Based on observations, staff interviews, record review, and review of the facility's policy titled Patients/Resident Rights, Accommodation of Needs, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity for one of 50 sampled residents (R) (R73). This deficient practice had the potential to diminish R73's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: Review of the facility's policy titled, Patients/Resident Rights, Accommodation of Needs, dated 12/1/2023, documented under Policy Statement: It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center. Under Procedure: .B. Privacy: 1. Patients/residents will be provided full visual privacy during routine care and treatment by means of privacy curtains and closed doors. Review of R73's Annual Minimum Data Set (MDS) assessment, dated 2/2/2025, documented Section GG (Functional Abilities and Goals) documented R73 was dependent on staff for assisting with toileting. Review of R73's care plan dated 4/8/2025 documented that R73 required skills training in toileting/toilet transfer with an approach to assist the resident to the bathroom throughout the day to reduce the risk of falls when taking self to the bathroom. Observation on 5/12/2025 at 2:16 pm revealed Activities Assistant II assisting R73 with her briefs while the door was open, and no privacy curtain was pulled. In an interview on 5/12/2025 at 2:23 pm, the Activities Assistant II confirmed that the door should be closed. In an interview on 5/15/2025 at 8:56 am, the Director of Health Services (DHS) stated that staff tried their best to keep the resident doors shut during care, but that couldn't always be maintained. The expectation was for staff to close the doors while providing care.

Based on observations, resident and staff interviews, and review of the facility's policy titled Infection Control-Housekeeping Services, the facility failed to maintain a safe, clean, comfortable, and homelike environment in four of 97 resident rooms (Room F11, Room F13, Room F15, and Room F21). Specifically, buildup of food on a television, stained and sticky floors, and dust-covered ceilings and wall vents were observed. Findings include: Review of the facility's policy titled Infection Control- Housekeeping Services, revised 10/16/2023, revealed under Friction Cleaning: 1. Thorough scrubbing will be used for all environmental surfaces that are being cleaned in patient/resident care areas. A deep cleaning will be performed for each patient/resident room monthly and at discharge. Under Routine Cleaning of Horizontal Surfaces: 1. In patient/resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be performed daily and more frequently if spillage or visible soiling occurs. Observations made on 5/12/2025 at 11:00 am revealed that resident room F11's ceiling and wall vent filter had approximately two inches of thick dust and particle buildup. The floor had sticky substances along with discoloration. Observations made on 5/12/2025 at 11:15 am revealed that resident room F13 had sticky and brown substances on the floor, and the ceiling and wall vents were covered in dust and particle buildup. Observations made on 5/12/2025 at 11:25 am and on 5/13/2025 at 2:00 pm revealed that resident room F15 had a television with food particles built up on the top and sides. Observations made on 5/12/2025 at 11:40 am revealed that resident room F21's ceiling and wall vent filter had approximately two inches of thick dust and particle buildup. During an observation and interview on 5/14/2025 at 12:06 pm with the Housekeeping Supervisor and Maintenance Director, both confirmed all the findings. The Housekeeping Supervisor stated that she used a calendar that the facility goes by to select rooms slated for deep cleaning, and if a room was not selected, needed extra cleaning, that room would be chosen instead. The Housekeeping Supervisor also stated that the housekeeper on the F hall was a regular scheduled staff member and was aware of the issues in room F15 and that it required extra attention daily. The Maintenance Director stated that he understood that there was a lot to be done in the facility. The Maintenance Director admitted that none of the wall or ceiling vents had been opened, pulled down, or cleaned since she had been working in the facility, and added that to be truthful, I don't think it has been done in years. The Maintenance Director also confirmed that the filters in the ductwork had not been changed either, but were on the list of things to do. He stated that this was an old building and needed a lot of work. During an interview on 5/14/2025 at 4:47 pm, the Administrator stated her expectation was that each department had adequate staff and that they were adequately trained, and the managers were going back and doing quality checks to make sure that whatever they delegated was being done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R10's Quarterly MDS assessment dated [DATE] revealed Section N (Medications) revealed R10 received antipsychotic, antianxiety, and antidepressant medications. Review of R10's care plan revealed Problem areas of behavioral symptoms; psychotropic drug use related to antipsychotic, antianxiety, and antidepressant medications; elopement risk; and cognitive loss/dementia. Review of R10's EMR revealed diagnoses including, but not limited to, schizoaffective disorder and bipolar disorder. Review of R10's EMR revealed there was no PASRR Level II. In an interview on 5/1/2025 at 4:00 pm, the Social Worker confirmed R10 should have been submitted for a PASRR Level II based on her diagnoses. Based on staff interviews and record review, the facility failed to ensure two of 20 sampled residents (R) (R112 and R10) were referred to the appropriate state-designated authority for a review for a Preadmission Screening and Resident Review (PASRR) Level II. This failure had the potential to place R112 and R10 at risk of not receiving specialized services. Findings include: 1. Review of R112's electronic medical record (EMR) revealed R112 was admitted to the facility on [DATE] with diagnoses including, but not limited to, bipolar disorder, major depressive disorder, and anxiety. Review of R112's admission Minimum Data Set (MDS) assessment, dated 9/22/2023, revealed Section A (Identification Information) documented R10 had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. Section I (Active Diagnoses) documented diagnoses included psychiatric/mood disorder and depression, other than bipolar. Review of R112's Quarterly MDS assessment, dated 3/26/2025, revealed Section I (Active Diagnoses) documented diagnoses included psychiatric/mood disorder and depression, other than bipolar. Review of R112's care plan, dated 10/2/2023, revealed a Problem area of signs and symptoms of mood distress related to a diagnosis of bipolar disorder. Review of R112's EMR revealed there was no PASRR Level II. In an interview on 5/15/2025 at 1:30 pm, the Director of Health Services (DHS) confirmed R112 did not have a PASRR Level II and stated she could not explain why it was not completed.

Based on observations, staff interviews, record review, and review of the facility's policy titled Care Plan, the facility failed to implement the individualized care plan for one of 50 sampled residents (R) (R52) related to high fall risk. The deficient practice had the potential to place R52 at risk for safety and injuries, which could lead to hospitalization and a diminished quality of life. Findings include: Review of the facility's policy titled Care Plan Policy, revised 7/27/2023, revealed under Policy Statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RÄI) Manual and the patient/resident choice. The policy also revealed under admission Comprehensive Plan of Care: .4.The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. Short and concise instructions, which can be understood by all partners, should be written and have a relationship to the problem and goal(s), and should include any PASSAR Level II intervention as needed. Some interventions require all disciplines to be involved in the implementation, while others may only involve specific team members. When approaches that involve the certified nursing assistant (CNA) have been added to the care plan, those approaches should also be included on the CNA Care Record or Resident Profile/Care Plan. Review of R52's care plan, last revised on 4/28/2025, for R52 revealed the resident is at risk for falls related to impaired mobility, cerebral vascular accident (CVA) with hemiparesis, behaviors, and a witnessed fall with major injury fracture to the right distal femur on 2/5/2025. Approaches include placing frequently used items within reach, placing the right leg knee immobilizer to maintain alignment of the right leg until follow up with Ortho (orthopedic), assist resident with getting out of bed when agitated, non-skid socks, fall mats and encourage resident to use call light for assistance. It was noted that the resident refuses to wear the immobilizer. Observation on 5/12/2025 at 12:09 pm revealed R52 was observed in private room, lying in bed. There were no fall mats on the floor next to the bed. Observation on 5/14/2025 at 9:03 am revealed R52 sitting up in bed eating breakfast. Non-skid socks were not on R52. Fall mats were not in place. On 5/14/2025 at 1:28 pm, R52 was observed lying in bed. The bed was in a low position. Non-skid socks were not on R52's feet. Fall mats were not in place next to the bed. Licensed Practical Nurse (LPN) EE entered the room and confirmed that R52 was at high risk for falls due to a recent fall. LPN EE also revealed that high fall risk residents should have their beds in a low position, and items should be in reach. Residents should be encouraged to use their call light for assistance. He also confirmed that the resident did not have fall mats on the floor nor non-skid socks on. Interview on 5/15/2025 at 1:39 pm with the Director of Health Services (DHS) revealed that any interventions related to fall risk would be on the care assist dashboard for the Certified Nursing Assistants (CNA) to view the activities of daily living (ADL) profile, nurses would provide the information in report, and that fall risk would also be on the resident's face sheet. The DHS also confirmed that she expected the CNAs to follow the interventions. Interview on 5/15/2025 at 1:48 pm with CNA HH confirmed that she would know if a resident were on fall precautions because it would be in the ADL care area of the Care Assist record, but was not sure if interventions were listed. CNA HH also revealed that no shift report was done, but if there was a change with the resident, her nurse would tell her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review, the facility failed to ensure services for hearing were provided for one of 50 sampled residents (R) (R106). The deficient practice had the potential to cause a decrease in R106's quality of life. Findings include: Review of the admission record revealed that R106 was admitted to the facility with diagnoses that include, but are not limited to, paraplegia, acquired absence of the left leg below the knee, shigellosis, methicillin-susceptible Staphylococcus aureus infection, osteomyelitis, and other lesions of the oral mucosa. Review of R106's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview of Mental Status score of 15 (indicating little to no cognitive impairment). Section B (Hearing, Speech, and Vision) documented moderate difficulty with hearing. Review of R106's care plan, dated 1/14/2025, revealed a Problem of Resident is noted to be hear [sic] of hearing. Speaker may have to adjust his/her tone in which resident is able to hear. And a goal stating Resident will makes his needs known thru next review. Interventions include Face the resident when speaking. Provide with materials for written communication. Repeat phrases as needed. Rephrase if necessary. Speak clearly and adjust tone as needed. Speaker to adjust his/her tone in which resident is able to hear. Review of R106's Physician's Orders revealed no referral to audiology from the time of admission, nor any order for further assessment or evaluations. In a concurrent observation and interview on 5/12/2025 at 11:43 am, R106 revealed that he did not have a hearing aid and requested a repeat of the question or statement multiple times. R106 stated he didn't hear well and asked the surveyor to speak louder. R106 also requested that staff remove their mask so he could read their lips during conversation. He stated he had not been evaluated for a hearing device or the cause of his impairment and that no one at the facility had spoken to him about his hearing loss. In an interview on 5/14/2025 at 2:11 pm, the Social Services Director (SSD) confirmed that R106 was not on her current referral list for audiology consultation and revealed that R106 had not been seen by an audiologist that she was aware of. The SSD confirmed a note in R106's electronic medical record (EMR) that referred him to audiology in January, and confirmed there was no follow-up or visit to the audiologist. In an interview on 5/14/2025 at 2:59 pm, the Director of Health Services (DHS) stated the facility provided audiology services and that R106 should have been evaluated on admission and all necessary referrals made. The DHS confirmed there had been no audiology referrals made for R106 since admission and confirmed that his care plan and MDS both indicated that he was hard of hearing with no interventions of referral to audiology.

