**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration: General Guidelines, the facility failed to adhere to accepted standards of quality care by crushing medications that cannot be opened or crushed in one out of seven residents observed during a medication pass, and not measuring the correct dosage of Diclofenac ointment (nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain and inflammation) in one out of seven residents (R) (R12) who have diclofenac ointment ordered. This deficient practice could result in serious adverse effects, including an increased risk of medication side effects or reduced efficacy due to improper administration techniques. Findings include: A review of the facility policy Medication Administration: General Guidelines revised 4/10/2019 reveals that Medications are administered as prescribed. 2. Medications are administered in accordance with written orders of the attending physician .If a dose seems excessive considering the resident's age or condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. 21. Liquid dosage forms may be used whenever physically practical in place of solid tablets that would have to be crushed and especially for administration through enteral feeding tubes. The nurse checks with their provider pharmacy to determine if a liquid form is available and covered by the applicable payment program. The physician is contacted for a new order before changing the dosage, unless the physician has previously authorized that alternate dosage forms of the ordered drug may be used if necessary and appropriate. 22. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a patient/ resident has difficulty swallowing or is tube fed using the following guidelines: -long-acting or enteric-coated dosage forms should generally not be crushed and require a physician-specific order to do so. The physician must record in the medical records that the benefit of crushing the dosage form outweighs any potential risk. -The need for crushing medications is indicated on the patient/ resident paper MAR or e-MAR so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety and alternatives, if appropriate, during paper MAR or e-MAR reviews. R12 was admitted to the facility on [DATE] with diagnoses including, but not limited to old cerebral infraction, aphagia and dysphagia, pneumonia, gastroesophageal reflux disease, chronic pain syndrome, dysarthria and anarthria, and pain in left knee. A review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 9, indicating the resident has moderate cognitive deficit. Section K, Swallowing/Nutrition Status, indicated the resident is on a mechanically altered diet. Section J indicates that the resident is experiencing pain. A review of the Orders dated 6/2/2021 reads: Resident gets medication crushed and takes them orally. Review of the Orders for diclofenac sodium gel [over-the-counter (OTC)] gel; 1%; amount. 4 grams (g); topical with a start date of 5/27/2022. Apply 4g to the left knee four times daily. Review of the Orders for potassium chloride capsule, extended release; 10 milliequivalent (mEq); amount 3 capsules; oral with a start date of 1/16/2025. Special Instructions: for hypokalemia. Do Not Crush. Ok to open capsule and pour in apple sauce. Review of the Orders for rivastigmine tartrate; 3 milligram (mg); 1 cap; oral with a start on 11/2/2023. Special Instructions: Do not crush. During the med pass conducted on 1/16/2025 at 8:45 am by a Licensed Practical Nurse (LPN) AA on a R12, it was observed that when administering medications to the resident, she crushed them finely and mixed them with water, stating that the resident could not swallow them. Upon reviewing the medications, some medications, such as extended-release potassium chloride capsules and rivastigmine tartrate capsules, were identified to not be opened or crushed, as indicated on the medication package and in the order. LPN AA agreed that she should have contacted the pharmacist or the doctor to explore alternative forms of the medications. When further observing the LPN AA administering Diclofenac gel to the resident, LPN AA was noted to squeeze an unmeasured amount of the ointment into a small medicine cup, locking the tube back into the med cart, and proceeded to the resident's room. When LPN AA was questioned about how she ensured she was administering the doctor-ordered 4 grams (g) of the gel, the LPN AA admitted she did not know how to measure it correctly. An interview with a Unit Manager (UM) for the first floor, LPN BB on 1/16/2024 at 12:00 pm revealed that if a resident cannot swallow a pill, they would call the pharmacy to clarify if a medication could be crushed, or if it could be changed to another form. She further reported that they would then reach out to the doctor to get it okayed by the MD. UM LPN BB reported that the correct way of measuring the diclofenac ointment is to squeeze the gel on a measuring card to ensure the correct dosage is administered. During an interview with UM LPN CC on 1/16/2025 at 12:05 pm she revealed that if a resident cannot swallow a medication, the nurse should first call the pharmacy to see whether the medication can be changed to another form. UM LPN CC reported the correct way of measuring and administering diclofenac ointment, was to just squeeze the gel into a small medication cup. UM LPN CC further reported that she would use somewhere around 5-15 ml but was unclear on the precise amount. When asked about using the measuring card that comes with the medication UM LPN CC revealed that she was unaware of the measuring card. During an interview with the Director of Nursing (DON) on 1/16/2025 at 12:50 pm, it was revealed that if a resident has problems swallowing medication and the extended-release capsule cannot be opened or crushed, they call the pharmacy and then a doctor to get it switched to another form, if possible. The DON then stated that they do not measure and administer it liberally when referring to the correct way of measuring diclofenac ointment. The DON acknowledged not being aware that the ointment comes with a measuring card and was not sure if there was a policy concerning this. During an interview on 1/16/2025 at 3:15 pm Pharmacist DD revealed that they write special instructions on the Medication Administration Record (MAR) if a medication cannot be crushed or if a capsule cannot be opened. She further stated that nurses often notice and inform the pharmacy services when a resident has difficulty swallowing. At this point the pharmacy would advise them if an alternative form is available. Nurses then return to the doctor to have the order changed. The DON further explained that when a resident is admitted to the facility, and their medications are entered, the staff are attentive for signs of dysphagia and notifying pharmacists. In such cases, alternative forms of medication are explored. For instance, potassium chloride (KCL) can be switched to a liquid form, and rivastigmine (Exelon) also comes in a transdermal form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the Transmission Based Isolation Precautions policy, effective date 3/1/2019, section five, Enhance Barrier Precautions (EBP) revealed that Enhanced Barrier Precautions expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multi-drug resistant organisms (MDROs) to staff hands and clothing. The use of gown and gloves for high-contact resident care activities is indicated when contact precautions do not otherwise apply, for nursing home residents with wounds and or indwelling devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Review of the electronic medical record for R3 was admitted to the facility on [DATE] following hospitalization. She was admitted to the facility with diagnoses that included but were not limited to the wound of right elbow, unstageable pressure ulcer of sacral region, stage II, Bacteremia, Unspecified fracture of lower end of left radius, and encounter for attention to gastrostomy. A review of the annual minimum data set (MDS) dated [DATE], revealed Section M which indicated R3 had a stage II pressure ulcer/injury on the sacrum, which was in place at admission to the facility. R3 also was being treated for a right elbow unstageable wound by off-site wound care provider. Review of the care plan revealed that R3 had an abrasion of unknown origin to left elbow at admission on [DATE]. Last review of care plan was 1/16/2024. Care plan last reviewed 1/16/2025 notes tube feeding creates risk for aspiration, weight loss and dehydration. Risks for MDRO due to this medical device. Review of the physician orders for R3 regarding wound care on elbow states effective R3 was placed on Enhanced Barrier Precautions effective 12/12/2024 due to wound with wound vac. Physician's orders for Gastrostomy bolus of Jevity 1.5 five times a day and to check for residual before feeding. If residual is greater than 100 mL, hold feeding and call MD for further orders. Check tube placement prior to med administration/flushes. During medication administration times, flush tube with 15 milliliters (mLs) water before and after medications and 5 mLs with each medication. On 1/15/2025 at 8:39 am, licensed practical nurse LPN LL, was observed sitting next to R3 reclasping percutaneous (peg) tube. He stated that he had just completed her bolus feeding. At the time of this observation no PPE was in use. It was noted that the room of R3 was not marked for EBP although the matrix indicated Stage II pressure ulcers and g-tube feeding. LPN LL left room with supplies remaining on the side table, formula bottle and syringe unlabeled. LPN LL continued his med pass to other residents. There was a cart for personal protective equipment available in the hallway however none was donned. On 1/16/2025 at 10:35 am, an interview with the Assistant Director of Health Services (ADHS) regarding TBP for R3, was shared by ADHS that the room was indeed not properly marked with EBP for g-tube and open wounds. ADHS noted that this would be corrected and by the end of shift, the room was properly marked for EBP. Based on observations, resident and staff interviews, and review of facility policy titled Transmission Based Isolation Precautions, the facility failed to maintain sanitary conditions for two of 50 sampled residents (R)(R23 and R3). Specifically, oxygen equipment (nasal cannula) was hung over the humidifier and touched the floor when not in use for R23 and the facility failed to use appropriate Personal Protection Equipment (PPE) for a resident R3 on Enhanced