered; however there was no documentation as to the percentage of the supplement consumed. The MARs did not indicate any of the offered supplements were refused by R#37. An observation was made of R#37 in the dining room on 03/23/2022 at 12:29 PM. R#37's meal tray contained mixed vegetables, spaghetti, and bread. R#37 also had thickened tea, thickened lemon-flavored water, and an orange sherbet. The tray card indicated the resident was to receive a fruit cup as well. The diet order was carb controlled, mechanical soft with ground meat and thickened liquids. Staff assisted the resident in setting up the meal tray, but did not offer to cut up the spaghetti noodles or remove the tin-foil top from the lemon-flavored water. When finished eating, R#37 had consumed less than 25% of the meal. The Unit Manger (UM) EE was interviewed on 03/23/2022 at 3:51 PM. The UM stated supervision and assistance meant cueing the resident, setting up the meal, or physically assisting a resident if needed. She stated she expected all fluids to be opened and expected staff to assist residents who were observed eating with their fingers by either cueing the resident to use utensils or physically feeding the resident. UM EE stated R#37 required minimal assistance with feeding and would physically pull away if staff attempted to help. The UM stated even with R#37's contracted hand, the resident was able to pull the tin foil lid off the water container. UM EE confirmed R#37 was unable to cut up food independently. When the UM was informed she was one of the staff members who had walked by R#37 during the meal observation and had not assisted the resident with cutting the food or opening the container, UM EE stated she had been distracted trying to get assistance for another resident. The UM checked the computer and stated staff had documented R#37 consumed 76%-100% of the meal observed by the surveyor. A request was made to speak to the staff member who had recorded R#37's meal consumption; however, the name of the staff member was not identified. Licensed Practical Nurse (LPN) JJ was interviewed on 03/24/2022 at 8:57 AM. LPN JJ stated R#37 received a liquid supplement four times a day. LPN JJ added that R#37 usually drank 100% of the supplement. The Director of Nursing (DON) was interviewed on 03/24/2022 at 1:19 PM. The DON stated the CNA who documented the wrong intake for the resident needed to be retrained. She agreed the MAR needed to include the percentage of the supplement consumed and added without the percentage of the supplement consumed there would be no way to determine if the supplement was an effective intervention to stop the resident's weight loss. On 03/25/2022 at 10:52 AM, the RD was interviewed by telephone. The RD stated the information on the resident's chart was used for determining what interventions would be used to stop weight loss. The RD stated he was told R#37 rarely drank the supplement but without documentation it would be impossible to determine the effectiveness of the supplement. The RD stated most of R#37's weight was lost in a short amount of time and added the liquid supplement was the only intervention he had recommended to stop the resident's weight loss. UM EE was interviewed on 03/25/2022 at 12:09 PM. She reported she had been wrong about the meal documentation for R#37 and instead of documenting 76% to 100% intake, staff had not documented lunch intake for R#37 for three days. The UM stated without the lunch intake documentation there was no way to know what R#37 consumed. The UM stated the expectation was for nurses to document the percentage of supplement consumed on the MAR. She stated without the amount of supplement consumed, the effectiveness of the supplement could not be evaluated. The UM reviewed the MAR for R#37 and confirmed the percentage of supplement had not been recorded. UM EE stated when the RD gave dietary recommendations, the nurse on the hall was responsible to verify the recommendation with the physician and then the UM entered the order on the MAR. She stated she became UM in February and the UM that worked in December (when the Med Pass supplement was recommended by the RD) no longer worked at the facility. LPN GG was interviewed on 03/25/2022 at 12:31 PM. The LPN stated R#37 was able to eat independently after all foods had been cut up. The LPN stated accurate documentation of intake was especially important for those residents losing weight. She added nurses were expected to document the percentage of supplement consumed by a resident on the MAR adding without this documentation it was impossible to know how much the resident was drinking or if the supplement was effective. The LPN stated it was the responsibility of the CNA to document meal intake after each meal and the responsibility of the nurse to follow up for completeness.