Based on observations, staff and resident interviews, and record review, the facility failed to ensure one of 50 sampled residents (R) (R127) received restorative nursing as ordered by the physician. This deficient practice had the potential to place R127 at risk for medical complications, such as decreased range of motion of her left hand. Findings include: Review of the R127's Quarterly Minimum Data Set (MDS) assessment, dated 2/17/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented upper extremity impairment on one side. Section O (Special Treatments, Procedures, and Programs) documented that the resident did not receive Restorative Nursing or splint/brace assistance. Review of R127's electronic medical record (EMR) revealed diagnoses including, but not limited to, cerebrovascular accident (CVA), hemiplegia, and hemiparesis. Review of R127's Physician's Orders revealed an order dated 4/24/2024 for LUE (left upper extremity) hand orthodic three to four hours daily as tolerated. Observation on 5/13/2025 at 10:00 am revealed R127 had a contracted left hand. Further observation revealed that R127 did not have a brace on her left hand. Observation on 5/14/2025 4:50 pm revealed R127 did not have a hand brace on her left hand. In an interview, R127 stated she rarely wore the brace and had not worn it in a couple of weeks. Observation on 5/15/2025 at 10:42 am revealed R127 did not have a brace on her left hand. In an interview on 5/14/2025 at 1:45 pm, Certified Nursing Assistant (CNA) NN stated R127 received restorative care for her lower body and did not receive restorative care for her upper body. In an interview on 5/14/2025 at 2:10 pm, Licensed Practical Nurse (LPN) JJ confirmed R127 had a physician's order for a splint for her LUE. She further stated she was unsure if the resident ever wore the splint. In an interview on 5/15/2025 at 12:05 pm, the Director of Health Services (DHS) confirmed R127's physician's order for a left hand splint and stated her expectation was for staff to ensure the splint was applied as ordered.

3. Review of R49's revealed diagnoses including, but not limited to, unspecified dementia, schizophrenia, major depressive disorder, peripheral vascular disease, unspecified glaucoma, heart failure, unspecified, chronic obstructive pulmonary disease (COPD), drug induced subacute dyskinesia, major depressive disorder, mild cognitive impairment, intermittent explosive disorder, Alzheimer's disease with early onset, and major depressive disorder. Review of R49's Quarterly MDS assessment, dated 5/1/2025, revealed Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 3 (indicating severe cognitive impairment). Review of R49's Annual MDS assessment, dated 3 19/2024, revealed Section J (Health Conditions) documented tobacco use. Review of R49's care plan revealed a Problem area of The resident is noted to be at risk for injury related to the resident is a smoker. The resident requires supervised smoke breaks. Last Reviewed/Revised: 04/22/2025. The Long Term Goal Target Date 07/22/2025 revealed The resident will not have any injuries related to smoking thru [sic] the next review. Interventions included 5/14/2019 cigarettes and lighters in the activities office, educate the resident of the smoke breaks, notify the md [sic] (medical doctor) as needed, provide the resident with a smoking apron to prevent injury. Review of R49's Quarterly Observation dated 2/10/2025 revealed the resident had a past history of smoking, but currently not smoking. Observation of R49 on 5/12/2025 at 2:30 pm revealed R49 in the designated smoking area, smoking a cigarette. Observation of R49 on 5/13/2025 at 2:05 pm revealed him smoking in the designated area. During an interview on 5/15/2025 at 10:15 am, the Director of Health Services (DHS) confirmed R19 did not have a smoking assessment or an area for smoking on the care plan, R20 did not have a completed and updated quarterly assessment, and confirmed that R49's quarterly assessment related to smoking was not accurate. The DHS continued to state that smoking assessments were completed by the nursing staff and should be done quarterly and annually. She revealed that if a resident was not assessed or accurately assessed, and if care plan interventions were not in place, staff would not know what to monitor. Based on observations, staff interviews, record review, and review of the facility's policy titled Smoke Free Policy, the facility failed to ensure three of seven residents (R) (R19, R20, and R49) who smoked had complete and accurate smoking assessments. In addition, the facility failed to ensure one of seven R (R19) who smoked had a care plan related to smoking. These deficient practices had the potential to place R19, R20, and R49 at an increased risk of accident hazards related to smoking. Findings include: Review of the facility's policy titled Smoke Free Policy, revised date 12/12/2023, revealed the Assessment and Care Planning section included, . 2. Grandfathered patients/residents will be assessed, utilizing the Smoking Observation Form in the Electronic Health Record (EHR), by a Licensed Nurse upon admission, re-admission, and/or with a significant change. A re-admission smoking care plan shall be developed by the licensed nurse on the admission Interim Care Plan Form, or electronically. 3. An assessment utilizing The Smoking Observation Form in the EHR is completed at least quarterly thereafter if the answer to either of the first two (2) questions indicates the resident either smokes or has a history of smoking. After completion of the assessment, the care planning team shall review and utilize the assessment when developing the resident's care plan. 1. Review of R19's Face Sheet revealed an admission date of 1/27/2010 with diagnoses including, but not limited to, dementia, psychotic disturbance, mood disturbance, and anxiety. Review of R19's Annual Minimum Data Set (MDS) assessment, dated 4/11/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview of Mental Status (BIMS) of 11 (indicating moderate cognitive impairment). Section J (Health Conditions) documented no tobacco use. Review of R19's care plan revealed no care plan related to smoking. Review of R19's clinical record revealed no smoking assessments. Review of the facility-provided smoking list revealed R19 was identified as a tobacco user. Observation on 5/12/2025 at 2:30 pm revealed R19 was in the designated smoking area smoking a cigarette. 2. Review of R20's Face Sheet revealed an admission date of 1/27/2010 with diagnoses including, but not limited to, major depression disorder, generalized anxiety disorder, delusional disorder, and nicotine dependence. Review of R20's Quarterly MDS assessment, dated 3/3/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview of Mental Status (BIMS) of 7 (indicating severe cognitive impairment). Section J (Health Conditions) documented no tobacco use. Review of R20's care plan revealed R20 was at risk for injury related to going outside for supervised smoke breaks. Review of the facility-provided smoking list revealed R20 was identified as a smoker. Review of R20's Smoking Observation Form, dated 4/23/2024, revealed the assessment was incomplete and marked as in process.

Based on observations, staff interviews, and record reviews, the facility failed to ensure oxygen (O2) was administered as prescribed by the physician for two of 20 residents (R) (R22 and R95) receiving O2. This deficient practice had the potential to place R22 and R95 at risk of respiratory complications and a diminished quality of life. Findings include: 1. Review of R22's electronic medical record (EMR) revealed diagnoses including, but not limited to, sarcoidosis, shortness of breath, and eosinophilic asthma. Review of R 22's Quarterly Minimum Data Set (MDS) assessment, dated 3/14/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) revealed R22 received O2 therapy. Review of R22's care plan, last reviewed/revised 4/29/2025, revealed Problem area stating the resident was at risk for respiratory complications related to diagnosis of asthma and shortness of breath. The Approach revealed O2 has an ordered flow rate. Review of R22's Physician's Orders included an order dated 1/16/2024 for O2 at 3 liters per minute (LPM) via a NC as needed (PRN). Observation on 5/13/25 at 9:33 am revealed R22 in her bed, wearing oxygen via a NC. Observation revealed that the flow rate of the O2 was set between 1.5 and 2 LPM. R22 stated she could not feel the O2 flowing through the NC and called for a nurse. 2. Review of R95's EMR revealed diagnosis, including but not limited to, acute respiratory failure with hypoxia. Review of R95's Quarterly Minimum Data Set (MDS) assessment, dated 3/14/2025, revealed Section O (Special Treatments, Procedures, and Programs) revealed R95 received O2 therapy. Review of R95's Physician's Orders revealed an order dated 4/30/2025 for O2 at 3 LPM continuous. Observation on 5/12/2025 at 1:06 pm revealed R95 lying in bed with an NC not in place in his nostrils, and the flow meter was set on 2.5 LPM. Observation on 5/13/2025 at 9:41 am observed R95 lying in bed, appeared asleep, and with the O2 not in place. Observation on 5/14/2025 at 8:52 am revealed R95 lying in bed with O2 in place, and the flowmeter was set on 1 LPM. In an interview on 5/14/2025 at 9:15 am, Licensed Practical Nurse/Unit Manager (LPN/UM) EE reviewed O2 orders for R22 and R95 and confirmed the physician's orders were for O2 at 3 LPM continuous for both residents. LPN/UM EE stated that it was his expectation for nursing staff to review the physician orders and ensure the O2 settings were correct each shift. In an interview on 5/15/2025 at 11:54 am, the Director of Health Services (DHS) revealed that she expected nursing staff to review and monitor O2 orders each day.

2. Observations on 5/12/2025 at 9:55 am, 5/14/2025 at 2:55 pm, and 5/15/2025 at 12:10 pm revealed one wash basin and one urinal in the restroom of room A1, unlabeled, uncovered, and exposed to the environment. In a concurrent observation and interview on 5/15/2025 at 12:39 pm, the DHS confirmed that the basin and urinal should be covered and labeled. She stated they would be thrown away. Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Infection Prevention and Control Plan, the facility failed to ensure staff followed infection control practices during wound care for one of 18 residents (R) (R106) with pressure ulcers. In addition, the facility failed to properly store personal care supplies in one of 11 resident restrooms observed. These deficient practices had the potential to place R106 at increased risk of infection related to cross-contamination, and had the potential to increase the risk of cross-contamination to the residents residing in room A1. Findings include: Review of the facility's policy titled Infection Prevention and Control Plan, revised 6/21/2024, revealed the Procedure section included A. Infection Control Administrative Structure . 10. Partners are responsible for implementing the Infection Prevention and Control Policy and Procedures. 1. Review of R106's Quarterly Minimum Data Set (MDS) assessment, dated 3/20/2025, revealed Section M (Skin Conditions) documented the resident had three stage four pressure ulcers, and received pressure ulcer care, applications of nonsurgical dressings, and application of ointments/medications. Review of R106's care plan revealed a Problem area for impaired skin integrity and has pressure ulcers to the sacrum, right buttock, left hip/buttock, right leg, and right foot. Approach included treatment and wound care per the provider's orders. Review of R106's diagnoses included, but not limited to, pressure ulcer of the sacral region, unspecified open wound, and osteomyelitis. Observation of wound care on 5/14/2025 at 11:21 am with Licensed Practical Nurse (LPN) AA revealed that she prepared supplies on a lined bedside table. LPN AA washed her hands and donned her gown and gloves. She cleaned the right ischial wound, removed her gloves, and donned (put on) another pair of gloves without performing hand hygiene. She then applied the dressing, removed her gloves, and work surface. LPN AA went on to perform a dressing change to the sacral wound. She donned gloves and did not perform hand hygiene between removing the previous gloves and donning the new gloves. After cleaning the wound, LPN AA removed her gloves and used sanitizer before donning clean gloves. She then assisted with removing fecal matter from the bed with a gloved hand, removed the glove from that hand, did not perform hand hygiene, and donned a new glove before continuing the wound care. In an interview on 5/14/2025 at 1:40 pm, the Infection Preventionist (IP) and the Director of Health Services (DHS) stated that all staff have been educated on several occasions on the importance of infection control and hand hygiene. The DHS stated that it is her expectation that all nursing staff follow infection control practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and review of the facility policy titled Self-Administration of Medications by Patients/Residents, the facility failed to ensure one resident (R) (R48) reviewed for self-administration of medications did not have medications stored at the bedside. This deficient practice had the potential to allow R48 to administer the medications in an unsafe manner. The sample size was 37 residents. Findings include: A review of the facility policy titled Self-Administration of Medications by Patients/Residents, with a revision date of 1/28/2020, revealed the Policy Statement: Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center. The Procedure section revealed: 1. The opportunity to self-administer medications is reviewed during routine assessment by the healthcare center's interdisciplinary team utilizing the Electronic Health Record Observation tool, Medication Self-Administration Observation. 5. Bedside storage of medications is permitted only when it does not present a risk to confused patients/residents who wander into the rooms of, or room with patients/residents who self-administer. The following conditions are met for bedside storage to occur: The Electronic Health Record form is printed and maintained at the bedside and is reviewed on each nursing shift, and the administration information is transferred to the electronic medication record. Attending physician enters an order into the electronic health record for bedside storage. 6. All nurses and aides are required to report to the Charge Nurse on duty any medications found at bedside not authorized for bedside storage and to give unauthorized medications to the Charge Nurse for return to the family or responsible party. Observations on 1/12/2024 at 8:59 am and 12:01 pm, and on 1/13/2024 at 8:19 am revealed a container of medicated chest rub and a pack of cough and throat relief drops within R48's reach on the bedside table. A review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed section C - Cognitive Patterns: Brief interview for Mental Status (BIMS) score of 13, indicating little to no cognitive impairment. A review of R48's electronic medical record (EMR) under the Order tab revealed that R48 did not have a current order for the cough drops, the chest rub, or an order for self-administration of medications. Further review of the EMR under the Observation tab revealed a self-administration of medication observation dated 9/8/2023 which indicated R48 did not want to self-administer medications. The facility will administer medications. There also was a self-administration of medication observation dated 10/27/2023 which indicated R48 did not want to self-administer medications and resident had a history of noncompliance with medication and other treatments. The observation also indicated that based on the answers, it was not appropriate for R48 to self-administer medications. This determination was reached due to a history of noncompliance. The resident will not be self-administering medications. During an interview on 1/13/2024 at 8:19 am, R48 revealed that his wife brought him the chest rub and the cough drops to the facility over a week ago. R48 also stated he uses the cough drops and places the chest rub above his top lip. R48 informed the surveyor that both over-the-counter medications had remained on his bedside table since his wife brought them to him, and no one informed him that he was not allowed to have them. During an interview and walking rounds on 1/13/2024 at 9:18 am, Licensed Practical Nurse (LPN) Unit Manager BB revealed that R48 should not have any medications at the bedside. LPN BB stated that she was in R48's room earlier this morning and she did not notice any medications in his room. LPN BB verified medications were on the resident's bedside table and with R48's permission, she removed the medications. LPN BB verified R48's Self-Medication Observation indicated he would not have medications at the bedside and R48 did not have current physician orders for the medications. During an interview on 1/13/2024 at 9:36 am with the Director of Health Services (DHS), she stated there were no residents residing in the facility who had been assessed and deemed appropriate to self-administer medications. DHS confirmed that R48 did not have a physician order for the medications that were located at his bedside. DHS further stated that she would educate her staff to make them aware that over-the-counter medications are not allowed in residents' rooms unless that resident has been assessed and deemed appropriate to self-medicate. DHS confirmed R48's self-administration observation dated 10/27/2023 indicated he was inappropriate to self-administer medications.