Barrier Precautions (EBP) of 50 sampled residents. This deficient practice could risk equipment contamination, increasing the likelihood of infections and health complications. Findings include: 1.A policy on maintaining oxygen supplies, such as nasal cannulas, under sanitary conditions was requested but not provided. A review of the Electronic Medical Record (EMR) revealed that R23 was admitted to the facility on [DATE] with diagnoses including, but not limited to intracerebral hemorrhage, pneumonia, nasal congestion, pulmonary nodule, acute respiratory failure with hypoxia, and COVID-19. A review of the recent Quarterly Minimum Data Set (MDS) dated [DATE] documented R23 had a Brief Interview for Mental Status (BIMS) of 14 indicating intact cognition. Further review of the MDS revealed that R23 received oxygen therapy. Review of the care plan dated 1/14/2025 for R23 revealed a problem: Resident needs nebulizer treatment/Oxygen (O2) use related to history of pneumonia, respiratory failure, COVID-19 with a goal that Resident will not exhibit signs of hypoxia (cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse) with approach: Monitor oxygen saturation via pulse oximetry as ordered/needed, administer nebulizer treatment/O2 as ordered. A review of the Physician Orders for R23 revealed an order dated 11/18/2024 for O2 at 2 liters (L) via nasal cannula (NC) as needed to keep O2 saturation (sat) above 95%. Change respiratory supplies weekly on Sundays. During an observation on 1/14/2025 at 12:04 pm in the resident's room, R23 was resting in bed. The oxygen concentrator was on, but the resident was not wearing the nasal cannula. The long tubing of the nasal cannula was connected to the concentrator, draped over it, tangled on top, and with portions touching the floor, rather than being stored hygienically in the bag attached to the concentrator. The resident stated that she does not use oxygen continuously, only as needed. During an observation on 1/15/2025 at 9:00 am R23 was resting in bed, asleep, and comfortable. The oxygen tubing was connected to the concentrator in the same manner as observed the previous day, not stored in a bag. During an observation and interview on 1/15/2025 at 11:00 am with the Assistant Director of Nursing (ADON) while in R23's room, ADON confirmed the O2 was not bagged. ADON reported that O2 tubing should be bagged when not in use and should not be placed on the floor or the concentrator. He stated that he would provide R23 with new tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, and staff interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment as evidenced by wedged items in privacy curtain and dust build up in PTAC in room [ROOM NUMBER], a loose PTAC unit in room [ROOM NUMBER], peeling trim near the second floor shower room, substances on the floor/tile in the A-Hall shower room, black and black/brown substances in the ceiling of kitchen dish washing room and dry storage area. This deficient practice had the potential to jeopardize the health and safety of all 106 residents in the facility in three resident rooms, two of four shower rooms, and the kitchen. Findings include: Observation made on 1/14/2025 at 11:27 am in room [ROOM NUMBER] revealed a privacy curtain rail with a brown item wedged into the end of the railing and exposed insulating spray foam on the left wall of the PTAC unit. Observation made on 1/14/2025 at 11:55 am in room [ROOM NUMBER] revealed a loose PTAC unit. Observation made on 1/14/2025 at 12:01 pm in room [ROOM NUMBER] revealed dust buildup on filter of the PTAC unit. Observation made on 1/14/2025 at 12:12 pm the entrance of the B-Hall second-floor shower room and room [ROOM NUMBER] revealed peeling trim. Observation made on 1/15/2025 at 12:00 pm in the A-Hall first-floor shower room revealed orange substances on the floor of the shower room floor and ceiling vent. Observation made on 1/16/2025 at 4:30 pm in the A-Hall first-floor shower room revealed clusters of black substances between the tiles of the shower. Observation made on 1/16/2025 at 4:50 pm in the kitchen dish washing room revealed clusters of black substances on the ceiling and in the kitchen dry storage room there were brown and black substances on the ceiling vent. An interview with the resident council on 1/14/2025 at 3:08 pm revealed concerns about black substances in the A-hall shower room on the first floor. An interview and observation with the Maintenance Director on 1/16/2025 at 4:07 pm confirmed the missing part from the curtain rail, buildup on PTAC filter and exposed insulating foam spray in room [ROOM NUMBER], a loose PTAC filter in room [ROOM NUMBER], clusters of black substances on the ceiling in the kitchen dish room and in the kitchen pantry, substances in the first floor shower room ceiling, floor and tile. The Maintenance Director further confirmed the peeling trim near the second-floor shower room. He acknowledged that he was unaware of these concerns. He reported that he expected staff to identify concerns in resident rooms and around the facility and report them in the facility's electronic building management system. He further stated he is the only maintenance employee and has no assistants, so it is challenging to address all the concerns in the building right away. An interview with the Administrator on 1/16/2025 at 5:36 pm revealed she has been in the role since the end of July 2024. She stated that PTAC units should be checked and cleaned weekly and ceiling vents should be cleaned monthly. She further stated that there should be no negative outcomes since these concerns will be addressed immediately. A policy for the environment was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and document review, the facility failed to accommodate the needs of three of 48 sampled residents (R) (R#3, R#21, and R#52) related to providing a functional shower bed for use on the second floor of the facility, resulting in the residents failing to receive showers as preferred. Findings included: A review of a facility Daily Census Report dated 10/6/22 revealed five of 48 residents on the second floor desired a shower bed for bathing. 1. A review of R#3's Face Sheet revealed the resident had diagnoses including a left-hand contracture, generalized muscle weakness, lack of coordination, functional quadriplegia, spinal stenosis, osteoarthritis, degenerative disease of the nervous system, and morbid obesity. A review of R#3's Quarterly Minimum Data Set (MDS) Assessment, dated 9/24/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment indicated that R#3 had bilateral impairments in range of motion of the upper and lower extremities; R#3 was totally dependent on two or more people for bathing (how the resident took a full body bath/shower); and it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. A review of R#3's care plan, last dated 7/28/22, revealed the resident required staff assistance with activities of daily living (ADLs). The facility developed a care plan intervention directing staff to provide the resident physical assistance with ADLs. A review of R#3's Point of Care History from 9/7/22 to 10/4/22 revealed the resident received bed baths. There was no documented evidence that the resident received a shower. An interview with R#3 on 10/7/22 at 3:58 p.m. revealed the resident only received bed baths and had not had a shower for some time. R#3 said it would be nice to go to the shower room and take a shower. 2. A review of R#21's Face Sheet revealed the resident had diagnoses of muscle weakness, amputation of the left leg between left hip and knee, amputation at the right hip joint, and polyneuropathy. A review of R#21's Annual MDS assessment dated [DATE], revealed the resident had a BIMS score of 15, indicating intact cognition. The assessment indicated R#21 had range of motion limitations to both lower extremities and was totally dependent on staff for bathing (how the resident took a full body bath/shower) and that it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. A review of R#21's care plan, last dated 9/20/22, revealed the resident required staff assistance with activities of daily living (ADLs). A review of R#21's Point of Care History from 9/13/22 to 10/7/22 revealed the resident received complete bed baths and there was no documented evidence the resident received a shower. An interview and observation of R#21 on 10/7/22 at 3:50 p.m. revealed the resident was lying in bed. Observation revealed the resident had bilateral leg amputations. R#21 stated he/she used a shower chair for showers, but noted it would be nice to use a shower bed. 3. A review of R#52's Face Sheet revealed the resident had diagnoses including contractures of the left and right lower legs and muscle weakness and received palliative care. A review of R#52's quarterly MDS dated [DATE], revealed the resident had a BIMS score of one, indicating severely impaired cognition. The assessment indicated the resident had lower extremity impairments in range of motion on both sides and was totally dependent on two or more people for bathing. A review of R#52's care plan dated 4/1/22, revealed the resident had a severe cognitive decline and was unable to complete most daily activities independently. The care plan indicated the resident was in hospice care for heart disease. The facility developed an intervention that directed staff to provide total assistance with showers. A review of R#52's Point of Care History from 9/8/22 to 10/4/22 revealed the staff provided a partial or complete bed bath and there was no documented evidence staff provided showers for the resident. An interview with Certified Nursing Assistant (CNA) ZZ on 10/6/22 at 2:25 p.m. revealed the shower bed for the second floor did not fit into the shower room. CNA ZZ stated they had shower chair; however, there were residents who were not able to sit up in the chair for a shower. An observation of a second-floor shower room revealed a shower chair and mechanical lifts were stored in the room. There was no shower bed observed in the shower room. An interview with Maintenance QQ on 10/6/22 at 3:03 p.m. revealed the facility had one shower bed that should fit in the shower stall on each floor. An observation with Maintenance QQ on 10/6/22 at 3:05 p.m. revealed the shower bed was too big to fit in the shower stall in the second-floor shower room. Maintenance QQ stated that until now he was unaware the shower bed would not fit in the shower room on the second floor. An interview with Senior Nurse Consultant WW and