Based on interviews and record review, the facility failed to maintain a Registered Nurse (RN) on duty for eight consecutive hours per day, seven days per week. This had the potential to affect all 80 residents. Findings include: A review of the Facility Two Week Staffing Grid dated 03/01/2022 through 03/14/2022 revealed the facility had an RN in the building eight hours per day on four of the 14 days reviewed. An RN was present in the building for eight hours on 03/05/2022, 03/06/2022, 03/12/2022, and 03/13/2022. During an interview with the Medical Records Director (MRD) LL on 03/23/2022 at 3:30 PM, MRD LL stated she was responsible for staffing for the facility. MRD LL reviewed the staffing sheets and confirmed there had been RN coverage for four shifts out of 14 days. She stated there had been no problems with RN staffing until the Assistant Director of Nursing (ADON) quit at the end of February 2022. MRD LL stated both the Director of Nursing (DON) and the Administrator were aware of the lack of RN coverage, since they both received a copy of the staffing from her twice a week. MRD LL stated she thought the DON counted toward RN coverage but was recently told by corporate that this was not accurate. MRD LL stated the Administrator had also confirmed that the DON did not count toward RN coverage. MRD LL stated the facility had hired an RN, but she was unsure when the RN would start . The Administrator was interviewed on 03/25/2022 at 1:45 PM. When asked about the facility's RN staffing, the Administrator indicated she had an RN in the building daily because the DON was there daily. She stated she found out on Monday, 03/21/2022, from the Regional [NAME] President, that a DON was not counted toward the daily RN coverage. The Administrator added that steps had been put in place to use agency RNs to make sure the facility had daily RN coverage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of policy and procedures, the facility failed to ensure social services, including referrals to other facilities closer to a resident's family, were provided for one of three residents (Resident [R] #19) whose responsible party (RP) had requested a transfer. Findings include: A review of the facility's policy titled, Discharge Summary and Plan F660, F661, revised 11/2017, revealed, Policy Statement: When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Policy Interpretation and Implementation. 4. For residents whom [sic] are going to be transferred to another SNF [skilled nursing facility] or whom are discharged to a HHA [home health agency], IRF [inpatient rehabilitation facility] or LTCH [long term care health facility], assist the resident or representative in selecting such locations by utilizing data such as standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. Document such in the record. A review of R #19's admission Record indicated R#19 had been admitted to the facility with a diagnosis which included vascular dementia. A review of R#19's annual Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score was not assessed due to R#19 being rarely/never understood. Section Q noted the question, Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? The response was noted to be, Yes. The last question in Section Q was titled, Referral, and asked, Has a referral been made to the Local Contact Agency? The answer was entered as, No-referral is or may be needed. A review of R#19's care plan, revised 12/12/2021, indicated no mention of discharge planning or desires. An interview on 03/22/2022 at 12:56 PM with R#19's RP revealed that a request had been made in December 2021 that R#19 be moved to a facility closer to the RP. R#19's RP stated they had not heard from the facility regarding a single facility they could transfer to and they did not know if the facility had tried to make a referral for transfer. A review of R#19's Social Services Notes, written by the social worker (SW) from 12/30/2020 through 03/24/2022 revealed there were no notes written after 02/13/2021. On 08/17/2021, the SW noted that R#19's RP had requested a referral to another facility. On 02/13/2021, the SW note included, Resident will remain full code, placement is long term with possible transition to a closer family [facility]. An interview on 03/22/2022 at 8:57 AM with the Social Services Director (SSD) MM revealed the SSD had worked at the facility for two weeks. The SSD reported having talked to R#19's RP one time during the two weeks, and it was not mentioned that the RP wanted R#19 transferred to another facility. On 03/23/2022, the SSD reported being unable to locate any referrals to other facilities. An interview on 03/25/2022 at 12:26 PM with the Administrator revealed she was in operations only; any discharge request would go to the SW. The Administrator was not aware that R#19's RP wanted the resident discharged to a facility closer to the RP; it had not been mentioned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure there was a clean, comfortable environment, as evidenced by dirty and stained walls, floors, privacy curtains and air conditioning vents and missing or broken floor tiles in resident rooms/bathrooms and common areas. These environmental concerns were observed in the corridors on two of two wings, in eight resident rooms, and in one day room. Findings include: A review of the policy titled, Cleaning and Disinfection of Environmental Surfaces F880, effective 05/2021, revealed, 9. Housekeeping surfaces (e.g. [for example], floors, tabletops) will be cleaned on a regular basis and when surfaces are visibly soiled. 