Based on record review, resident responsible party interview, staff interviews, review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, and review of the website titled Agency of Healthcare Research and Quality (AHRQ), the facility failed to notify the physician and family of an allegation of abuse for one resident (R) (R9). The sample size was 37 residents. Findings include: A review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, review date of 1/11/2024 indicated: Policy line numbered 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. The Ombudsman should also be notified as required by state law. The Administrator or designee should direct an investigation into the allegation or incident. A review of the Agency of Healthcare Research and Quality (AHRQ) website states that an SBAR document is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue the team needs to address. https://www.ahrq.gov/teamstepps-program/curriculum/communication/tools/sbar.html A review of the Grievance/Complaint Form: Health Centers dated 1/8/2023{sic} revealed the Speech Licensed Therapist (SLP) and Certified Occupational Therapy Assistant (COTA) entered R9's room at 11:54 am. The resident was notably upset and asked that the police be called. When asked why R9 responded that she had been beaten. The resident was asked by the SLP and COTA did the incident happened prior to her admission to the facility. The resident stated no that the incident took place the night before and last night. The SLP asked R9 where it occurred and the resident responded, I have been beaten, assaulted, and raped. The SLP informed the resident the incident would be reported. A review of the Facility Incident Report Form dated 1/8/2024 revealed the facility Administrator reported an allegation of abuse via the State Survey Agency (SSA) online website. The box other was checked on the reportable. The date and time of the incident was documented as 1/6/2024. Details of the incident stated: Resident reported to staff member that the night before last she was beaten and raped. When interviewed further she stated that it happened when she got off the train and it was a tall black man who hit her on the gut and raped her. Steps taken by the facility to prevent further incidents: Nurse to complete full body assessment. MD and family notified. Police were notified, waiting for them to come out. Investigation initiated. Review of the Nursing Progress Notes recorded a note dated 1/8/2024 at 4:14 pm and edited on 1/9/2024 at 9:19 am: Head-toe assessment performed by Registered Nurse (RN) ZZ. There was no documentation that the resident's groin, vaginal area, or anal area was assessed. There was no documentation in the Electronic Medical Record (EMR) that the physician, family, and/or responsible party (RP) was notified. An interview on 1/13/2024 at 10:54 am with the Social Service Director (SSD) stated she is aware of R9's allegation of sexual abuse. She stated she did not notify anyone regarding R9's allegation. The SSD stated it is not her responsibility to notify the family and/or RP. An interview on 1/13/2024 at 11:54 am with the Administrator stated the physician, family/RP should be notified of a resident's change in condition notification and documented in the resident's EMR. The Administrator stated the physician was notified of R9's allegation on the day the incident was reported to the SSA. She stated the physician did not want the resident sent out to the hospital. The Administrated stated she was not sure of the time the family was notified of the incident. An interview on 1/13/2024 at 1:59 pm with RN ZZ stated a skin assessment was completed on R9 after the allegation of sexual assault was reported. The RN stated the resident had no vaginal or rectal redness or skin tears. The RN stated she did not notify the physician, family, and/or the RP of the incident. She stated The Director of Health Services (DHS) is the person to ask regarding R9's family and physician notification. An interview on 1/13/2024 at 3:55 pm with the DHS stated the speech therapist was the person who reported to the Administrator R9's allegation. She stated she is not sure if the physician, family, and/or RP was notified. She stated she would check and get back to the surveyor. The DHS never returned with the information. A telephone interview on 1/13/2024 at 5:20 pm with R9's family/RP stated the facility notified the family today (1/13/2024) of the incident that was reported by R9 on 1/8/2024. The family stated they had no prior notification of the incident. The family stated that R9 has a history of being assaulted at the age of 14 or 15. The family stated it is difficult for her to talk about but as she has gotten older, she tells the family fragments of the assault which is upsetting to her (R9). The family stated that R9 is re-experiencing trauma from that incident that happened to her as a young girl. During an interview on 1/14/2024 at 10:15 am with the Administrator and DHS, the Administrator stated that when the initial report was sent to the SSA, she did document that the physician and family were notified. The Administrator and DHS confirmed that the physician or the family were not notified on 1/8/2024 of R9's allegation of sexual abuse. The DHS stated she expects her staff to document in the progress notes, complete the SBAR, document a complete skin assessment, and for the physician and responsible party to be notified. The Administrator stated she did not think it through, and further stated that going forward she will communicate clearly with the team to ensure that the physician and families are notified of a resident change in condition or allegation of abuse/neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Initial observation tour on D Unit on 1/12/2024 at 9:18 am of Room D-3 revealed a 30 cubic centimeter (cc) syringe on the floor next to a trash can that had no liner. The trash can was observed with trash stuck in the bottom of the can along with a brown liquid substance. There was dried formula observed on a tube feeding pump and pole. A dried formula was observed on the left bed rail. Observation revealed the floor was dirty with trash. The nightstand had flaky particles and stains next to a suction machine with the suction tubing hanging from the left side of the nightstand. The floor on the right side of Bed B had a fall mat partially rolled up with trash on top of it. Observations from 1/12/2024 through 1/14/2024 revealed all environmental concerns listed above remained unchanged. Observation and interview on 1/13/2024 at 8:45 am with Licensed Practical Nurse (LPN) HH confirmed the dirty tube feeding pump, dirty floor, dirty trash can, dirty bed rail, and trash on the floor. LPN HH stated that it is the responsibility of the housekeepers to make sure the feeding pump is clean. She stated that it is also the housekeeper's responsibility to clean the nightstand and the floors. LPN HH stated that she guessed that the nurses could clean the formula from the feeding pump and the bed rail. During an interview with the Director of Health Services (DHS) on 1/14/2024 at 8:54 am, the DHS stated that the nurse taking care of the resident should make sure that the feeding pump is clean. Interview with the Housekeeping Supervisor on 1/14/2024 at 1:58 pm, s/he stated that the nursing department is responsible for making sure the feeding pumps and feeding tubes are clean. S/he stated that housekeeping staff is responsible for cleaning the beds and floors. S/he stated that Housekeepers clean all rooms daily and that they have a deep cleaning schedule that they go by to deep clean the rooms. S/he stated that the Housekeeping Supervisor makes sure that the rooms are cleaned daily. The Housekeeping Supervisor viewed pictures of the environmental issues in D Unit room [ROOM NUMBER]. The Housekeeping Supervisor stated that should not have happened. In an interview with the Administrator on 1/14/2024 at 3:00 pm, the Administrator stated that she met with her staff on 1/13/2024 and discussed the environmental issues. Based on record review, observations, staff interviews, and review of the facility policies titled Infection Control - Housekeeping Services and Infection Control - Maintenance Department, the facility failed to ensure that there was a safe, clean, and homelike environment for two of seven Units (F Unit and D Unit) as evidenced by housekeeping and maintenance concerns identified. The census was 153 residents. Findings included: A review of the facility policy titled Infection Control - Housekeeping Services, last revised 10/16/2023 revealed the Policy Statement: It is the policy of this facility to ensure housekeeping services will be performed on a routine and consistent basis to ensure orderly, sanitary, and comfortable environment. The Procedure section included: Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. A deep cleaning will be performed for each resident's room monthly and at discharge. In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be performed daily and more frequently if spillage or visible soiling occurs. A review of the facility policy titled Infection Control - Maintenance Department, last revised 12/1/2023 revealed the Procedures section line numbered 3 stated: Routine monitoring of the facility will be completed, and repairs or maintenance needs will be reported to the Administrator. 1. On 1/12/2024 at 10:14 am, the following was observed in Room F (F Unit) room [ROOM NUMBER]: [NAME] substance in the bathroom on the floor around the toilet, uneven tiles exposing area under the tiles and presenting a non-cleanable surface, two opened and unlabeled bars of soap, an opened and unlabeled bottle of personal cleansing shampoo, brown stains/substance inside the sink, a bagged plunger with a brown substance on the bag, an unbagged basin and bedpan, the room wall had scraped and unpainted areas, the paint was peeling on the wall, and opened bags of briefs were sitting around the room. On 1/12/2024 at 10:40 am, the following was observed in Room F-06: The bathroom light was not working, an opened and unlabeled bottle of body wash; a used cup, glove, and paper towels were on the sink; four unbagged basins, the area around the bottom of the toilet was discolored and the floor was dirty. On 1/12/2024 at 11:08 am, the following was observed in Room F-12: Two opened and unlabeled bottles of personal cleanser and lotion on the sink, an opened and unlabeled bar of soap on the sink, one unbagged bedpan and three unbagged stacked basins, a call light cord was missing in the bathroom, the tile was broken in the room, the floor was dirty, the walls had scratches, and the over the bed light fixtures for bed A and B were missing pull cords. On 1/12/2024 at 11:19 am, the following was observed in Room F-17: The room reeked of urine odor, there was a large yellow puddle of liquid on the floor with the edges of the liquid dried on the floor, the floor was sticky, and shoes adhered to the floor when walking in the room, there was a discolored and lifting floor tile, multiple unbagged personal items were in the bathroom above the sink, an unbagged urine graduate in the bathroom, the wall behind the toilet was damaged and the floor tile behind the toilet was stained and dirty, and the tile behind the toilet had missing area presented an uncleanable surface. On 1/12/2024 at 6:08 pm, the following was observed in Room F-17: A puddle of yellow liquid remained on the floor behind the head of the bed. The edges of the puddle were dried, and a strong ammonia-like smell was present in the room radiating out into the hall. During an interview on 1/13/2024 at 9:20 am, Housekeeper TT stated that the housekeeping staff are assigned a set area. She stated she was assigned room F-29 on the F Unit. She stated that on her set, there are five hot rooms that she cleans multiple times a day. She identified those rooms as Room F-17, F-8, F-7, F-20, and F-14. She stated that she would hit those rooms first thing and then again after lunch. She clarified that she cleans the hot rooms three times during her shift. For the other rooms, she cleans once. She stated that cleaning the rooms included sweeping and mopping. She stated that she used an odor eliminator chemical in Room F-17 to clean the floor, and further stated she ran out of the chemical and her supervisor had to order more. She stated that the resident in Room F-17 urinates on the floor throughout the day, so they must clean that room often. On 1/13/2024 at 9:28 am, the following was observed in Room F-17: The yellow pooled liquid was still on the floor and the edges were dried up. The yellow liquid was pooled behind the bed and seeping from under the nightstand. The resident's bed was the only bed in the room and there were no chairs or room décor to make the room homelike. During a comprehensive environmental tour of the F Unit on 1/13/2024, the following was observed: At 9:31 am the shared bathroom for Room F-3 and F-4 had a urinal hanging on the towel holder (labeled with R58 but R58 was not a resident assigned to either room sharing this bathroom), two unbagged bedpans