Director of Nursing (DON) BB on 10/7/22 at 2:39 p.m. revealed if residents could not shower in the reclining shower chair, they could take residents to another floor for a shower. An interview with Administrator AA on 10/7/22 at 2:11 p.m. revealed the facility purchased the shower bed approximately six months prior and the Administrator was unaware the shower bed did not fit in the shower stall on the second floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility's policy, the facility failed to prevent abuse for one of three sampled residents (R) (R#193) related to sexual abuse. Findings included: A review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 10/27/20 indicated Procedures: 1. Providers are to identify, correct, and intervene in situations in which abuse, neglect, mistreatment, or exploitation may occur. The assessment, care planning, and monitoring of patients with needs and behaviors that might lead to conflict or neglect, such as patients with a history of aggressive behaviors, patients who have behaviors such as entering other patients' rooms, patient with self-injurious behaviors, patients with communication disorders, and patients who require heavy nursing care or are totally dependent on staff. A review of the Facility Incident Report Form, dated 11/24/21, indicated the Administrator was informed by the Social Worker (SW) at 9:30 a.m. that the SW received a note from nursing staff that R#193 was seen performing a sexual act on R#195 the previous evening. The report indicated R#193's had a Brief Interview for Mental Status (BIMS) score was seven, indicating severe cognitive impairment, and R#195's had a BIMS of 15, indicating that R#195 was cognitively intact. The report indicated the residents were separated by staff once identified. The report indicated R#193 stated R#195 made them perform the act. The report indicated the Certified Nursing Assistant (CNA) that witnessed the act was unsure at first what to do and reported it to the nurse, who stopped the act. The report indicated the staff did not report to the Administrator immediately because the staff thought they were respecting the rights of two adults and assumed it was acceptable. The nurse left a note to the SW as a courtesy. The report indicated the Administrator interviewed R#195, who denied the incident. The Administrator informed R#195 they would be moved to a different floor and was given a 30-day notice of discharge. The report indicated that due to the eyewitness account of the resident, as well as three other staff members, the allegation was substantiated. R#195 was moved off the floor where R#193 lived, R#195 was placed on 30-minute observation when away from their room, and monitoring when moving through the facility for activities. R#195 was medicated appropriately, provided psychiatric services including psychotherapy, and was transferred to another facility on 12/3/21. The report indicated R#193 was provided psychiatric services, and the staff were educated on abuse, recognizing abuse, and reporting abuse, with a focus on sexual abuse. A review of the Resident Face Sheet revealed R#195 had diagnoses which included dementia with behavioral disturbance, adjustment disorder with depressed mood, mood disorder, restlessness and agitation, and altered mental status. A review of the quarterly Minimum Data Set (MDS) Assessment, dated 10/7/21, indicated R#195 had no cognitive impairment with a BIMS score of 15 out of 15. The resident required supervision with set up only for their activities of daily living (ADLs). A review of R#195's Care Plan, dated 10/11/21, indicated the resident exhibited inappropriate sexual behavior towards another resident and watched pornography on their cell phone. A review of the Resident Face Sheet indicated R#193 had diagnoses which included senile degeneration of the brain, dementia with behavioral disturbance, and schizophrenia. A review of the Quarterly MDS Assessment, dated 10/8/21, indicated R#193 had moderate cognitive impairment with a BIMS score of seven out of 15, indicating the resident was severely cognitively impaired. The resident had a behavior of wandering that occurred daily. The resident required limited to extensive assistance for their ADLs. A review of the Care Plan, dated 8/31/21, indicated R#193 had the potential for presence of behavioral symptoms related to a history of aggressive behavior, care rejection, and dementia with behavioral disturbance. A review of R#195's social service Progress Note, dated 10/13/21, indicated SW FF spoke with R#195 about a report that the resident was in their room the previous night with another resident (R#193) with the door closed and lights out. The note indicated R#195 stated the residents were talking and were just friends. The note indicated the SW told R#195 the other resident had a different idea about their relationship, so R#195 told the SW they would be careful not to let it happen again. A review of R#195's Psychotherapy Progress Note, dated 10/15/21, written by Licensed Clinical Social Worker (LCSW) GG, an outside provider, indicated R#195 presented as fully alert and oriented. The note indicated R#195 used most of the session to talk about relationships with residents of the opposite sex and was encouraged to work on ways to avoid giving others mixed signals about their intentions. The note indicated the resident was encouraged to be clear in communication with healthy boundaries. A review of R#195's Psychotherapy Progress Note, dated 10/29/21, indicated R#195 continued to join in activities and to socialize with a resident of the opposite sex (R#31) with a goal of a cessation of episodes of sexualized behaviors that the peer found unsettling despite their stated affection for R#195 and wish to continue seeing them. The note indicated the facility social worker was updated and addressed the issues with both residents to clarify intentions and safe/healthy boundaries. A review of R#195's Psychiatry Follow Up Note, dated 11/2/21, written by Nurse Practitioner (NP) JJ, an outside provider, indicated R#195 had questionable behaviors displayed, evidenced by the increased online use of possible adult sites and some sexually suggestive verbalizations being made with no actual or specific acting out. The note indicated SW FF and staff reported the resident was overly sexual verbally at times with others. The note indicated the psychiatrist was to be notified if the sexualized behaviors worsened, and a trial of Depakote (often used as a mood stabilizer) may be considered. The note indicated if the resident had increased behaviors, laboratory blood tests should be obtained, including [a gender specific hormone] level. A review of R#195's Psychotherapy Progress Note, dated 11/5/21, indicated R#195 reported enjoying sexual content on a social media platform and engaged in it often, sometimes for hours a day. The note indicated the resident used the platform to direct message people of the opposite sex to send sexy photos of themself. The note indicated the writer of the note had a discussion with the facility SW about R#195's relationship with a mentally competent peer (R#31) that had grown very attached to R#195 but stated they did not wish to have sexual encounters, despite calling R#195 their boy/girlfriend. The note indicated the discussion focused on making sure R#195 respected the other resident's wishes and boundaries and that their relationship was not sexual unless they both wanted it to be. The note indicated R#195 conveyed mixed feelings about the friend, acting sad when they stayed away but acting annoyed at times if they did not wish to engage. The note indicated the writer spoke with the facility SW about a goal of stopping behaviors that the friend reportedly found unsettling despite their stated affection for R#195 and wish to continue seeing them as a friend in either one of their rooms. A review of a nurse practitioner (NP) Resident Progress Note, dated 11/9/21, indicated R#195 was complaining of discharge from their sexual organ and showed the NP with no discharge noted. The note indicated a nurse had reported the resident had been watching porn on their phone and was having hypersexual behavior. The note indicated blood tests were ordered, including a [hormone] level. R#195 was to be evaluated for hypersexual behavior by a psychiatrist with follow-up by psychiatric services already seeing the resident. A review of a Psychotherapy Progress Note, dated 11/19/21, indicated R#195 talked about relationships with other residents and considered the resident a friend and not a romantic partner, even though they believed the other person was more serious and considered them a boy/girlfriend. The note indicated R#195 was encouraged to not lead the resident on to avoid causing misunderstandings and hurt feelings. A review of a NP Resident Progress Note, dated 11/23/21, indicated R#195 was seen by the psychiatrist for their hypersexual behavior, and adjustments were made to the resident's medications. The note indicated the psychiatrist's progress note was not available. The note indicated the resident was also seen by an outside psychotherapist that week. The note indicated the resident's lab results were negative and [hormone] level was normal. A review of R#195's nursing Progress Note, dated 11/24/21, indicated Licensed Practical Nurse (LPN) CC was called to the hallway on 11/23/21 at 8:30 p.m. by staff standing near R#195's room and told LPN CC to look in the room. The note indicated that when LPN CC looked in the room, she observed R#193 performing a sexual act on R#195. The note indicated LPN CC told the residents to stop and R#195 continued to stroke R#193's head, then R#193 stopped and went out of the room stating they were sorry, they did not want to do it, but R#195 made them do it. A review of R#195's SW Progress Note, dated 11/24/21, indicated it was reported to the SW upon their arrival to the facility that R#195 made another resident (R#193) perform oral sex on them the previous night (11/23/21). The note indicated the SW spoke with R#193 and they confirmed the act. R#193 stated they did not want to do it, but R#195 made them. A review of R#195's NP Resident Progress Note, dated 11/24/21, indicated they were notified by the facility Administrator that R#195 made a confused resident perform oral sex on them. The note indicated Psychiatrist II was notified and started R#195 on Depakote 250 milligrams (mg) at 9:00 a.m. and 1:00 p.m. and 500 mg at bedtime. The note indicated Psychiatrist II discontinued