10. Environmental surfaces will be disinfected on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 11. Walls, blinds and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. During an initial tour of the facility, on 03/21/2022 beginning at 9:30 AM, the following was observed. Follow-up observations were made on 03/23/2022 at 10:06 AM, 10:07 AM, 10:15 AM, 10:19 AM, 10:24 AM, 10:27 AM, and 12:05 PM, and on 03/24/20222 at 9:14 AM, 9:19 AM, 9:22 AM, 9:24 AM, and 9:27 AM, and the environmental conditions remained the same. On the Right Wing, the baseboards had brown debris and dirt on them. In room [ROOM NUMBER], beside Bed B, there were two 8 by (x) 8-inch tiles broken and not adhered to the floor. The wall beside Bed A was dirty and had a dried, brown stain in a splatter formation. In room [ROOM NUMBER], there was one 8 x 8-inch floor tile missing at the entrance to the bathroom, and additional floor tiles broken and missing inside the bathroom. In room [ROOM NUMBER]A, there was a brown, sticky substance on the floor, on the tube feeding pole, on the resident's bedside table, and on the privacy curtain. In room [ROOM NUMBER], paint was peeling from the wall above the door frame. On the Left Wing, the baseboards had brown debris and dirt on them. In room [ROOM NUMBER], there were 12 x 8-inch linoleum flooring tiles missing under the end of the bed frame for Bed A and under Bed B. In room [ROOM NUMBER], the vent running the length of the air conditioner was covered in dried food debris and trash. In room [ROOM NUMBER], the floor was dirty and sticky. In the day room on the Right Wing, the floor was sticky and dirty with a dried orange substance, black, sticky debris, and scattered food crumbs. In room [ROOM NUMBER], the floor was sticky and dirty with scattered debris and bits of paper. In room [ROOM NUMBER], there was a thick layer of dirt on the floor across the doorway to the room and in the corner behind the door. The surveyor used a wet paper towel to wipe the floor, and the dirt was easily removeable. A review of the Daily Housekeeping forms for March 2022, revealed the following: The Daily Room Cleaning sections of the forms for the Right Wing (A Hall), which included Resident Rooms 125-148, were incomplete for each day and did not include staff's initials or times completed, except on 03/02/2022, 03/23/2022, and 03/24/2022. The Daily Room Cleaning sections of the forms for the Left Wing (B Hall), which included Resident Rooms 101-122, were incomplete for each day and did not include staff's initials or times completed, except on 03/24/2022. The Daily Room Cleaning sections of the forms for C Hall, which included Resident rooms [ROOM NUMBERS] on the Right Wing and rooms [ROOM NUMBERS] on the Left Wing, were not completed for each day. In an interview on 03/24/2022 at 10:31 AM, Licensed Practical Nurse (LPN) GG indicated the housekeeping staff were responsible for keeping the building clean and providing daily room cleaning. LPN GG indicated if she had a maintenance concern, she put in a work order for the maintenance department. If she had a housekeeping concern, she notified the Housekeeping Manager (HM). In an interview on 03/24/2022 at 12:50 PM, the Director of Nursing (DON) revealed her expectations of the housekeeping staff included following the cleaning schedule and providing daily sweeping, mopping, wiping of environmental surfaces, cleaning walls and stains, and cleaning bathrooms. The DON indicated the Housekeeping Manager (HM) should be making daily rounds to identify cleaning concerns. The DON indicated the housekeeping staff were new, and deep cleaning started on the Right Wing first. The DON indicated if other staff observed unclean areas in the facility, they should notify housekeeping. The DON acknowledged the building was not clean and needed improvements. The DON indicated the potential negative outcomes for residents in an unclean environment included allergies, bacterial growth, and depressed mood. In an interview on 03/24/2022 at 1:30 PM, the Housekeeping Manager (HM) revealed he had worked at the facility for 24 days and had started the cleaning on the right side of the facility. rooms [ROOM NUMBERS] were on the left side. The HM stated they did have housekeepers but just hired someone to help with the floors. When asked about the dirt that was removable with a wet paper towel in room [ROOM NUMBER], the HM stated it should not have been there and should have been cleaned by the housekeepers. The HM stated the facility mops were not effective and they had ordered the right kind. In an interview on 03/24/2022 at 4:11 PM, the HM made rounds of the building with the surveyor and indicated the cleanliness of the building did not meet his expectations. He revealed it was the housekeeping department's responsibility to clean the inside of the building, including resident rooms, offices, floors, bathrooms, walls, and resident equipment. The HM stated the housekeeping staff should be following a daily cleaning schedule and initialing the housekeeping forms with the date and time of cleaning but were not doing so. He acknowledged the daily cleaning schedules for housekeepers were mostly incomplete except for a few days, and it was his job to monitor the daily cleaning sheets. The HM indicated it was his responsibility to make daily