on the floor, two unbagged basins on the floor, and a can of shaving cream sitting on the sink. At 9:34 am the shared bathroom for Rooms F-5 and F-6 had four unbagged basins, stains around the bottom of the toilet, a bottle of soap, an empty cup, and used paper towels sitting above the sink. At 9:37 am the shared bathroom for Rooms F-7 and F-8 had two unbagged bars of soap and personal cleanser, and an unbagged basin. In room F-8, the tube feeding pump had a brown substance on both sides and the side rail of Bed B had a brown substance on it. At 9:41 am Room F-10 observation revealed the floor was stained with dirt build-up and the drywall had scratched and damaged areas. At 9:44 am the shared bathroom in Rooms F-11 and F-12 had an unbagged and unlabeled bar of soap and a container of lotion sitting on the sink, three unbagged basins, one unbagged bedpan, and the call light was without a string. Room F-12 had scrapes on the wall. At 9:49 am the shared bathroom for Room F-13 and F-14 had an unbagged basin, a broken piece of a metal toilet paper holder sitting on the sink, the sink was stained with rust, the call light cover was not attached to the wall and was hanging on the call light cord. Room F-13 walls had scratches and discolored areas. There was no chair or décor in the room. At 9:54 am the shared bathroom for Rooms F-15 and F-16 had a hand bar near the toilet with rust and discoloration, the floor and wall were dirty, and there were two unbagged basins, an unbagged bedpan, and an unbagged urine graduate. Room F-16 had a hole in the wall next to the outlet plug, the paint and drywall had scratches on them, the wall was scratched and discolored, and there was damaged drywall (the wall had an opening near the floor molding). At 10:04 am Room F-17 had a yellow puddle of liquid on the floor, and the room reeked of an ammonia-like urine smell. Standing outside the room, the surveyor's eyes watered and the scent of ammonia burned the surveyor's eyes and nasal area. At 10:06 am the shared bathroom for Rooms F-19 and F-20 had an unbagged basin on the floor and an unbagged bedpan on the shelf. room [ROOM NUMBER] walls were scraped, and an in-wall dresser had peeling paint. During a tour of the F Unit with the Maintenance Director, the Assistant Administrator, and the Housekeeping Supervisor on 1/13/2024 from 10:22 am to 10:50 am, all areas of concern were verified. During the tour, when observing Room F-5 and Room F-6, the Maintenance Director stated that the tile was clean but needed to be pulled up. He further stated that the housekeeping staff should have scrapers on their carts and should scrape the floors where there was dirt buildup. The Assistant Administrator stated that the housekeeping staff should be cleaning the side rails on the beds and that the nursing staff should be keeping the tube feeding pumps clean. She further confirmed that personal items should be in a basin, labeled and bagged and personal items such as briefs should not be sitting out on dressers and nightstands. She confirmed that some resident rooms had sitting chairs and décor but not all resident rooms. The Housekeeping Supervisor stated that he went out to replace the odor-eliminating chemical for room F-17 and that the housekeeping staff had to go into the room multiple times a day to ensure urine was not on the floor because the resident urinated on the floor. The Assistant Administrator stated that they have tried multiple interventions, but it was the resident's behavior to urinate on the floor. She stated housekeeping may need to go in more often or have the resident on a 30-minute to hourly check. The Maintenance Director stated that they must pull up the tile in the room to clean underneath the tile in Room F-17. On 1/14/2024 at 10:07 am, Resident in F-16B was observed sitting in a geriatric chair. The armrests on the chair were cracked and exposed, presenting a non-cleanable surface, and a hazard for skin tears. This was confirmed by LPN SS at this time. During an interview with the Maintenance Director on 1/14/2024 at 12:57 pm, he stated that all management staff completes compliance rounds, and his assigned rooms were Rooms F-13 through F-18. He stated they were supposed to go in daily and check to make sure that everything was working, and that the room was home-like. He stated they use a check-off list to look at all areas of the room and give the completed checklist to the Administrator. He further stated the maintenance department did not conduct any routine maintenance-specific compliance rounds. During an interview with the Administrator on 1/14/2024 at 1:23 pm, she stated that she expected management to complete compliance rounds, but with the holidays and people outside, she had not been strict on them completing the forms. She stated she would like them to do the rounds at least twice a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of facility policy titled Care Plans, the facility failed to develop a baseline care plan regarding dementia and hospice care for one resident (R) (R206) of 13 newly admitted residents in the past 30 days. Findings include: A review of the facility policy titled Care Plans, revised 7/27/2023, revealed the Definitions section to state: Baseline Care Plan - must include the minimum healthcare information necessary to properly care for each patient/resident immediately upon their admission, which would address patient/resident specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. The Procedure section stated: New admission Baseline Plan of Care: 1. Upon a new admission, a baseline care plan will be developed by the admitting nurse/nurses in conjunction with other IDT, the patient/resident, and/or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. Resident 206 was admitted to the facility on [DATE]. Her diagnosis included but was not limited to, chronic obstructive pulmonary disease (COPD) and dementia with anxiety. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R206 had an active diagnosis of dementia and was receiving hospice services while in the facility. A review of the medical record revealed a hospice contract signed by R206 Power of Attorney (POA) dated 12/27/2023 for R206 to receive hospice services due to COPD. A review of the care plan dated 12/28/2023 revealed there was no care plan developed for dementia or hospice services. During an interview on 1/14/2024 at 8:25 am, the Director of Health Services (DHS) revealed that the nurse admitting new residents to the facility is responsible for developing the baseline care plan. The DHS revealed that a resident with a diagnosis of dementia or who is receiving hospice service should have a care plan. During an interview on 1/14/2024 at 12:10 pm the Minimum Data Set (MDS) Coordinator confirmed that there was no baseline care plan developed for dementia or hospice services. MDS LL revealed the nurse admitting R206 was responsible for developing the baseline care plan for dementia and hospice care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, and record review, the facility failed to provide Activities of Daily Living (ADL) care related to showers and shaving for four of 38 sampled residents (R) dependent on staff for ADL care, (R17, R18, R58, and R123.) This failure had the potential to negatively impact R17, R18, R58, and R123's quality of life. Findings included: 1. On 1/12/2024 at 11:22 am and 6:08 pm and on 1/13/2024 at 10:48 pm, R17 was observed in bed, not shaven with a full and uneven beard. A review of the clinical record revealed that R17 had diagnoses including, but not limited to, cerebral palsy, lack of coordination abnormal posture; convulsions; mild cognitive impairment; and anoxic brain damage. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R17 was dependent on staff for personal hygiene. A review of the clinical record for R17 revealed no recent documentation that the resident refused to be shaved. 2. On 1/12/2024 at 10:35 am and on 1/14/2024 at 1:11 pm, R18 was observed in bed with a hospital gown on and not shaven. A review of the clinical record revealed that R18 had diagnoses including, but not limited to, polyneuropathy, Alzheimer's disease, obesity, muscle spasm, and muscle weakness. A review of the Quarterly MDS assessment dated [DATE] revealed that R18 was dependent on staff for showering and bathing. The assessment further noted that R18 required partial to moderate assistance with dressing and personal hygiene. A review of the care plan with the last revision date of 12/13/2023 revealed that R18 had a self-care deficit related to ADL care due to impaired physical status, vision, and muscle weakness (generalized) and that R18 required extensive to total assistance with ADL's, transfers, and bathing. 3. In an interview on 1/12/2024 at 12:25 pm, R58 stated he had not had a shower since he had been at the facility. When asked if he had been shaved, R58 stated that the staff did not shave him. He stated that he would like to be shaved and for all his facial hair to be shaved off. At that time, Certified Nursing Assistant (CNA) UU came into R58's room to bring him his lunch. He asked CNA UU if she could shave him, and she replied that she didn't have her clippers today but would bring them tomorrow. A review of the clinical record revealed that R58 was admitted to the facility on [DATE] with diagnoses including, but not limited to, muscle weakness, anemia, unsteadiness on feet, diabetic neuropathy, and weakness. A review of the Quarterly MDS assessment dated [DATE] revealed that R58 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment, and required partial to moderate assistance with showering and hygiene. A review of the care plan with the last revision date of 1/4/2024 revealed that R58 presented with a self-care deficit for ADL care due to impaired mobility and weakness and that R58 required limited to extensive assistance with ADLs care and transfers. In an interview on 1/13/2024 at 2:20 pm, the F Unit Manager (UM) stated that all showers had been done for the day for the first shift. She stated that the shower sheets were being worked on at this time. 4. During an observation and interview with R123 on 1/12/2024 at 11:35 am, he stated that the staff does wash his face and wipe him down a little bit, but they don't do a full cleaning. He stated that he can't walk so they don't get him into the shower room. He was asked if he wanted a shower and he stated he would want that. When asked when the last time he was taken to the shower room was, he stated he had never been to the shower room. Observation revealed his nails were dirty and uncut and he was unshaven. When asked if he would like a shave, he stated that he would and he would like all the hair on his face shaven. He stated that he also needed a haircut. He was observed to have a short afro that was uneven and untrimmed. During an interview on 1/13/2024 at 2:22 pm, CNA UU confirmed that it was R123's shower day but she gave the resident a bed bath, not a shower. Observation of the resident at this time verified he was not shaved. A review of the clinical record revealed that R123 was admitted to the facility on [DATE] with diagnoses including, but not limited to, difficulty in walking, muscle weakness, abnormal posture, unsteadiness on feet, lack of coordination, abnormalities of gait and mobility, muscle wasting and atrophy, type 2 diabetes mellitus with diabetic neuropathy, and overweight. A review of the Quarterly MDS dated [DATE] revealed that R123 presented with a BIMS score of 15, indicating that the resident was cognitively intact. The assessment further noted that R123 required partial moderate staff assistance with bathing and hygiene. A review of the care plan with the last revision date of 12/14/2023 revealed that R123 presented with a self-care deficit related to ADL care due to impaired physical mobility. The care plan noted that R123 will be assisted with daily grooming, oral hair, and skin care. During an interview on 1/13/2024 at 2:22 pm, CNA UU confirmed that it was R123's shower day but she gave the resident a bed bath, not a shower. Observation of the resident at this time verified he was not shaved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the policy titled Restorative Nursing Program, the facility failed to ensure Occupational Therapy recommendations were implemented for two of 17 residents (R) (R56 and R127). This deficient practice had the potential to cause a negative outcome to the resident's physical, mental and psychosocial health, or well-being. The sample size was 37 residents. Findings include: A review of the policy titled Restorative Nursing Program, revised 11/04/2021, revealed the Policy Statement: It is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and maintain optimal physical, mental, and psychological functioning and well-being of the patient/resident. Restorative nursing program is under the supervision of a Registered Nurse (RN) and a License Practical Nurse (LPN), and restorative nursing services are provided by Restorative Nursing Assistants (RNAs), Certified Nursing Assistants (CNAs), and other qualified staff. Nursing assistants/aids must be trained in the techniques that promote resident involvement in the activity. 