the resident's Razadyne (used to treat mild to moderate confusion) and Remeron (an antidepressant). The note indicated Psychiatrist II was notified of the most recent [hormone] levels and Psychiatrist II wanted to start the resident on Depo-Provera injections (decreases sexual drive). The note indicated the resident was sent to the emergency room for a mental health evaluation. A review of a nursing Resident Progress Note, dated 11/24/21, indicated R#195 was moved to room [ROOM NUMBER]. A review of a Nursing Progress Note, dated 11/25/21, indicated R#195 was on 30-minute checks until further notice. A review of a Psychotherapy Comprehensive Clinical Assessment, dated 11/30/21, indicated R#195 was referred to counseling services to assess their well-being following a sexual encounter with another resident. The assessment indicated per chart review R#195 was upset at the time of the incident and said the act was forced on them. A review of a social service Resident Progress Note, dated 12/2/21, indicated R#195 was given a transfer notice that day and would be transferring to another facility on 12/3/21. During a telephone interview on 10/6/22 at 12:10 p.m. with SW FF, they stated they had retired and no longer worked at the facility. SW FF stated as far as they could recall, the incident between R#193 and R#195 happened before Thanksgiving 2021 because it was a hard conversation to have with R#193's family at that time; the family did not want to do anything about the incident. SW FF stated that when he came into work, the incident was reported to him and he reported it to the Administrator, who told him to get statements. SW FF stated when he questioned R#193 that day, R#193 stated they had never done anything like that before, but R#195 made them do it. SW FF stated R#195 denied it. SW FF stated R#195 was always looking on their phone at porn. SW FF stated he spoke with R#195 about the incident on 10/13/21 and R#195 told him nothing happened. SW FF had no way of proving anything did or did not occur. SW FF stated R#193 had nothing to report when asked if anything happened. SW FF stated he could not recall who reported the 10/13/21 incident to him. During an interview on 10/6/22 at 11:55 a.m. with LPN CC, she stated the staff called her to R#195's room and stated R#193 was in the room. She stated she stopped them and asked R#193 what they were doing. She said R#193 told her R#195 made them do it and they had never done that kind of thing before. LPN CC stated she was told the following day by the Administrator that she should have reported it to him, the state, and police. She stated the other nurse told R#193 earlier in the shift that it was not appropriate for R#193 to go into R#195's room at that time of evening. She stated R#193 frequently went into R#195's room. During an interview on 10/6/22 at 1:28 p.m. with Psychiatrist II, she stated she usually gave Depakote for elderly residents with hypersexual behaviors, and if it was not effective, then she would prescribe Depo Provera weekly for 12 weeks. She stated Depo Provera was a birth control shot that was used in the elderly to safely decrease hypersexual behaviors. She stated she wanted the resident's [hormone] level to be less than 50, but they would need to give the medications time to work. Psychiatrist II stated she only saw R#195 once. She stated she was told the resident was hypersexual and going around to residents' rooms propositioning them for sex. She stated she thought she ordered Depakote for R#195 but was not sure without checking the chart. After review of the medical record, she stated R#195 was ordered both Depakote and Depo Provera due to the incident on 11/23/21. She stated R#195 was discharged to another facility and she never saw the resident again to be able to follow up. She stated she was unsure why she was contacted instead of the resident's normal provider. On 10/6/22 at 3:08 p.m., an attempt to contact Nurse Practitioner (NP) HH was made, and a message was left. There was no response from NP HH by the end of the survey. During an interview on 10/6/22 at 3:37 p.m. with LCSW GG stated R#193 was confused about the incident and thought R#195 was their spouse. LCSW GG stated she had no information to suggest R#193 had any previous sexual behaviors. She stated R#193 missed their spouse and seemed confused at times about who they thought other people were. During an interview on 10/6/22 at 8:27 p.m. with CNA DD, she stated she was walking by R#195's room and saw R#193 performing a sex act on R#195. She stated she turned around right away and went and got the nurse, who stopped it. She stated she did not report it because the nurse knew about it, but she would report it next time. She stated she was told they should have reported it right away. CNA DD stated R#193 said R#195 made them do it and they had never done that type of thing before. CNA DD stated she had never known of either resident doing anything like that before. She stated R#195 had never made any sexual comments to her. CNA DD stated R#193 would go into R#195's room and talk. She stated they would redirect R#193 out of the room and R#195 would tell staff it was okay. During an interview on 10/7/22 at 9:59 a.m. with CNA EE, she stated she only saw R#193's head in R#195's lap and did not see the actual act occur. CNA EE stated she told the nurse, and the nurse handled it. She stated she did not remember either resident saying anything. During an interview on 10/7/22 at 4:15 p.m. with the Director of Nursing Services (DNS) and Senior Nurse Consultant (SNC) WW, the DNS stated she became the DNS in April of 2022, so she was not part of the investigations. She stated she was informed of it afterwards. The SNC stated she was notified of the incident and stated R#195 was put on a medication to get their [hormone] levels in check and they were placed on every-30-minute checks until they were discharged . During an interview on 10/7/22 at 4:49 p.m. with the Administrator, he stated he reported the incident between R#195 and R#193 as soon as he heard about it on 11/24/21. He also notified R#193's family. He stated he felt they took care of the situation quickly and appropriately. The Administrator stated the psychiatrist was notified and medications were started while placement in a more appropriate setting was being found. He stated the staff should report any incident when they found an issue. He stated he felt like the staff had a grasp on the education that was given on abuse. He stated he told the staff he would make the decision if a situation was abuse or not because he knew more about the residents' whole story than the staff may have knowledge of, such as BIMS and background.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, facility document review, and review of the facility's policy, it was determined that the facility failed to report allegations of abuse for two of three residents (R) (R#31 and R#193) reviewed for abuse. Specifically, the facility failed to: -Ensure staff reported an incident of sexual abuse that occurred to R#193 in a timely manner; and -Ensure staff reported an allegation of sexual abuse that occurred to R#31 to the Administrator so an appropriate investigation could occur. Findings included: A review of the facility's policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 7/29/19, indicated, Procedures: 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. 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 allegation of abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within two hours after the allegation is made if the events upon which the allegation is based involved 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. 1. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated R#193 had severe cognitive impairment, with a BIMS score of seven out of 15. The resident had a behavior of wandering that occurred daily. The resident required limited to extensive assistance for their ADLs. A review of R#193's Care Plan, dated 8/31/21, indicated R#193 had the potential for presence of behavioral symptoms related to a history of aggressive behavior, care rejection, and dementia with behavioral disturbance. A review of the quarterly MDS, dated [DATE], indicated R#195 had no cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required supervision with set up only for their activities of daily living (ADLs). A review of R#195's Care Plan, dated 10/11/21, indicated the resident exhibited inappropriate sexual behavior towards another resident and watched pornography on their cell phone. A review of R#195's social service Progress Note, dated 11/24/21, indicated it was reported to the Social Worker (SW), upon their arrival to the facility, that R#195 made another resident (R#193) perform oral sex on them the previous night. The note indicated the SW spoke with R#193 and the resident confirmed the act. R#193 stated they did not want to do it, but R#195 made them. The note indicated R#193 stated they had never even done that with their spouse and asked for forgiveness. A review of R#195's nursing Progress Note, dated 11/24/21, indicated Licensed Practical Nurse (LPN) CC was called to the hallway on 11/23/221 at 8:30 p.m. by staff standing near R#195's room who told LPN CC to look in the room. When LPN CC looked in the room, she observed R#193 performing a sexual act on R#195. The note indicated LPN CC told the residents to stop, and R#195 continued to stroke R#193's head. R#193 stopped and went out of the room, stating they were sorry; they did not want to do it, but R#195 made them do it. During a telephone interview on 10/6/22 at 12:10 p.m. with SW FF, he stated he had retired and no longer worked at the facility. SW FF stated that as far as he could recall, the incident between R#193 and R#195 happened before Thanksgiving 2021 because it was a hard conversation to have with R#193's family at that time. R#193's family did not want to do anything about the incident. SW FF stated that when he came in to work on 11/24/21, the incident was reported to him and he reported it to the Administrator, who told him to get statements. During an interview on 10/6/22 at 11:55 a.m. with LPN CC, she stated the staff called her to R#195's room and stated R#193 was in the room. She stated she stopped them and asked R#193 what they were doing. She said R#193 told her R#195 made them do it and they had never done that before. LPN CC stated she was told the following day by the Administrator that she should have reported it to him, the state, and police. During an interview on 10/6/22 at 8:27 p.m. with CNA DD, she stated she was walking by R#195's room and saw R#193 performing a sex act on R#195. She stated she turned around right away and got the nurse, who stopped it. She stated she did not report it because the nurse knew about it, but she would report it next time. She stated she was told they should have reported it right away to the Administrator. During an interview on 10/7/22 at 4:49 p.m. with the Administrator, he stated he reported the incident between R#195 and R#193 as soon as he heard about it on 11/24/21 and notified R#193's family. He stated he felt they took care of the situation quickly and appropriately. He stated the staff should report any issue like that when they found it. He stated he felt like the staff had a grasp on the education that was given on abuse after the incident. He stated he told the staff he would make the decision if a situation was abuse or not because he knew more about the residents' whole story than the staff may have knowledge of, such as BIMS score and background. 