rounds, but he was not able to make rounds as often as he liked and was not aware of the unclean areas in the building that were identified on rounds with the surveyor. He indicated he only had two housekeepers for a whole building when he started but he now had four housekeepers. He indicated the missing tiles and peeling paint were a maintenance issue, and he was unaware of those issues. The HM indicated he had been pulled to laundry approximately four times since he had started, and sometimes he was not able to fulfill his other duties. In an interview on 03/25/2022 at 8:53 AM, Resident #60 indicated housekeeping did not perform daily cleaning, and the housekeeping staff did not sweep, mop, or wipe spills and stains from surfaces. Resident #60 indicated housekeeping staff only emptied the trash bags daily. Resident #60 indicated they saw housekeeping staff in the facility, but they were not doing their job. In an interview on 03/25/2022 at 8:59 AM, Resident #30 indicated daily housekeeping was not provided and their room was dirty. Resident #30 indicated housekeeping cleaned the room maybe a couple of times a week. In an interview on 03/25/2022 at 9:06 AM, Unit Manager (UM) FF revealed she worked on the Right Wing and that daily cleaning in every room was not completed because the facility lacked housekeeping staff. UM FF indicated she told the housekeepers on the floor and the HM when cleaning was not completed. UM FF indicated she sometimes cleaned a room if she found the cleaning was not completed. In an interview on 03/25/2022 at 9:48 AM, Certified Nursing Assistant (CNA) QQ indicated daily housekeeping was not performed, and no one monitored to ensure the daily cleanings were completed. CNA QQ indicated she had worked at the facility for about a year and a half, and the housekeeping department had numerous staff changes over the last several months. CNA QQ indicated she sometimes had to clean the resident rooms because it was not done by housekeeping. CNA QQ indicated she had recently told the HM about the resident rooms not being cleaned. In an interview on 03/25/2022 at 10:22 AM, the District Manager (DM) for the facility's housekeeping service indicated he expected the HM and housekeepers to follow the 5-step cleaning process, to include emptying trash, sweeping and mopping the floor, cleaning/mopping the restrooms and restocking toiletries, cleaning blinds, sinks, and dusting blinds, and would expect housekeeping to remove any visible debris. The DM expected deep cleaning of designated rooms to follow the 5-step cleaning process, and staff should pull all furniture away from the wall and clean the bed/mattress and bed rails. The DM indicated housekeeping should be checking privacy curtains for holes/stains and should wash or replace them as needed. The DM indicated dirty floors, walls, and baseboards should be cleaned daily. He stated the HM should make rounds to inspect the building to ensure the housekeeping staff and floor technicians (techs) were cleaning daily. DM RR indicated the HM started the position on 03/05/2022 and started working on the Right Wing, but four or five rooms still needed deep cleaning, and deep cleaning on the Left Wing had not yet started. The DM indicated the cleanliness did not meet his expectations but was improved since the HM had started. He indicated staff should be initialing the daily housekeeping sheets but did not know if that was being done. During an interview on 03/25/2022 at 1:49 PM, the Administrator made rounds in the building with the surveyor. The Administrator agreed the cleanliness of the building did not meet her expectations. The Administrator indicated the HM started deep cleaning the Right Wing first when he started in early March and had not been able to deep clean the Left Wing of the building yet. The Administrator indicated she had not been making rounds to observe the physical environment since the HM started in early March. The Administrator indicated the facility had not had enough housekeeping staff until now to clean and sanitize the building. The Administrator indicated that housekeeping should be performing daily cleaning of all rooms and surfaces, and the staff were not completing daily cleaning, based on the observations with the surveyor. The Administrator indicated she was not aware of the broken tiles in room [ROOM NUMBER] but was aware of the peeling paint and missing linoleum tiles in room [ROOM NUMBER] and had contacted a company to repair the areas. The Administrator indicated she just found out that the daily housekeeping sheets were not completed, but it was the HM's responsibility to ensure that daily cleaning was done and documented. In an interview on 03/25/2022 at 3:48 PM, the Assistant Maintenance Director (AMD) revealed he was aware of broken and missing tiles caused by water that got into the building. The AMD indicated he was waiting to ensure the floor was completely dry to glue the tiles back down. He indicated he was aware of the missing linoleum tiles in room [ROOM NUMBER], and this was a project the facility was working on to get the linoleum replaced. The AMD indicated he was not responsible for the cleaning the facility but felt the cleaning had improved since the current HM was hired. He indicated the cleaning did still need improvement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to develop and implement comprehensive care plans for four (Residents #9, #22, #72, and #78) of 19 sampled residents whose care plans were reviewed. Findings include: A review of the facility's policy titled, Care Plans - Comprehensive, revised 11/2017, indicated, An individualized comprehensive person care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The facility's care planning interdisciplinary team, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem area; b. Incorporate risk factors associated with identified problems. 