1. A review of R56's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section GG - Functional Abilities and Goals: dependent on staff for eating, oral hygiene, toileting hygiene, shower/bath, and upper and lower body dressing. Section O - Special Treatments and Programs: Did not receive Restorative Nursing. A review of the diagnoses included, but was not limited to, contracture right and left hand, muscle weakness. A review of the care plan revealed a Problem start date of 10/17/2023: Resident requires passive range of motion and orthotic management to bilateral upper extremities daily. Approaches included: Provide passive range of motion (PROM) to bilateral upper extremity digits in extension followed by hand hygiene, followed by orthotic application, once a day. Review of discharge information from Occupational Therapy (OT) included: Patient has reached maximal functional potential currently, necessitating discharge from OT services. The patient was placed on the Restorative Nursing Program (RNP) for bilateral upper extremity hands PROM, hand hygiene, and orthotic management to reduce the risk of further contracture and development and skin breakdown. Observation of R56 on 1/14/2024 at 8:59 am revealed she was unable to open her hands and she can move the right hand but not the left. 2. Review R127's Quarterly MDS dated [DATE] revealed: Section GG - Functional Abilities and Goals: dependent on staff for oral hygiene, shower/bath, and lower body dressing and required partial/moderate assistance with eating, toileting hygiene, and upper body dressing. Section O - Special Treatments and Programs: Did not receive Restorative Nursing. A review of the diagnoses included, but was not limited to, contracture left hand and muscle weakness. A review of the care plan revealed a Problem start date of 3/23/2023: Resident requires splint/brace assistance to left hand seven times per week. Approaches included: Place resident in the restorative nursing program: Patient will wear left resting hand splint one time per day for 2-3 hours, seven times per week to prevent further contractures and improve wrist stiffness, and overall maintain joint integrity. Review of OT discharge information included: OT discharge. Caregivers were educated on splinting schedule and assessment of skin with good understanding. Skilled services provided since the start of care included splinting management, progressive stretching, grooming/hygiene tasks, and PROM which improved the patient's abilities to tolerate the splint for a longer duration and decrease stiffness in the wrist. An observation on 01/13/24 at 9:08 am of R127 revealed she was able to move her right hand but not her left. During an interview with LPN SS on 1/14/2024 at 9:00 am, it was revealed there is no Restorative Nursing Program at this facility and there is nothing on the Medication Administration Record (MAR) about Range of Motion (ROM). During an interview with RN NN on 1/14/2024 at 9:10 am, it was revealed the R56 cannot feed herself or wash her face, nor can she open her hands. RN NN reviewed the MAR and verified there was nothing on it for a splint. She verified there was a statement on the care plan for ROM. During an interview on 1/14/2024 at 9:20 am with CNA PP, it was revealed that R56 had a ball that she puts in her hand, and she stated it may be in the laundry and not in the room. During an interview on 1/14/2024 at 9:30 am with CNA CC, it was revealed that R56 was getting a bath and CNA CC found the resident's splint at the bedside. She stated it was supposed to be put on every day, but usually, it was not on. During an interview on 1/14/2024 at 9:33 am with Physical Therapy Assistant (PTA) QQ, it was revealed that R56 was seen by OT in October 2023, and she was discharged from OT because skill services were not needed. She stated ROM can be maintained with a splint. She further stated that R127 was last seen by OT in March 2023. She verified OT discharge instructions for R127 included increased ROM left hand and left resting hand splint to be used four hours at a time daily. During an interview on 1/14/2024 at 10:15 am with LPN Unit Manager (UM) OO, it was revealed that R127 cannot wash her face, requires total care assistance, she can move her hands but with no coordination. LPN OO stated if a resident has an order for a splint, the nursing staff would be the ones who would put the splint on. LPN OO verified R127's care plan stated: splint/brace assistance to the left hand. During an interview on 1/14/2024 at 10:50 am with the RN MDS Director, it was revealed that any updates to the care plans are done by the Interdisciplinary Team. The RN MDS Director stated if therapy added a splint to the treatment plan, they would update the information on the care plan. The RN MDS Director stated there was not a Restorative Nursing Team at the facility, and further stated that CNAs were trained to provide Restorative Care. During an interview on 1/14/2024 at 11:30 am with the Director of Nursing (DON), it was revealed that resident care information is discussed in the morning meetings. The DON stated OT would recommend information for the care plan during the meetings, and the Infection Control Nurse would put the information in the computer. The nurse who takes care of the resident will notify the physician for an order. The DON further stated that CNAs are taught how to provide Restorative Nursing Care by the Staff Educator. The books the CNAs use for training are Nursing Rehabilitation/Restorative Program and Restorative Nursing Educational Response. The DON did not have the sign-in sheets for this program. The DON stated CNAs document ADL care in the computer including information about ROM and Restorative Care. The DON verified there was no documented Restorative Nursing care for R56 or R127. During an interview on 1/14/2024 at 1:00 pm with Senior CNA RR, it was revealed the CNAs document Restorative Care on the computer. CNA RR stated he did work in the Restorative Nursing Program before it was discontinued. He stated he believes it was discontinued due to low staffing schedules. During an interview on 1/14/2024 at 1:00 pm with Senior CNA RR, it was revealed the CNAs document Restorative Nursing Care on the computer. He stated he previously worked in the Restorative Program, but they do not have it now. He stated that R127 had not had a splint on today or yesterday. He could not show the surveyor documentation of when R127 had the splint on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration: Enteral Tubes, the facility failed to provide enteral nutrition and hydration according to current physician orders for one of twenty-one residents (R) (R64) receiving tube feeding via a gastrostomy tube (G-tube) (a tube placed into a patient's stomach through the abdominal wall to provide a means of feeding when oral intake is not adequate). The sample size was 37 residents. Findings include: A review of the facility's policy titled, Medication Administration: Enteral Tubes, revised 1/30/2020 revealed a Policy Statement: The healthcare center provides safe and effective administration of enteral formula and medications. Enteral formulas will be administered via feeding tube by physician order following nursing assessment of the patient/resident's condition and in consultation with the dietician and consultant pharmacist. The Procedure section line numbered 1 stated: Choice of enteral formula, route of administration, and rate of flow will be selected and administered on physician's order following assessments by nursing and dietician. Record review for R64 revealed diagnoses including dysphagia following cerebral infarction, gastro-esophageal reflux disease without esophagitis, and dysphagia (oropharyngeal phase). A review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R64 revealed Section G - Functional Abilities: resident was dependent on staff for assistance with activities of daily living (ADL), and Section K - Swallowing/Nutrition Status: received 51 percent or more of total calories through a tube feeding. A review of Active Orders for R64 revealed an order dated 7/20/2022 for Glucerna 1.5 at 60 milliliters (ml) per hour for 20 hours (1200 ml 1800 kilocalories) and water flush at 200 ml every 4 hours for 20 hrs. Turn feeding off 4 hours daily from 7:00 am until 11:00 am. A review of a Progress Note by the Registered Dietician (RD) dated 12/12/2023 at 4:21 pm revealed R64 was being followed by the RD due to nothing by mouth (NPO) with percutaneous endoscopic gastrostomy (PEG) tube in place. Glucerna 1.5 was ordered via PEG at 60ml per hour for 20 hours and 200ml flushes in place every 4 hours. No RD recommendations at this time. Observation on 1/12/2024 at 12:19 pm of R64 revealed Glucerna 1.5 infusing at 60 ml per hour via a feeding pump. The water flush bag was also attached, and the feeding pump was set to deliver 250 milliliters of water every 4 hours. Observation 1/13/2024 at 7:54 am revealed Glucerna 1.5 infusing at 60 ml per hour. The pump was programmed to deliver 250 ml of water every 4 hours. Observation 1/13/2024 at 9:52 am and 10:27 am revealed Glucerna 1.5 infusing at 60 ml per hour and water flush at 250 ml every 4 hours. During an interview and walking observation on 1/13/2024 at 10:41 am with Licensed Practical Nurse (LPN) BB and Registered Nurse (RN) AA, they verified R64's G-tube feeding was infusing at 60ml per hour and the water flush was infusing at 250 ml every 4 hours. RN AA stated the night nurse usually turns the feeding off before leaving her shift. LPN BB confirmed the water flush was being delivered at an incorrect rate and should be at 200 ml every 4 hours. LPN BB further stated that she had no idea how the pump got programmed incorrectly or how long R64 had been receiving the incorrect water flush. During an interview on 1/13/2024 at 10:56 am with the Director of Health Services (DHS), she indicated she would expect the nurses to check the feeding pump settings every shift. DHS stated that the night nurse should have turned the feeding off before leaving and the day nurse is responsible for resuming the feeding as ordered. Cross-reference F656.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews, and a review of the facility policy titled Oxygen Administration, the facility failed to ensure that oxygen therapy was administered as ordered by the Physician for one resident (R) (R48) receiving oxygen. The sample was 37 residents. Findings include: A review of the facility policy titled Oxygen Administration, revised 8/2/2023, revealed the Policy Statement: It is the policy of [NAME] Health Hospice and Healthcare Centers/Veteran Homes to provide oxygen safely and accurately to appropriate patients/residents. Record review revealed R48 had diagnoses including pulmonary hypertension and wheezing. A review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating little to no cognitive impairment; Section O -Treatments/Procedures revealed R48 received oxygen therapy. A review of the Physician's Orders for R48 revealed an order dated 12/7/2023 for oxygen at 2 liters per minute via nasal cannula continuously. A review of R48's January 2024 medication administration record (MAR) revealed oxygen at 2 liters continuously was documented as administered from 1/1/2024 to 1/12/2024. Further review of the MAR revealed a note on 1/9/2024 that indicated the order for the oxygen was discontinued. A review of the Progress Notes for R48 revealed as of 1/13/2023 at 9:01 am there was no documentation related to the existing oxygen order being changed or discontinued. Observation on 1/12/2024 at 8:59 am revealed that R48 was not wearing oxygen. The oxygen concentrator was turned off, and the nasal cannula was on the floor. Observations on 1/12/2024 at 12:01 pm and 4:29 pm revealed that R48 did not have oxygen on. The nasal cannula continued to be on the floor. Observation and interview on 1/13/2024 at 8:19 am with R48 revealed there was not an oxygen concentrator in R48's room. R48 told the surveyor that a nurse informed him a couple of days ago that he no longer needed to wear the oxygen. R48 further stated that the oxygen was started due to him having an excess of fluid in his body. During an interview on 1/13/2024 at 9:19 am with Licensed Practical Nurse (LPN) BB, she verified that R48 was not wearing oxygen on 1/12/2024 or at this time. LPN BB informed the surveyor R48 had not been wearing oxygen for days and that it should have been discontinued. LPN BB stated that she got an order to discontinue the oxygen late yesterday evening (1/12/2024). LPN BB stated she did not document the conversation in the progress notes or call the family. During an interview on 1/13/2024 at 9:36 am with the Director of Health Services (DHS), she revealed the issue related to R48 not wearing oxygen should have been addressed as soon as the resident expressed that he did not need the oxygen. She further stated that if the order is continuous, the resident should have it on, or the nurse should call the physician to get the order changed or discontinued.