2. A review of the quarterly MDS, dated [DATE], indicated R#195 had no cognitive impairment, with a BIMS score of 15 out of 15. The resident required supervision with set up only for their ADLs. A review of R#195's Care Plan, dated 10/11/21, indicated the resident exhibited inappropriate sexual behavior towards another resident and watched pornography on their cell phone. A review of the annual MDS, dated [DATE], indicated R#31 had no cognitive impairment, with a BIMS score of 15 out of 15. The resident required supervision with set up with their ADLs. A review of R#31's Care Plan, dated 6/1/22, indicated R#31 had impaired understanding of health regimen maintenance and restrictions. A review of R#31's Progress Notes from September 2021 through December 2021 revealed no documentation of any interaction between R#31 and R#195. During a telephone interview on 10/6/22 at 12:10 p.m., SW FF stated he had retired and no longer worked at the facility. SW FF stated R#195 was always looking on the resident's phone at porn and would send pictures to R#31, their boyfriend/girlfriend. SW FF stated R#31 showed him (the SW) an inappropriate picture that R#195 had sent to R#31. SW FF stated he spoke to R#195 about not sending those types of pictures, and the resident stated they understood. During an interview on 10/6/22 at 11:55 a.m. with LPN CC, she stated R#195 had residents in their room including R#31, who was sort of their boyfriend/girlfriend. She stated R#31 was upset once, saying R#195 did something or told them something, but R#31 would not elaborate. During an interview on 10/6/22 at 3:37 p.m. with Licensed Clinical Social Worder (LCSW) GG (with the psychiatric services provided outside of the facility staff), she stated she had seen both R#195 and R#31. LCSW GG stated she was aware of the things going on with R#31, the boyfriend/girlfriend of R#195. She stated R#31 would get mad at R#195 for showing R#31 their private parts. She stated R#195 would not discuss any sexual urges, but R#31 would tell LCSW GG about it. LCSW GG stated she mentioned it to the facility social worker, and he told her R#195 and R#31 were both consenting adults and they could not interfere. During an interview on 10/7/22 at 4:49 p.m. with the Administrator, he stated the staff should report when they found an issue. He stated he felt like the staff had a grasp on the education that was given on abuse. He stated he told the staff he would make the decision if a situation was abuse or not because he knew more about the resident's whole story than the staff may have knowledge of, such as BIMS score and background.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interviews, it was determined that the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was accurate upon admission for one of two residents (R) (R#34) reviewed for PASARR. Findings included: A review of the facility's policy titled, admission Policy for Healthcare Centers, revised 1/4/21, revealed the Admissions Director will obtain a copy of state specific PASARR form. The state contractor for PASRR was contacted by phone for information related to the state's PASRR requirements. On 8/19/22 at 4:00 p.m., Licensed Professional Counselor and Supervisor with the state's contracted PASRR department was interviewed about the PASRR Level I Assessment Form, DMA-613. Regarding question 4, she stated if the primary diagnosis for nursing home admission was not a mental health diagnosis, if the individual had mental health or behavioral health diagnoses, the facility should mark yes on question 4, primary diagnoses for serious mental illness, regardless of the reason for the admission. A review of R#34's History and Physical from a local hospital with a date of service 5/13/22 indicated the resident's diagnoses included bipolar and schizoaffective disorder, depressive type. A review of the Resident Face Sheet indicated the facility admitted R#34 admitted from a local hospital with a primary/admission diagnosis of second degree burn of the lower back and a medical history to include diagnoses of generalized anxiety disorder and schizoaffective disorder, depressive type. A review of R#34's admission Minimum Data Set (MDS), dated [DATE], revealed the resident was moderately impaired in cognitive skills for daily decision making with a Brief Interview for Mental Status (BIMS) score of nine. The MDS indicated R#34 had diagnoses of bipolar disorder and schizophrenia. A review of R#34's Preadmission Screening/Resident Review Level I Assessment (Form DMA-16) dated 7/28/22, indicated R#34 did not have a primary diagnosis of serious mental illness, developmental disability, or related condition. Question 4, on the form indicated, Does the individual have a Primary Diagnosis of Serious Mental Illness, developmental disability or related condition? The facility indicated, No. An interview with the Administrator on 10/7/22 at 1:13 p.m. revealed the PASARR should be accurate. According to the Administrator, it was his impression that mental illness only had to be a primary diagnosis for it be noted on the PASARR Level I. In an interview on 10/7/22 at 1:15 p.m., Staff WW, the Senior Nurse Consultant, stated the PASARR was done at the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's policy, it was determined that the facility failed to ensure one of five residents (R) (R#15) reviewed for unnecessary medications received blood sugar monitoring and medications as ordered by the physician. Findings included: A review of the facility's policy titled, Medication Administration: Insulin Injections last reviewed 10/15/21, indicated, Record the results of blood glucose testing on the resident's Blood Glucose Monitoring form in the MAR [Medication Administration Record] and prepare any needed insulin according to the prescriber's orders. The policy further indicated, Document the dose administered and injection site location in the resident's MAR/EMAR [electronic MAR]. A review of the Resident Face Sheet indicated the facility admitted R#15 with a diagnosis of type II diabetes mellitus. A review of R#15's quarterly Minimum Data Set (MDS), dated [DATE], indicated R#15 was severely impaired in cognitive skills for daily decision making with long and short-term memory problems according to the Staff Assessment for Mental Status. The MDS indicated R#15 had a diagnosis of diabetes mellitus and received insulin injections seven out of seven days during the assessment period. A review of R#15's Care Plan with a problem start date of 4/22/22, indicated R#15 was at risk for hyper/hypoglycemia (high/low blood sugar) related to diabetes mellitus. The care plan had a goal for the resident to maintain appropriate blood glucose levels. The care plan interventions directed staff to monitor for signs of hyperglycemia [a blood glucose reading of greater than 140 milligrams (mg)/deciliter (dl)] and monitor for signs of hypoglycemia (a blood glucose reading of less than 60 mg/dl). A review of the active physician Orders for R#15 revealed that on 6/3/22 the resident was ordered to receive Levemir Insulin 12 units subcutaneous twice a day at 9:00 a.m. and 5:00 p.m. and Novolog Insulin per sliding scale subcutaneous before meals at 6:30 a.m., 11:30 a.m., and 4:30 p.m. and at bedtime at 9:00 p.m. The orders directed staff to call the physician if R#15's blood sugar was less than 70 mg/dl or greater than 400 mg/dl, to administer 4 units of insulin if the resident's blood sugar was between 201-250 mg/dl, to administer 8 units if the resident's blood sugar was between 251-200 mg/dl, to administer 12 units if the resident's blood sugar was between 301 - 350 mg/dl, and to administer 16 units if the resident's blood sugar was between 351- 400 mg/dl. A review of R#15's August 2022 Medication Administration Record (MAR) revealed no documentation (blank spaces on the MAR) of Levemir Insulin being administered on 8/3/22 at 9:00 a.m., 8/22/22 at 9:00 a.m. and 5:00 p.m., and 8/30/22 at 9:00 a.m. Further review of the August 2022 MAR revealed no documentation (blank spaces on the MAR) R#15's blood sugar was checked on 8/1/22 at 9:00 p.m.; 8/3/22 at 11:30 a.m. and 4:30 p.m.; 8/4/22 at 6:30 a.m.; 8/22/22 at 11:30 a.m., 4:30 p.m., and 9:00 p.m.; 8/27/22 at 6:30 a.m.; 8/29/22 at 4:30 p.m. and 9:00 p.m.; and 8/30/22 at 11:30 a.m. and 4:30 p.m. A review of R#15's September 2022 MAR revealed no documentation of Levemir Insulin being administered on 9/10/22 at 9:00 a.m.; 9/15/22 at 9:00 a.m. and 5:00 p.m.; 9/19/22 at 9:00 a.m. and 5:00 p.m.; and 9/24/22 at 9:00 a.m. Further review of the September 2022 MAR revealed no documentation R#15's blood sugar was checked on 9/10/22 at 11:30 a.m.; 9/15/22 at 11:30 a.m. and 4:30 p.m.; 9/19/22 at 6:30 a.m., 11:30 a.m., and 4:30 p.m.; 9/24/22 at 9:00 p.m.; 9/26/22 at 9:00 p.m.; 9/28/22 at 11:30 a.m.; and 9/30/22 at 9:00 p.m. A review of R#15's October 2022 MAR revealed no documentation of Levemir Insulin being administered on 10/4/22 at 5:00 p.m. and 10/5/22 at 5:00 p.m. Further review of the October 2022 MAR revealed no documentation R#15's blood sugar was checked on 10/1/22 at 9:00 p.m.; 10/4/22 at 6:30 a.m. and 4:30 p.m.; and 10/5/22 at 4:30 p.m. During an interview on 10/6/22 at 11:55 a.m., Licensed Practical Nurse (LPN) CC stated blank spaces on the MAR indicated a medication was not administered. During an interview on 10/6/22 at 2:44 p.m., LPN LL stated there should not be blank spaces on the MAR. According to LPN LL, he was unsure