1. Resident (R) #9 was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/2021, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS indicated R#9 was diabetic and received insulin injections. The resident required extensive assistance with bed mobility, transfers, dressing, eating, and toilet use and was totally dependent on staff for bathing. Review of the comprehensive care plan, dated as initiated on 12/21/2021, revealed R#9's diabetes was not addressed. There were no documented interventions related to diabetes management and insulin administration. Review of the Order Summary Report revealed R#9 had a physician's order dated 02/06/2022 for Humulin R (fast-acting insulin for control of blood sugar levels) 100 units per milliliter (ML). The Humulin R was to be injected as per sliding scale orders, subcutaneously, before meals and at bedtime for diabetes mellitus. The report indicated R#9 also had a physician's order dated 02/06/2022 to receive insulin detemir solution (a long-acting insulin) 16 units, to be injected subcutaneously at bedtime for diabetes mellitus. In an interview on 03/24/2022 at 11:00 AM, Licensed Practical Nurse (LPN) GG indicated R#9 was admitted to the facility with a diagnosis of diabetes mellitus and that the care plan should address all diagnoses and interventions to care for the resident. LPN GG revealed she was not aware R#9 was not care planned for diabetes, and it was the responsibility of nurses, nurse aides, the Director of Nursing (DON), and the Minimum Data Set Coordinator (MDSC) to ensure care plans were developed with accurate information that reflected the resident's needs. In an interview on 03/24/2022 at 12:20 PM, the DON indicated she had reviewed R#9's medical record, and the resident was not care planned for diabetes mellitus. The DON indicated it was the responsibility of the MDSC to ensure care plans were developed with accurate information to reflect the resident's needs. The DON stated it was her expectation that care plans were developed with accurate information to give the best picture of how to care for the resident. The DON stated she was not employed when R #9 was admitted and did not know who was responsible for auditing to ensure accuracy of information at that time. The DON indicated care plan audits would be performed to ensure all information related to residents' needs was addressed in the care plans. In an interview on 03/24/2022 at 4:10 PM, the MDSC revealed R#9 was admitted with a diagnosis of diabetes mellitus but was not care planned for that diagnosis. The MDSC indicated the care plan should contain the diabetes diagnosis and interventions. The MDSC revealed she was on medical leave at the time R#9's care plan was developed by the treatment nurse. The MDSC indicated it was ultimately her responsibility to ensure care plans contained all medical information to care for the resident, and she should have caught that the diagnosis and interventions were not on the care plan. In an interview on 03/25/2022 at 1:43 PM, the Administrator revealed she was not aware of R#9's clinical status when the resident was admitted . The Administrator indicated she had reviewed R#9's care plan, and it did not include interventions for diabetes. The Administrator indicated care plans should show the resident's complete clinical status. The Administrator indicated it was her expectation that all departmental managers reviewed the care plans to ensure all information was included and advise the MDSC with any changes as needed. The Administrator revealed it was ultimately the responsibility of the MDSC to develop the care plan, but the MDSC was off on medical leave when the resident was admitted . The Administrator indicated the nurse that initially developed R#9's care plan was currently on paid time off. The Administrator revealed no audits of care plans had been performed since she began as the Administrator about six months ago. 2. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident (R) #78 was admitted to the facility on [DATE] and had diagnoses which included seizure disorder, hypertension, and aphasia. The MDS indicated the resident was rarely understood by others and rarely understood others and was moderately impaired in cognitive skills for daily decision-making per a staff assessment for mental status. The MDS revealed the resident had verbal behavioral symptoms directed toward others on 1 to 3 days of the assessment period and had other behavioral symptoms not directed toward others daily. Review of a Nursing Note dated 02/12/2022 at 12:09 AM revealed R#78 was found at approximately 7:00 PM with the call light cord wrapped around his/her neck multiple times. The Certified Nursing Assistant (CNA) called the nurse to the room, and the nurse and CNA removed the cord from the resident's neck. The resident was placed on 1:1 supervision and the call light was placed on the other side of the room. A review of the resident's comprehensive care plan with a start date of 02/10/2022 revealed R#78's suicide attempt had not been care planned. Unit Manager (UM) FF, a Licensed Practical Nurse (LPN) was interviewed on 03/24/2022 at 9:14 AM. The UM stated she would expect the suicide attempt for R#78 to be care planned. The UM reviewed the care plan and acknowledged the suicide attempt had not been included on the resident's care plan. She stated the MDS nurse was responsible for care planning. The Director of Nursing (DON) was interviewed on 03/24/2022 at 1:01 PM. The DON stated she was not at the facility when the resident's suicide attempt occurred. She indicated her expectation would have been for the suicide attempt to be care planned, with interventions put in place. The Minimum Data Set (MDS) Coordinator was interviewed on 03/25/2022 at 8:42 AM. The MDS nurse stated the nursing department, or the Social Worker wound have been responsible for care planning R#78's suicide attempt. The MDS nurse reviewed the care plan for R#78 and confirmed the suicide attempt had not been care planned. She stated the information about the resident's suicide attempt would be important for R#78's health, care, quality of life and it was important for the staff to be aware. The Administrator was interviewed on 03/25/2022 at 1:45 PM. The Administrator stated the MDS nurse, and the DON were responsible for making sure the care plan accurately reflected the resident's status. The UM should also review the care plan to make sure the resident was accurately reflected. The Administrator added the MDS nurse was responsible to audit care plans to make sure the care plans were accurate on quarterly and annual basis and with any updates in the residents' conditions. The Social Worker (SW) had worked in the building for three weeks and had no knowledge of R#78's incident. The previous SW was unable to be contacted. 3. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident (R) #72 was readmitted to the facility on [DATE] with diagnoses which included left below-knee amputation and malnutrition. The MDS indicated the resident had short-term and long-term memory impairment and was severely impaired in cognitive skills for daily decision-making per a staff assessment of mental status. The MDS also indicated the resident had a functional limitation in range of motion of both lower extremities. Observations starting on 03/21/2022 at 12:40 PM revealed R#72's right knee was approximately 6 inches from her chin. During an interview with Certified Nursing Assistant (CNA) BB on 03/21/2022 at 12:40 PM, the CNA confirmed the resident was unable to straighten the leg out. Review of the resident's care plan, dated as initiated 08/08/2021, revealed the contracture was not addressed. The MDS Nurse was interviewed on 03/25/2022 at 8:42 AM. The MDS nurse confirmed R #72 had significant contractures that should have been care planned. The Administrator was interviewed on 03/25/2022 at 1:45 PM. The Administrator stated she expected R#72's contractures to be care planned with interventions to prevent worsening or development of new contractures. The Administrator stated the MDS Nurse and the Director of Nursing (DON) were responsible for making sure the care plan accurately reflected the resident's status. The UM should also review the care plan to make sure the resident was accurately reflected. The Administrator added the MDS nurse was responsible to audit care plans to make sure the care plans were accurate on quarterly and annual basis and with any updates in the residents' conditions. The DON was interviewed on 03/25/2022 at 4:15 PM. The DON stated the contractures should be care planned, either actual contractures or potential contractures, to include interventions. 4. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident (R) #22 was readmitted to the facility on [DATE] and had diagnoses which included end stage renal disease and malnutrition. The MDS indicated the resident's Brief Interview for Mental Status score was 6, which indicated severe cognitive impairment. A review of the Order Summary Report revealed that R#22 had a physician's order dated 09/30/2021 for dialysis on Tuesdays, Thursdays, and Saturdays at 10:30 AM. The care plan for R#22 dated as reviewed most recently on 01/13/2022 did not include a care plan for dialysis. The Minimum Data Set (MDS) Nurse was interviewed on 03/25/2022 at 8:42 AM and dialysis should be care planned, with interventions such as checking the dialysis shunt for thrill and bruit. The Administrator was interviewed on 03/25/2022 at 1:45 PM. The Administrator stated she expected dialysis residents to have a care plan and interventions that included checking the bruit and thrill and checking the dialysis access site for bleeding. The DON was interviewed on 03/25/2022 at 4:02 PM. The DON stated a resident who received dialysis services should be care planned for dialysis.