Based on observations, interviews, record review, and review of the facility policy titled State Minimum Staffing for Healthcare Center, the facility failed to ensure sufficient staffing to meet residents' needs on one of seven units (F Unit). The census was 153 residents. Findings included: A review of the facility policy titled State Minimum Staffing for Healthcare Center, with the last revised date of 7/15/2016, revealed the Policy Statement included: Staffing shall be sufficient to meet the healthcare needs of each patient/resident as identified in the patient/resident's plan of care. 1. On 1/12/2024 at 10:35 am and 1/14/2024 at 1:11 pm, R18 was observed in bed with a hospital gown on and not shaved. A review of the care plan with the last revision date of 12/13/2023 revealed that R18 had a self-care deficit related to ADL care due to impaired physical status, vision, and muscle weakness (generalized) and that R18 required extensive to total assistance with ADL's, transfers, and bathing. 2. On 1/12/2024 at 11:22 am, 1/12/2024 at 6:08 pm, and 1/13/2024 at 10:48 am, R17 was observed in bed, not shaven and with a full and uneven beard. A review of the Quarterly MDS (Minimum Data Set) dated 12/14/2023 Section GG - Functional Abilities and Goals revealed that R17 was dependent on staff for personal hygiene, including combing hair, applying makeup, shaving, washing/drying face, and hands. 3. An observation of R123 on 1/12/2024 at 11:35 am revealed his nails were dirty and uncut and he was unshaven. He was observed to have a short afro that was uneven and untrimmed. A review of the care plan with the last revision date of 12/14/2023 revealed that R123 presented with a self-care deficit related to ADL care due to impaired physical mobility. The care plan noted that R123 will be assisted with daily grooming, oral, hair, and skincare. 4. On 1/12/2024 at 10:16 am, 1/13/2024 and 1/14/2024, R127 was observed in bed with a hospital gown on. Her fingernails were observed to be long and dirty. A review of the care plan with the last revision date of 2/28/2023 revealed that R127 presented with a self-care deficit related to impaired mobility and cognition. The care plan noted that R127 will be assisted with nail care as indicated. 5. Observation on 1/12/2024 at 12:25 pm and 1/13/2024 at 1:56 pm, R58 was observed to be unshaven. An interview with R58 on 1/12/2024 at 12:25 pm revealed he would like to be shaven, and that staff did not shave him. A review of the care plan with the last revision date of 1/4/2024 revealed that R58 presented with a self-care deficit for ADL care due to impaired mobility and weakness and that R58 required limited to extensive assistance with ADLs care and transfers. 6. An interview on 1/13/2024 at 1:55 pm with R79 revealed staff did not provide showers, bathing, shaving, and personal hygiene assistance. A review of the care plan with the last revision date of 9/30/2019 revealed that R79 presented with a self-care deficit for ADL care due to impaired mobility, weakness, and blindness and that R58 required supervision to limited assistance with ADL care and transfers. On 1/13/2024 at 2:27 pm, Certified Nursing Assistant (CNA) RR, CNA UU, and Unit Manager (UM) OO were interviewed. CNA RR stated that he had worked at the facility for 12 years and CNA UU stated that she had worked at the facility for 16 years. They confirmed that they worked 12-hour shifts, and stated they do the best they can with showers. CNA RR stated that he can get maybe two residents in the shower during his shift, but the rest of the residents must get bed baths because they just don't have time to shower everyone. When questioned about shaving residents, CNA UU stated that she tries to bring her clippers once a week. She stated the facility did not have clippers for the residents, so she must bring her own. Unit Manager (UM) OO stated that the census on the F Unit was 45, that they have one nurse to pass medications, and have two CNAs on the unit. A review of the Midnight Census Worksheet dated 1/13/2024 compared to the shower assignment sheet revealed that there were nine showers assigned for 1/13/2024. During an interview with the Director of Nursing (DON) on 1/13/2024 at 2:35 pm, she stated that the goal was to have two nurses on the F Unit on the 7:00 am to 7:00 pm shift. She stated they were aggressively hiring. She confirmed that the facility does not use agency staff and that when they are short-staffed, they try to call people in and depend on as-needed (PRN) staff. When questioned about agency staff, she stated she would like to have that as an option. During an interview with the Administrator on 1/13/2024 at 2:38 pm she stated that they have five CNAs coming on board and ideally, they would have more CNAs. When asked how they decide how many CNAs and nurses they need to staff each unit, she stated that they look at the resident care needs when they decide how to staff the unit. She stated it depended on the type of residents. She confirmed that the use of agency staff was not an option as it had not been approved by the corporation to employ agency staff. During an interview on 1/14/2024 at 9:40 am, CNA UU stated that she had expressed to the management that they needed more help on this unit. She stated they have three meals, bathing, and personal care for each resident. She further stated they do the best they can. During an interview on 1/14/2024 at 10:00 am, LPN SS stated that she was the only nurse on the unit on this date and that she had to pass medication for all 36 residents, complete blood sugar for 10 residents, provide a tube feeding for one resident, complete five skin assessments Monday through Thursday, and complete four skin assessments on Friday and Saturday on the 7:00 am-7:00 pm shift. She stated that on the weekends, the wound care nurse was not there, so she had to complete the wound care and change bandages if they were soiled. She stated there were six residents with wounds on the F Unit. She further stated she had to make appointments and schedule transportation for all appointments including dialysis. She stated she had to assess the dialysis residents when they returned, and she confirmed that there were four residents receiving dialysis on the F Unit. She stated that she must complete all tasks for new admissions, send residents to the hospital, assess after falls, and do all the vital signs. She further stated that many days she leaves late and stated nine out of ten days, she was the only nurse assigned to the F Unit. During an interview on 1/14/2024 at 10:15 am, LPN FF, the wound care nurse, stated that she is not scheduled to be at the facility on weekends, so the nurses do any wound care on the weekends. A review of the Gardinia Unit Focused Observation/Skin Note Schedule revealed that the 7:00 am to 7:00 pm shift had five skin assessments scheduled Monday through Thursday and four skin assessments scheduled Friday and Saturday on the 7:00 am to 7:00 pm shift. On 1/14/2024 at 11:03 am, CNA UU was observed using the mechanical lift with a resident and without staff assistance. She brought the resident into the hall and placed the resident in a geriatric chair. She stated that the other CNA was busy and stated, she would usually use two people, but she does the best she can. She confirmed that seven residents required the use of a mechanical lift on her assigned unit.

Based on staff interviews, record review, and review of the facility policy titled Monitoring of Antipsychotics, the facility failed to ensure one of five residents (R) (R26) reviewed for unnecessary medications received medications as ordered. Specifically, the facility failed to decrease the dose of aripiprazole (an antipsychotic medication) for R26 as ordered by the Nurse Practitioner (NP). Findings include: A review of facility policy titled Monitoring of Antipsychotics revised 7/20/2020 revealed the Policy Statement: Patients/residents receive antipsychotic medications only when medically necessary. Every effort is made for patients/residents who use antipsychotics to receive the intended benefit of the medications and to minimize the unwanted effects of the antipsychotic medications. The Procedure section line numbered 6 stated: Gradual dose reduction is attempted with all patients/residents who receive antipsychotic medications. A review of R26's Face Sheet revealed the resident was admitted to the facility with a diagnosis including unspecified schizophrenia, major depressive disorder, generalized anxiety, and delusional disorder. A review of R26's electronic medication administration record (eMAR) indicated aripiprazole tablet 10 milligrams (mg) (a medication used to treat schizophrenia) one tablet by mouth once a day was started on 8/29/2022. A review of a Consultant Pharmacist Communication to Physician document dated 7/25/2023, revealed a recommendation to review R26's antipsychotic medications. Further review of the recommendation revealed the facility's NP wrote an order for trial dose reduction to decrease Abilify (a brand name for aripiprazole) to 5 milligrams. This order was dated 7/28/2023. A review of the eMAR for July 2023 through January 13, 2024, revealed R26 received aripiprazole 10 mg tablet once daily at 9:00 am every day. A review of the Life Source Psychiatry Follow Up note with a date of service of 8/9/2023 revealed a list of R26's current medications to include aripiprazole 10 mg 1 tablet daily. During an interview on 1/13/2024 at 1:33 pm with Licensed Practical Nurse (LPN) DD, it was revealed that R26 currently had a supply of aripiprazole 10 mg on the medication cart for administration. During an interview on 1/14/2024 at 8:16 am with LPN Unit Manager KK, she revealed she is responsible for following up on pharmacy recommendations. LPN KK verified that the gradual dose reduction (GDR) for R26 was approved by the NP on 7/28/2023 to decrease the Abilify to 5mg daily. LPN KK also verified the medication was not adjusted and R26 was still receiving aripiprazole 10 mg daily with a start date of 8/29/2022. During an interview on 1/14/2024 at 9:25 am, the Director of Health Services (DHS) revealed the pharmacy consultant comes into the facility monthly and provides her with recommendations. The recommendations are addressed by the provider and the orders are written and documented with what the physician orders. DHS further stated that R26's care is managed by a NP who would usually put her orders into the electronic system herself. DHS verified that NP approved the recommendation, and the dose did not appear to have been reduced, due to the current order having a start date of 8/29/2022. During a telephone interview on 1/14/2024 at 9:36 am with LPN Unit Manager BB, she revealed she cannot remember back to July. LPN BB further stated that she was the only Unit Manager working in the facility during that time. LPN BB also stated that if she wrote a progress note, and did not change the medication order, maybe she had gotten called to do something and forgot to change the order in the system. LPN BB further stated that typically new orders or changes in care are discussed in the morning meetings, but she was being pulled to the medication cart a lot, so it may have gotten missed. During an interview on 1/14/2024 at 1:33 pm, the Administrator revealed that she expected the physician's orders to be carried out and followed. She further stated the DHS holds a clinical meeting daily to check on these things, and the DHS is overall responsible for ensuring compliance. Cross-reference F656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review, the facility failed to provide routine dental services for one of 37 sampled residents (R) (R17). This failure had the potential to negatively impact R17's quality of life. Findings included: On 1/12/2024 at 11:22 am R17 was observed with only a few natural and they were discolored/decayed. A review of the clinical record revealed that R17's funding source was Medicaid GA. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed to have obvious or like cavities or broken natural teeth. During an interview with the Administrator and the Director of Nursing on 1/14/2024 at 3:32 pm, they confirmed if a resident was evaluated by the dentist, the consult would be in the Electronic Medical Record (EMR). A review of the EMR revealed there was no documentation of a dental exam or consult for routine dental examination.