why there were blank spaces on R#15's MAR related to the administration of insulin. During an interview on 10/6/22 at 2:58 p.m., Registered Nurse (RN) NN stated R#15 refused insulin at times, which RN NN noted should be documented as a refusal and not left as a blank space on the MAR. During an interview on 10/7/22 at 4:15 p.m., the Director of Nursing, RN BB, stated the expectation was for staff to check the resident's blood sugar and document the administration of insulin. During an interview on 10/7/22 at 4:49 p.m., the Administrator stated he expected medications to be administered and for documentation to be complete with no blank spaces on the MAR. According to the Administrator, if a medication was not administered, the physician should be notified, and the nurse should document the reason the medication was not administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility document review, it was determined the facility failed to provide wound care per physician's orders for one of three residents (R) (R#56) reviewed for pressure ulcers. Findings included: A review of a facility job description titled, LPN [Licensed Practical Nurse] Skin Integrity Coordinator, dated December 2016, revealed one key responsibility was performs wound care and/or treatments following physician orders using aseptic or sterile technique following orders and policy. A review of the Resident Face Sheet for R#56 revealed the resident had diagnoses that included local infection of the skin and subcutaneous tissue and a non-pressure chronic ulcer of the right ankle with necrosis (cell injury which results in death, caused by infection or trauma) of bone. A review of R#56's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. According to the MDS, the resident had an open lesion, other than ulcers, rashes, cuts. Skin and ulcer/injury treatments included the application of dressings to the feet (with or without topical medications. A review of R #56's care plan, dated 4/29/22, revealed the resident was at risk for frequent development of infection to the right foot related to old unresolved injury. The goal was for the resident to be free of infection to the foot. The facility developed an intervention to apply dressing as ordered by the resident's provider. A review of the September 2022 Treatment Administration Record (TAR) indicated an order, with a start date of 9/9/22 and end date of 9/30/22, to cleanse the right dorsal proximal foot (top of the right foot closest to the leg) with wound cleanser, pat dry, pack with Dakin's 0.5% packing, cover with a 4 x 4 gauze, and secure with rolled gauze. Change three times weekly with frequency on Monday, Wednesday, and Friday. The TAR indicated there was no documentation of the dressing change being performed on 9/19/22, 9/26/22, or 9/28/22. A review of the September 2022 TAR revealed an additional treatment order, start date of 9/9/22 and end date of 9/30/22, to cleanse the right ankle with wound cleanser. Pay dry. Apply HydroFera Blue and secure. Change three times a week with a frequency on Monday, Wednesday, and Friday. The TAR indicated there was no documentation of the dressing change being performed on 9/19/22, 9/26/22, or 9/28/22. A review of a Progress Note Report dated 9/30/22 revealed the right dorsal proximal foot wound measured 0.8 centimeters (cm) long x 0.8 cm wide x 0.5 cm deep, with moderate, yellow serosanguinous drainage. The right anterior medial malleolus (the ankle bone on the inside of the foot) wound measured of 0.5 cm long x 0.5 cm wide x 0.5 cm deep and had mild, yellow serous drainage. A review of Active [physician] Orders for R#56 revealed an order with a start date of 9/30/22, to cleanse the resident's right dorsal proximal foot and right malleolus of the anterior foot with wound cleanser, pat the areas dry, pack with Dakin's 0.5% packing, cover with 4 x 4 pad, and secure with rolled gauze. The order indicated the dressing was to be changed daily. An observation and interview with R#56 on 10/3/22 at 11:30 a.m. revealed the bandage to R#56's right foot was dated 9/30/22, the time and staff initials were not legible. R#56 stated the resident believed the dressing was changed every day. An interview with Wound Care Nurse OO on 10/3/22 at 10:26 a.m. revealed she was responsible for providing resident wound care four days per week. However, due to staffing issues she was pulled to work as a staff nurse and could not consistently provide wound care. Wound Care Nurse OO stated the facility really needed more staff so she could provide wound care. An observation of R#56's wound care with Wound Care Nurse #OO on 10/4/22 at 1:30 p.m. revealed Wound Care Nurse OO confirmed the date on the bandage was 9/30/22 at 12:00 p.m. She confirmed she provided the wound care on 9/30/22 and wound care had not been provided since 9/30/22. A follow-up interview with Wound Care Nurse OO on 10/4/22 at 1:44 p.m. revealed the risk of not changing a bandage was infection. She stated nursing staff were responsible for providing wound care when she was not available and should have followed R#56's orders for wound care on 10/1/22 through 10/3/22 An interview with Licensed Practical Nurse (LPN) #CC on 10/4/22 at 4:00 p.m. revealed she was responsible to complete R#56's wound care on 10/3/22 but admitted it was not done. She knew if the wound care was not done it could put the resident as a high-risk for infection. An interview with Wound Care Nurse OO on 10/5/22 at 9:05 a.m. revealed she thought maybe the daily wound changes were getting overlooked because the nurses were too busy. A phone interview with Wound Care Physician Assistant III on 10/5/22 at 12:59 p.m. revealed she expected the staff to follow the wound orders. She said the potential risk of not doing the wound care would depend on the wound and the health of the patient, and she had no knowledge of the wound care not being done. An interview with Registered Nurse NN on 10/5/22 at 3:49 p.m. revealed the wound care nurse was supposed to provide wound care, but if the wound care nurse was unable, it was the nurse's responsibility. She said it was very important to provide wound care because if it was not done it could put the resident at high-risk for infection or sepsis. A phone interview with Nurse Practitioner (NP) JJJ on 10/6/22 at 7:37 p.m. revealed he expected staff to follow the orders, and the risk of not following the wound care orders could potentially cause infections, worse wounds, and even death. He was not aware that wound care was not being done. An interview with Administrator AA on 10/7/22 at 2:11 p.m. revealed he expected the staff to do the wound care and to follow the orders so the wounds would heal. He said the risk of not doing the wound care would be a decline, infection, and possibly hospitalization. The nurses were responsible for the wound care if the wound care nurse was not able to do them. An interview with Senior Nurse Consultant WW and Director of Nursing (DON) BB on 10/7/22 at 2:39 p.m. revealed Wound Care Nurse OO had worked on the floor as a floor nurse instead of the wound care nurse, but the nurses were responsible to do the wound care if she was not available. If the wound care was not being done as ordered, it could cause infection or unnecessary pain. They were not aware of any concerns with wound care not being done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the facility's policy, it was determined that the facility failed to ensure two of 31 residents (R) (R#249 and R#15) reviewed had accurately documented medical records. Specifically, the facility failed to accurately document the correct amount of warfarin (an anticoagulant) administered to R#249 and failed to accurately document the amount of water flush being administered to R#15. Findings included: A review of the facility's policy titled, Maintenance of Medical Records, dated 11/21/16, indicated, It is the policy of (the facility) and its affiliated entities (collectively, the Organization) to maintain a medical record for each patient/resident in the healthcare center/agency that is to be accurate, complete, and systematically organized. Further review of the policy revealed All reports and entries in the medical record are to be accurate and complete. 1. A review of the Resident Face Sheet indicated the facility admitted R#249 with diagnoses that included the presence of a prosthetic heart valve and long-term use of anticoagulants (blood thinners). A review of the admission Minimum Data Set (MDS), dated [DATE], indicated R#249 had no cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required extensive assistance of one to two people for the activities of daily living (ADLs). The MDS indicated R#249 took an anticoagulant medication seven out of seven days during the look-back period. A review of the care plan dated 10/3/22 indicated R#249 was at risk for abnormal bleeding or hemorrhage because of anticoagulation usage. Interventions included: -Administer anticoagulant as currently prescribed - see Medication Administration Record (MAR). -Educate on risk and benefits of anticoagulation use. -Monitor for and report to the physician signs and symptoms of abnormal bleeding and/or hemorrhage. -Schedule lab tests as ordered by the physician to monitor coagulation factors and report abnormal findings to the physician. A review of the Order History revealed Resident #249's orders included: -Warfarin (an anticoagulant) 4 milligrams (mg) one tablet orally once a day on Sunday, Monday, Tuesday, and Friday, ordered 9/19/22 and discontinued 10/4/22. -Warfarin 2.5 mg one tablet orally once a day on Wednesday, Thursday, and Saturday, ordered 9/29/22 and discontinued 10/4/22. A review of the October 2022 MAR indicated that when the order for the warfarin 2.5 mg was entered into the computer system on 9/29/22 and scheduled on the MAR, it was scheduled to be given daily instead of three times a week on Wednesday, Thursday, and Saturday. The warfarin 2.5 mg was signed off by the nurses as being administered on 10/2/22, 10/3/22, and 10/4/22, along with the warfarin 4 mg that was scheduled to be given on those days. During observations of medication administration by the nurses, it was determined that each resident had their medications pre-packaged by the pharmacy, and the nurses would not have been able to administer both the warfarin 2.5 mg along with the warfarin 4 mg on 10/2/22-10/4/22, even though it was documented that way, making the resident's record inaccurate. A review of the pharmacy delivery record for R#249 revealed the correct dose ordered by the physician and amount of warfarin had been delivered to the facility in individual dated packages. This would have kept the nurses from being able to give the warfarin 2.5 mg at the same time as the warfarin 4 mg, indicating the documentation was incorrect and the resident's record was inaccurate. During an interview on 10/6/22 at 11:55 a.m., Licensed Practical Nurse (LPN) CC stated the nurses should not be documenting a medication was given if it was not prepped or given. During an interview on 10/6/22 at 2:44 a.m., LPN LL stated the computer system made the nurse prep the medications before they were given, and medications were pre-packaged. He stated the nurse should not sign off on a medication if it was not given. During an interview on 10/6/22 at 2:58 p.m., Registered Nurse (RN) NN stated medications were prepackaged by the pharmacy so it was difficult to have a medication error, but the nurses should not be signing off a medication or treatment if it was not given or done. During an interview on 10/7/22 at 4:15 p.m. with the Director of Nursing Services (DNS) and Senior Nurse Consultant (SNC) WW, the DNS stated that when a new order was received, it should be verified with the physician. Residents that are new admissions had two nurses verify the medications with the orders, had the physician verify, and then the pharmacy was to also verify. The SNC stated the nurse managers should be able to run a report to check for any new orders to be able to verify them; however, the DNS stated she did not have access to run those reports at that time. The SNC stated there was also a tab in the computer program that required the nurses to verify orders they had entered, but it only included discontinued orders or new orders, not changes in orders. The SNC stated the facility had identified areas of concern in Quality Assurance (QA) with documentation in the facility and had initiated a Performance Improvement Plan (PIP) for g-tube (gastrostomy tube) and medication administration documentation. She stated they were trying to identify barriers that were keeping the staff from completing documentation and were constantly reminding the staff to do their documentation by paging overhead. The DON stated the expectation was that all documentation be complete and accurate. During an interview on 10/7/22 at 4:49 p.m., the Administrator stated the staff should not be signing off on a medication or a treatment if they did not give it or do it. He stated the nurse managers should be monitoring for complete and accurate documentation. He stated the nurse that took the order was responsible for verifying it. 2. A review of the Resident Face Sheet indicated R#15 had diagnoses which included dysphagia (difficulty swallowing) with a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). A review of the quarterly MDS, dated [DATE], indicated R#15 had severely impaired cognitive skills for daily decision making. The resident required extensive to total assistance with all ADLs. The MDS indicated the resident received 51% or more of their calories and 501 cubic centimeters (cc) a day or more of fluid from a feeding tube. A review of the Active Orders revealed R#15's physician orders included g-tube (gastrostomy) tube flush with 150 milliliters (ml) of water every four hours, ordered 9/15/22. A review of the October 2022 Medication Administration Record indicated R#15 was scheduled to receive the above ordered flush of 150 ml of water via the g-tube every four hours but was also scheduled to have their g-tube flushed with 200 ml of water every four hours. Both of those water flushes were being signed off as being received, indicating the resident would have been receiving 350 ml of water every four hours instead of the ordered 150 ml every four hours. Observations on 10/5/22 at 10:15 a.m. revealed R#15's pump was set to deliver 150 ml of water every four hours. During an interview on 10/6/22 at 2:58 p.m., RN NN stated nurses should not be signing off a medication or treatment if it was not given or done. During an interview on 10/7/22 at 12:34 p.m., LPN WWW stated she did not do the flushes for R#15; the machine did it. After reviewing R#15's physician orders, she stated the machine must be programmed to administer both flushes, but she was not sure. During an interview on 10/7/22 at 12:43 p.m., RN NN stated R#15 should not have two flush orders, and the machine would only deliver one flush. RN NN stated she was going to talk to the other nurse and get the order clarified. During an interview on 10/7/22 at 4:15 p.m. with the DNS and SNC WW, the DNS stated that when a new order was received, it should be verified with the physician. Residents that are new admissions had two nurses verify the medications with the orders, had the physician verify, and then the pharmacy was to also verify. The DNS stated the Registered Dietitian (RD) put the new order in for R#15's flush of 150 ml every four hours and did not discontinue the old order of 200 ml every four hours. She stated education would be provided to the RD. The SNC stated the nurse managers should be able to run a report to check for any new orders to be able to verify them; however, the DNS stated she did not have access to run those reports at that time. The SNC stated there was also a tab in the computer program that required the nurses to verify orders they had entered, but it only included discontinued orders or new orders, not changes in orders. The SNC stated the facility had identified areas of concern in QA with documentation in the facility and had initiated a PIP for g-tube and medication administration documentation. She stated they were trying to identify barriers that were keeping the staff from completing documentation and were constantly reminding the staff to do their documentation by paging overhead. The DON stated the expectation was that all documentation be complete and accurate. During an interview on 10/7/22 at 4:49 p.m., the Administrator stated the staff should not be signing off on a medication or a treatment if they did not give it or do it. He stated the nurse managers should be monitoring for complete and accurate documentation. He stated the nurse that took the order was responsible for verifying it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the facility's policy, it was determined that the facility failed to ensure bed/side rails had been assessed for the risk of entrapment and only used bed/side rails after trying other alternatives for three of three residents (R) (R#15, R#46, and R#249). The facility also failed to obtain informed consent for the use of bed/side rails for two of three residents (R#15 and R#46) reviewed for bed/side rail use. Finding included: A review of the facility's policy titled Bed Rails last revised 2/1/18 indicated, Bed Rails (also referred to as side rails) are adjustable metal or rigid plastic bars that attach along the side of a patient's bed for the purpose of preventing a patient from falling out of the bed or for assisting a patient independently to turn or maneuver themselves in the bed. Bed rails are available in a variety of types, shapes, and sizes, ranging from full, to one-half, one-quarter, or one-eighth of a bed. Prior to installing or using bed rails on a patient's bed, the patient should be assessed by the admitting nursing and/or the interdisciplinary team (IDT) to determine whether the use of bed rails would constitute an enabler or a restraint for the patient. The patient and/or the patient's representative should be educated on the proper use of bed rails as well as the risks of using bed rails, which should include, but not be limited to, the risk of entrapment. 1. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated R#15 had severely impaired cognitive skills for daily decision making. The resident required extensive to total assistance with all activities of daily living (ADLs). The MDS indicated bed rails were not used as a restraint. A review of R#15's care plan, last revised 8/23/22, revealed the use of bed/side rails was not care planned. A review of the Observation Detail List Report for restraint-adaptive equipment use indicated the observation date was 4/22/22 and completion date was 4/22/22. This form indicated R#15 did not have restraints or adaptive equipment in use. There was no mention of the side rails. Observations on 10/3/22 at 12:30 p.m. revealed R#15 had quarter side rails on both sides of the resident's bed. A review of the active physician orders revealed R#15 had an order for half side rails for turning and repositioning dated 6/3/22. (The resident had quarter rails on their bed, not half rails). Further review of R#15's electronic health record (EHR) revealed no consent for the use of side rails describing the risks and benefits of use. The consent was requested from the facility on 10/4/22 and was not provided by the end of the survey. During an interview on 10/6/22 at 12:30 p.m. with Certified Nurse Aide (CNA) PP, he stated almost all of the beds had side rails and the residents used them for turning and repositioning. During an interview on 10/6/22 at 1:46 p.m. with Staff QQ, Maintenance Director, he stated all the beds except one, had rails and the rails were made to go on the beds. He stated they were checked monthly and was able to demonstrate how he checked the beds/rails for safety. During an interview on 10/6/22 at 2:44 p.m. with Licensed Practical Nurse (LPN) LL, he stated side rail assessments were done quarterly on the MDS schedule. He stated consents for side rails were obtained by the person doing the admission. He stated R#15 used their side rails for positioning. He stated the use of side rails should be care planned. During an interview on 10/6/22 at 2:58 p.m. with Registered Nurse (RN) NN, she stated side rail assessments were done quarterly and consents were obtained at admission. RN NN stated the rails were checked monthly by maintenance. During an interview on 10/6/22 at 6:48 p.m. with CNA UU, she stated R#15 used the side rails to hold themselves over during care. During an interview on 10/6/22 at 8:27 a.m. with CNA DD, she stated R#15 used the bed bars for positioning and assist with cares. During an interview on 10/7/22 at 9:23 a.m. with CNA TT, she stated R#15 used the side rails when they were being changed to be able to hold themselves over. 2. A review of the Resident Face Sheet indicated the facility admitted R#46 on 2/10/22 and was readmitted from the hospital on 5/23/22. A review of the quarterly