Based on observation, staff interview, and review of the facility recipe titled Puree Oven Baked Chicken, the facility failed to ensure dietary staff followed recipes for preparing pureed foods to avoid compromising the nutritive value, flavor, or appearance. This affected eight of 136 residents receiving an oral diet. Findings include: A review of the recipe titled Pureed Oven Baked Chicken, revealed the smallest amount to prepare was for 50 servings. The recipe ingredients included oven-baked chicken, broth, and thickener. Observation on 1/13/2024 at 10:05 am of Assistant Dietary Manager (ADM) puree chicken for lunch meal revealed she placed 12, four-ounce scoops of cooked chicken in the food processor bowl and pureed. The ADM opened the lid, scraped the sides of the bowl, and then added two large handfuls of breadcrumbs and continued to puree. The ADM opened the lid, scraped the sides of the bowl, added four, four one-ounce spoons of chicken broth, and continued to puree. The ADM placed the pureed chicken in a steam table pan and placed it in the oven to reheat. During an interview on 1/13/2024 at 10:05 am, the ADM revealed that eight residents received a puree consistency diet with one of those residents receiving double portions. The ADM revealed that she prepares 12 servings of puree to have extra. A continued interview with the ADM confirmed that she did not follow the recipe for puree chicken. The ADM revealed that they use breadcrumbs instead of thickener due to taste and texture. The ADM confirmed that the substitution of breadcrumbs for thickener had not been approved by the dietitian. During an interview on 1/13/2024 at 10:10 am with the Registered Dietitian (RD), she revealed that she was recently employed by the facility and has not had an opportunity to review menus. The RD confirmed that any modification of a recipe needs to be communicated to the dietitian.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review, review of the facility policy titled Nutritional Screening and Assessments/Food Preferences, and review of the facility document titled Position Description: Job Title: Dietary Manager, the facility failed to honor food preferences for one resident (R) (R84) of 67 residents with food likes, dislikes, and preferences. Findings include: A review of the policy titled Nutritional Screening and Assessments/Food Preferences, reviewed 1/8/2021 indicated the Policy Statement was: It is the policy of [NAME] Health for patient/resident to receive an initial nutritional screening and comprehensive nutritional assessment upon admission. The Food Preference Form is completed for each patient/resident upon admission and annually to ensure food choices and preferences are granted. The Procedure section revealed: 3: The Dietary Manager, Dietitian, or a designee will visit the patient/resident to discuss the patient/resident's preferences, choices, and/or religious, ethnic, and cultural preferences within five days. The preferences will be documented on the Diet History/Food Preference List Form (see attached sample form). 4: Each patient/resident's information from the Food Preference List will be transferred to the patient/resident's tray card in the electronic tray card system. 6: Patient/resident food preferences and choices will be honored within reason according to the patient/resident's diet order and menu selections available. Review of the document titled Position Description: Job Title: Dietary Manager, with a modified date of 1/2016 indicated: Job Purpose: Plans, organizes, develops, and directs the overall operation of the Dietary Department in accordance with current federal, state, and local regulations governing the center and as directed by the Administrator. Responsible for maintaining the Dietary Department in a clean, safe, and sanitary manner and provide nutritionally adequate meals in accordance with regulatory guidelines. Key Responsibilities: 1. Interview patient/family to obtain food preferences, habits, diet history, and other pertinent nutrition information. A review of R84's Annual Minimum Data Set (MDS) dated [DATE] revealed Section C - Cognition documented a Brief Interview for Mental Status (BIMS) was assessed as 15 which indicated R84 was cognitively intact. A review of the care plan initiated on 8/12/2022 revealed that R84 has a potential for alteration in nutrition related to protein-calorie malnutrition. Interventions to be implemented included adhering to likes and dislikes. Review of R84's electronic medical record (EMR) under Resident Documents, the Diet History/Food Preference List form dated 6/8/2021 revealed section E. Food Dislikes: fish, shrimp, cream of wheat, grits, and oatmeal were marked. The document was signed by the Dietary Manager (DM). In an interview on 1/13/2024 at 10:17 am with R84, the resident stated the facility does not honor her dislikes. The resident stated two years ago on admission she was asked about her likes, dislikes, and foods that she prefers. The resident stated the dislikes were listed on her tray card and that she does not like any type of seafood. She stated that fish was on the dinner meal tray that she received last night (1/12/2024). The resident stated she has not had any other follow-up visits since admission from the Dietary Manager regarding her (R84) likes, dislikes, or food preferences. An observation on 1/13/2024 at 12:32 pm revealed that R84 was eating lunch. The resident provided the surveyor with the tray card. A review of the tray card revealed fish, shrimp, oatmeal, and grits are listed in red as a dislike. An interview on 1/14/2024 at 11:50 am with the DM stated within 48 hours after a resident is admitted to the facility, she or the Assistant Dietary Manager will complete the Diet History/Food Preference List document with the resident, family, or responsible party. The DM stated she visits the residents annually and quarterly to review and update likes, dislikes, or preferences. She stated she became aware on 1/13/2024 that R84 was served fish for dinner on 1/12/2024. The DM stated after speaking with the dietary staff she believes that the resident was served fish. She stated she did counsel the cook and re-educated the dietary staff on reading the tray cards to ensure the residents were receiving the right food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. A review of Active Orders for R64 revealed an order dated 7/20/2022 for Glucerna 1.5 at 60 milliliters (ml) per hour for 20 hours (1200 ml 1800 kilocalories) and water flush at 200 ml every 4 hours for 20 hrs. A review of the care plan for R64 revealed resident had an alteration in nutrition and hydration related to the resident receiving all nutrition and hydration via a G-tube (a tube placed into a patient's stomach through the abdominal wall to provide a means of feeding when oral intake is not adequate). The approaches in the care plan included: Flushes as ordered and tube feeding as ordered. Observations on 1/12/2024 at 8:48 am, 1/13/2024 at 7:54 am, 9:52 am, and 10:27 am revealed the setting on the feeding tube pump to indicate the water flush was infusing at 250 ml every 4 hours. During an interview and walking observation on 1/13/2024 at 10:41 am with LPN BB, she confirmed the water flush was being delivered at an incorrect rate and should be at 200 ml every 4 hours. During an interview on 1/13/2024 at 10:56 am with the DHS, she verified that the staff was not following/ implementing R64's plan of care for tube feeding. 7. A review of R26's clinical record revealed a Consultant Pharmacist Communication to Physician document revealed the facility's Nurse Practitioner (NP) wrote an order for a trial dose reduction to decrease Abilify (a medication used to treat schizophrenia) to 5 milligrams (mg). This order was dated 7/28/2023. A review of the Electronic Medication Administration Record for July 2023 through January 13, 2024, revealed R26 received aripiprazole (the generic name for Abilify)10 mg tablet once daily at 9:00 am every day. A review of the care plan revealed that R26 was at risk for alteration in behavior due to schizophrenia. The approaches on the care plan included administering the resident's medication as ordered by the physician. During an interview on 1/14/2024 at 9:25 am the DHS revealed that the staff was not following or implementing R26's plan of care. 4. A review of R130's Quarterly MDS dated [DATE] Section M revealed that R130 had one unhealed stage 3 pressure ulcer. A review of R130's care plans revealed that there was not a care plan area for pressure ulcers, nor interventions to address pressure ulcers. An interview with RN GG on 1/13/2024 at 7:55 am revealed RN GG stated that she is the MDS Director. She stated that care plans are developed by the IDT. RN GG confirmed that there was not a care plan area to address R130's pressure ulcer. An interview with Licensed Practical Nurse (LPN) FF on 1/13/2024 at 2:33 pm confirmed that there was not a pressure ulcer care plan to address R130's pressure ulcer. She stated one of the treatment nurses should have developed a care plan to address R130's pressure ulcer. 5. A review of R133's Significant Change MDS dated [DATE] Section O - Special Treatments and Programs revealed she received hospice care while a resident. A review of R133's care plan revealed that there was not a care plan area for hospice/palliative care, nor interventions to address hospice/palliative care. An interview with RN GG on 1/14/2024 at 7:55 am confirmed that there was not a care plan area to address hospice/palliative for R133. She stated that care plans were developed by the IDT. She stated that the person who identifies a problem is the person who develops a care plan for it. RN GG stated that care plans are updated quarterly and as needed. RN GG stated that there is no individual care plan for hospice/palliative care. An interview with the DHS on 1/14/2024 at 8:26 am revealed the DHS stated that the nurses were responsible for the baseline 48-hour care plan upon admission. The DHS stated that she follows up to ensure care plans are in. An interview with Senior Nurse Consultant (SNC) II on 1/14/2024 at 8:43 am revealed the process for care plans was for the nurse to initiate the baseline care plan on admission. She stated that MDS makes sure that care plans are initiated. SNC II stated that a resident who is receiving hospice or palliative care should have a hospice or palliative care plan. SNC II stated that it should have been caught by MDS. She stated that consultants and MDS consultants come in annually and do care plan audits. She stated that she has not conducted a care plan audit because she acquired this facility on 12/1/2023. An interview with LPN HH on 1/14/2024 at 11:33 am revealed that R133 was no longer on hospice services. She stated that R133 is now receiving palliative care services. She stated that palliative care has a Nurse, CNA, Social Worker, and a Chaplain. LPN HH stated that palliative care is like hospice care, but they do not receive as many visits. LPN HH stated that R133 should have a palliative care plan. 2. A review of the clinical record revealed that R17's current funding source was Medicaid GA. A review of the Annual MDS assessment dated [DATE] Section L - Oral/Dental Status revealed that the resident was assessed to have obvious or like cavities or broken natural teeth. A review of the comprehensive care plan for R17 revealed there was not a care plan for dental services or care. During an interview on 1/14/24 at 3:27 pm with the MDS Director GG, she stated that R17 should have a dental care plan. She stated sometimes it was put under the care plan for nutrition. After reviewing the care plan, she confirmed that R17 did not have a dental care plan. During an interview on 1/14/24 at 3:40 pm, the MDS Director GG stated that she only signs off that the MDS is complete, and she does not check for accuracy. She stated that the MDS Coordinator LL completed the dental section and MDS Coordinator LL signed off that it was accurate. During an interview on 1/14/24 at 3:45 pm, the MDS Coordinator LL stated there should be a care plan for dental services and further stated she would complete one. 3. A review of R9's Quarterly MDS dated [DATE] revealed that she had a BIMS score of 99, which indicates severe cognitive impairment. Section I - Active diagnosis revealed a diagnosis of dementia. A review of R9's care plans revealed that there was not a care plan area for dementia, nor interventions to address dementia. During an interview with Registered Nurse (RN) GG on 1/14/2024 at 7:55 am, RN GG confirmed that there was not a dementia care plan for R9. She stated that care plans were developed by the Interdisciplinary Team (IDT). She stated that the person who identifies a problem is the person who develops a care plan for it. RN GG stated that care plans are updated quarterly and as needed. Based on record review, staff interviews, and review of facility policy titled Care Plans, the facility failed to develop or implement a care plan for seven of 37 sampled residents (R) (R81, R17, R9, R130, R133, R64, and R26). Findings include: A review of the facility policy titled Care Plans revised 7/27/2017, revealed the section titled admission Comprehensive Plan of Care line numbered 3: The comprehensive person-centered care plan is developed to include measurable goals and timeframe to meet a resident's medical, nursing, and psychosocial needs, the services that are furnished to attain or maintain the resident's highest practicable physical, mental psychosocial needs that are identified in the comprehensive assessment. The section titled Care Plan Review and Update line numbered 4: Care plans will be updated by nurses, Case Mix Directors, or any other interdisciplinary team member so that the care plan will reflect the resident's needs at any given moment. 1. A review of the clinical record revealed that R81 was admitted to the facility with diagnoses including, but not limited to, anxiety disorder and suicidal ideations. A review of a Psychotherapy Comprehensive Clinical assessment dated [DATE] revealed a treating diagnosis of chronic Post Traumatic Stress Disorder (PTSD). A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section I - Active Diagnoses revealed a diagnosis of post-traumatic stress disorder. A review of the care plan last updated on 12/19/2023 revealed a care plan had not been developed for R81 for PTSD. During an interview on 1/12/2024 at 2:20 pm with the Social Worker, she revealed that she was not aware of R81 presenting with the diagnosis of PTSD. During an interview on 1/14/2024 at 8:35 am the Director of Health Services (DHS) revealed if a resident has a diagnosis of PTSD, there should have been a care plan developed for PTSD. During an interview on 1/14/2024 at 11:30 am the Social Worker revealed that she missed the PTSD diagnosis on the psychotherapy assessment. The Social Worker revealed that she was not responsible for developing a care plan for any resident with PTSD and stated the care planning team/MDS was responsible for developing the PTSD care plan. During an interview on 1/14/2024 at 12:05 pm, MDS Coordinator MM confirmed that R81 did not have a care plan for PTSD. MDS Coordinator MM revealed that MDS was responsible for care planning PTSD, and R81's diagnosis of PTSD was missed by staff.

Based on observations, staff interviews, and review of the facility policies titled Labeling, Dating, and Storage, Leftovers, Food Ordering, Receiving, and Storage, Dishwashing, and Pot/Pan Washing and Sanitation, the facility failed to label, date, and securely wrap opened food items; failed to remove dented cans from general can storage; failed to prevent wet nesting in staked pans to eliminate potential of bacteria growth; and failed to sanitize dishware to prevent cross-contamination. This deficient practice affected 136 of 153 residents receiving an oral diet. Findings include: 1. A review of the facility policy titled Labeling, Dating, and Storage, revised 11/11/2022, revealed the Procedure section lines numbered 1. Food and beverage items will have an identifying label as well as a received date and opening date. 2. Foods will be stored in their original or approved container and if opened shall be wrapped tightly with film, foil, etc. A review of the facility policy titled Leftovers, dated September 2001, revealed the Guidelines section line numbered 5. Non-perishable leftovers need to be stored in a dry cool area and be dated and labeled after being opened. Observation on 1/12/2024 at 8:45 am of the dry storage area revealed a five-pound bag of grits that had been opened with no date, an opened package of square cheese crackers with no date, and an opened one-pound bag of potato chips with no date. During an interview on 1/12/2024 at 8:45 am, the Assistant Dietary Manager (ADM) confirmed that the bag of grits, cheese crackers, and potato chips had been opened and had no open date on them. The ADM revealed that dietary staff should have placed an open date on the items before storing them. Observation on 1/12/2024 at 9:15 am of the freezer located outside in a rented trailer revealed an opened case of sliced pepperoni that was not covered, the inside contents were completely exposed. Further observation revealed an open bag of steak fries that was not securely wrapped or dated. During an interview on 1/12/2024 at 9:15 am, the ADM confirmed that the case of sliced pepperoni was open to the air and the opened bag of steak fries was not securely wrapped and dated. The ADM revealed that dietary staff should have closed the case of sliced pepperoni after use and should have wrapped and dated the opened bag of steak fries. 2. A review of the facility policy titled Food Ordering, Receiving, and Storage, revised 6/14/2016, revealed the Procedure section line numbered 9. Dented cans should be kept in a separate designated area, with a dented can sign, and away from regular stock. Observation on 1/12/2024 at 8:45 am of the dry storage area revealed a large can storage rack. Continued observation revealed a 105-ounce can of mandarin oranges with a large dent to the side stored on the rack within general cans. During an interview on 1/12/2024 at 8:45 am, the ADM confirmed that the can of mandarin oranges had a large dent to the side and had not been placed in the dented can area. The ADM revealed that staff should have noted the large dent and placed the can in a separate area in the dry storage area specifically for dented cans. Observation on 1/14/2024 at 9:05 am of the dry storage area revealed another 105-ounce can of mandarin oranges with a large dent to the side and on the can rack. During an interview on 1/12/2024 at 9:05 am, the ADM confirmed that there was another can of mandarin oranges with a large dent to the side. The ADM revealed that she had gone through the cans after the initial kitchen tour on 1/12/2024 and she missed this can. The ADM revealed that the dented can should have been placed in the dented can location. 3. A review of the facility policy titled Dishwashing, revised 3/23/2016, revealed the Procedure section line numbered 8. Allow all items to thoroughly air dry before unloading racks or storing items. A review of the facility policy titled Pot/Pan Washing and Sanitation, revised 4/11/2016, revealed the Procedure section line numbered 1 contained: Air dry pots and pans on the drainboard. Inspect for cleanliness and store pots and pans, inverted in a clean, dry, protected area. Observation on 1/12/2024 at 9:30 am of the pot and pan rack revealed stacks of steam table pans. A stack of four medium-sized rectangle steam table pans were pulled apart and the top three pans had moisture inside. A stack of two medium-sized rectangle steam table pans were pulled apart and the top pan had moisture inside as well and had four areas inside with a white substance. The white substance was on each side of the pan, each about two to three inches in length and one-quarter inch in width. During an interview on 1/12/2024 at 9:30 am, the ADM confirmed that the stacked steam table pans were stored stacked and wet. The ADM confirmed that the one steam table pan was not cleaned properly and had a white substance inside. She revealed that staff should allow pans to completely dry before stacking and should check the inside of the pan to ensure the pans were clean before stacking. Observation on 1/14/2024 at 9:15 am of the pot and pan rack revealed a stack of seven square steam table pans. The top five pans were pulled apart and all five pans had moisture inside. One of the steam table pans was tipped to the side and water ran from the edge of the pan to the floor. During an interview on 1/14/2024 at 9:15 am, the ADM confirmed that all five square steam table pans were stacked and stored with moisture on the inside of the pans. The ADM revealed that dietary staff should have allowed the pans to completely dry before stacking. 4. A review of the facility policy titled Pot/Pan Washing and Sanitation, revised 4/11/2016, revealed the Procedure section line numbered 1. A three-compartment sink is used for manual washing, rinsing, and sanitizing of utensils, pots, pans, and all other items to be hand washed. Pots, pans, and utensils must be sanitized in the sanitizer sink according to one of the following methods: heat sanitizer or chemical sanitizer. Observation on 1/13/2024 at 11:50 am of Dietary Staff JJ using the three-compartment sink to wash a steam table pan and lid revealed she washed the items with soapy water and rinsed them under running water then placed them in the drying area. Dietary Staff JJ did not sanitize the steam table pan before drying. Further observation of the three-compartment sink revealed the sanitizing sink had not been set up with a sanitizing solution for usage at the time Dietary Aide JJ was washing dishware. During an interview on 1/13/2024 at 11:50 am, Dietary Aide JJ confirmed that she did not sanitize the steam table pan or lid with a sanitizing solution. Dietary Aide JJ confirmed that the sanitizing sink had not been properly set up with a solution for usage. Dietary Aide JJ revealed that she did not properly sanitize the pan or lid due to the sanitizing sink having no solution. Dietary Aide JJ could not explain why she did not fill the sanitizing sink with a sanitizing solution. During an interview on 1/13/2024 at 11:50 am, the Dietary Manager (DM) revealed that she expects the dietary staff to properly wash and sanitize dishes when using the three-compartment sink. The DM revealed that staff should have filled the sanitizing sink with a sanitizing solution if washing dishes using the three-compartment sink.

Based on observations and staff interviews, the facility failed to ensure that it was maintained in a safe clean and comfortable environment. Specifically, the facility failed to ensure residents rooms were in good repair on two of seven halls (D Hall and F Hall) that was occupied by residents. Findings include: On 4/26/22 at 12:32 p.m., observation of resident room F7 revealed paint in residents' bathroom behind the toilet was peeling near the base, brown ring on the floor around the toilet, and molding on the wall entering residents' room has cracked sheet rock noted. On 4/26/22 at 12:36 p.m., observation of room F10 wall behind bed B needs repair. Paint is scuffed off wall, behind bed A there were black spots and chipped paint under overbed light. On 4/26/22 at 12:40 p.m., observation of room F11 revealed wall to the right, walking into room adjacent to bed A revealed spackle applied to wall with areas of chipped paint, air vent located on the wall to left room entrance had noted hole under vent with cracked dry wall noted, two holes in wall right of bed B under the window, and chipped peeling paint noted on windowsill. On 4/26/22 at 12:44 p.m., observation of room F12 revealed black marks noted on the wall beside bed A above the bedside table, and black marks on wall by bed B under windowsill. On 4/28/22 at 8:30 a.m., interview with Licensed Practical Nurse (LPN) AA revealed that any maintenance concerns are written in the maintenance logbook that is located at the nurse's station. Further interview also revealed that repairs that require immediate attention, maintenance is notified verbally. Maintenance usually checks the maintenance logbook early in the morning and throughout the day. On 4/28/22 at 9:25 a.m., environmental rounds were conducted with Administrator, Maintenance Director, and Housekeeping Supervisor to confirm all repairs needed for F Hall that was observed during the three-day survey process. On 4/28/22 at 9:27 a.m., interview with Maintenance Director revealed the staff reports any maintenance issues to the department by logging the concern in the maintenance logbook that is located at each nursing station. Further interview also revealed there is also the Building Engines program that maintenance request is put into as well. The maintenance logbooks are checked several times throughout the day for needed repairs. Continued interview also revealed Maintenance Director was aware of confirmed observations on F Hall with no time frame of when repairs would be completed. On 4/28/22 at 9:47 a.m., interview with Administrator revealed the expectation is for the facility to be always in good repair. Further interview also revealed there had been a recent change in staff in the maintenance department that left only two staff members in that department. Continued interview also disclosed that there would be a call made to the corporate office to solicit for more help to address the concerns of the needed repairs. Further interview also revealed there are no policy or procedures pertaining to maintenance. There is a quarterly maintenance process that is followed by maintenance that alerts them to what areas to check for repairs.