MDS, dated [DATE], indicated R#46 had a BIMS score of 13, indicating the resident had no cognitive impairment. The resident required extensive to total assistance of one to two people for their ADLs. The MDS indicated bed rails were not used as a restraint. A review of R#46's care plan, last revised 8/23/22, revealed the use of bed/side rails was not care planned. Observations on 10/3/22 at 12:40 p.m. revealed R#46 had quarter side rails on both sides of the resident's bed. A review of the active physician orders revealed R#46 had an order for half side rails for turning and repositioning dated 5/23/22. (The resident had quarter rails on their bed, not half rails). A review of the Observation Detail List Report for restraint-adaptive equipment use indicated the observation date was 2/10/22 and completion date was 2/16/22. This form indicated R#46 did not have restraints or adaptive equipment in use. There was no mention of the side rails. A review of R#46's electronic EHR revealed no current assessment/reassessment for R#46's continued use of the side rails. Further review of R#46's EHR revealed no consent for the use of side rails describing the risks and benefits of use. The consent was requested from the facility on 10/4/22 and was not provided by the end of the survey. During an interview on 10/6/22 at 12:30 p.m. with CNA PP, he stated almost all the beds had side rails and the residents used them for turning and repositioning. During an interview on 10/6/22 at 1:46 p.m. with Staff QQ, Maintenance Director, he stated all the beds except one, had rails and the rails were made to go on the beds. He stated they were checked monthly and was able to demonstrate how he checked the beds/rails for safety. During an interview on 10/6/22 at 2:44 p.m. with LPN LL, he stated side rail assessments were done quarterly on the MDS schedule. He stated consents for side rails were obtained by the person doing the admission. He stated R#46 used their side rails for positioning. He stated the use of side rails should be care planned. During an interview on 10/6/22 at 2:58 p.m. with RN NN, she stated side rail assessments were done quarterly and consents were obtained at admission. RN NN stated the rails were checked monthly by maintenance. During an interview on 10/6/22 at 6:48 p.m. with can UU, she stated R#46 used the side rails to hold themselves over during care. During an interview on 10/6/22 at 8:27 a.m. CNA DD, she stated R#46 used the bed bars for positioning and assist with cares. During an interview on 10/7/22 at 9:23 a.m. with CNA TT, she stated R #46 used the side rails when they were being changed to be able to hold themselves over. 3. A review of the Resident Face Sheet indicated the facility admitted R#249 on 9/19/22. A review of the admission MDS, dated [DATE], indicated R#249 had a BIMS score of 15, indicating the resident had no cognitive impairment. The resident required extensive assistance of one to two people for their ADLs. The MDS indicated bed rails were not used as a restraint. A review of R#249's care plan, last revised 9/26/22, revealed the use of bed/side rails was not care planned. Observations on 10/3/22 at 11:55 a.m. revealed R#249 had quarter side rails on both sides of their bed. A review of the active physician orders revealed R#249 had an order for quarter side rails for turning and repositioning dated 9/21/22. A review of the Restraint-Adaptive Equipment Use form indicated the observation occurred on 9/19/22 but was recorded on 10/4/22. This form indicated R#249 did not have restraints or adaptive equipment in use. There was no mention of the side rails. During an interview on 10/6/22 at 12:30 p.m. with CNA PP, he stated almost all the beds had side rails and the residents used them for turning and repositioning. During an interview on 10/6/22 at 1:46 p.m. with Staff QQ, Maintenance Director, he stated all the beds except one, had rails and the rails were made to go on the beds. He stated they were checked monthly and was able to demonstrate how he checked the beds/rails for safety. During an interview on 10/6/22 at 2:44 p.m. with LPN LL, he stated side rail assessments were done quarterly on the MDS schedule. He stated consents for side rails were obtained by the person doing the admission. He stated R#249 used their side rails for positioning and to assist with standing up. He stated the use of side rails should be care planned. During an interview on 10/6/22 at 2:58 p.m. with RN NN, she stated side rail assessments were done quarterly and consents were obtained at admission. RN NN stated the rails were checked monthly by maintenance. During an interview on 10/6/22 at 6:48 p.m. with CNA UU, she stated R#249 used the side rails for positioning and to stand. During an interview on 10/6/22 at 8:27 a.m. with CNA DD, she stated R#249 used the bed bars for positioning and assist with cares. During an interview on 10/7/22 at 9:23 a.m. with CNA TT, she stated R#249 liked to have their side rails up all the time and she stated the resident would keep their call light and bed remote on the rail. During an interview on 10/7/22 at 9:59 a.m. with CNA EE, she stated all the residents had side rails and she would put them up if the resident requested. During an interview on 10/7/22 at 4:15 p.m. with the Director of Nursing Services, she stated that each resident had a restraint equipment device assessment done quarterly and annually and consents for the bed rails were to be obtained upon admission. During an interview on 10/7/22 at 4:49 p.m. with the Administrator, he stated his goal was to take all the side rails off all the beds but if the resident needed them, then consent should be obtained as part of the admission assessment. He stated they would be getting consent from all residents that had side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and document review, it was determined the facility failed to have sufficient nursing staff to provide care for two of nine (R) (R#12 and R#293) reviewed for activities of daily living and one of four residents (R#56) who required daily wound care. Findings included: A review of the Facility Assessment for 2022 revealed the facility evaluated Staffing, Training, Services & Personnel for Overall Staffing, Staff Competencies, and Services. According to the assessment, for a sufficiency analysis summary indicated to Use and/or refer to: 1. Staffing and scheduling systems 2. Staff training and competency programs 3. A review of individual staff assignments and systems for coordination and continuity of care for residents withing and across staff assignments. An interview with the Administrator on 10/7/22 at 2:40 p.m. revealed the facility was staffed according to the census. According to the Administrator, when the resident census ran in the 90s, he liked to have four or five certified nursing assistants (CNAs) for each floor on the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts. During an interview on 10/7/22 at 1:53 p.m., the Director of Nursing (DON)/Registered Nurse (RN) BB and Senior Nurse Consultant (NC) WW stated she would like to see four CNAs scheduled on each floor for the first shift, three CNAs on each floor for second shift, and five to six CNAs for third shift. 1. A review of R#56's quarterly admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. A review of the September 2022 Treatment Administration Record (TAR) indicated an order, with a start date of 9/9/22 and end date of 9/30/22, to cleanse the right dorsal proximal foot (top of the right foot closest to the leg) with wound cleanser, pat dry, pack with Dakin's 0.5% packing, cover with a 4 x 4 gauze, and secure with rolled gauze. Change three times weekly with frequency on Monday, Wednesday, and Friday. The TAR indicated there was no documentation of the dressing change being performed on 9/19/22, 09/26/22, or 9/28/22. A review of the September 2022 TAR revealed an additional treatment order, start date of 9/9/22 and end date of 9/30/22, to cleanse the right ankle with wound cleanser. Pay dry. Apply HydroFera Blue and secure. Change three times a week with a frequency on Monday, Wednesday, and Friday. The TAR indicated there was no documentation of the dressing change being performed on 9/19/22, 9/26/22, or 9/28/22. A review of Active [physician] Orders for R#56 revealed an order with a start date of 9/30/22, to cleanse the resident's right dorsal proximal foot (top of the right foot closest to the leg) and right malleolus of the anterior foot (the ankle bone on the inside of the foot) with wound cleanser, pat the areas dry, pack with Dakins 0.5% packing, cover with 4 x 4 pad, and secure with rolled gauze. An interview with R#56 on 10/3/22 at 11:32 a.m. revealed the resident thought the bandage was changed daily; however, observation revealed the bandage on the right foot was dated 9/30/22, three days prior. An interview with Wound Care Nurse OO on 10/3/22 at 10:26 a.m. revealed she was supposed to provide wound care for residents at least four days a week. However, she had not completed wound care consistently for the last couple of months because she had been reassigned to provide resident care due to staffing. She stated the facility needed more staff so she could provide wound care. During a follow-up interview on 10/4/22 at 12:05 p.m., Wound Care Nurse OO confirmed the last day she provided treatment to R#56's right foot was on 9/30/22. She stated she had to work as a staff nurse and was unsure whether the treatment was provided for the resident since 9/30/22. An interview with Licensed Practice Nurse (LPN) CC on 10/4/22 at 4:00 p.m. revealed she had mentioned to the DON that there was not enough staff and the DON told her that she would have to step up and help. LPN CC stated she told the DON that she had to administer residents' medications and would help the residents the best she could. However, she could not agree with the DON because she could not do her job and the duties of a CNA. According to LPN CC, the DON was working as a staff nurse and thought the DON had worked until 1:00 a.m. the previous night. LPN CC stated she and Wound Care Nurse OO worked as staff nurses on 10/3/22 because they did not have enough nurses; subsequently, Wound Care Nurse OO could not provide all wound care. She stated staff had been told the facility would not get agency staff because it cost the company too much money. An interview with RN NN on 10/5/22 at 3:49 p.m. revealed she thought wound care could be done better if they had more staff. An interview with DON BB and Senior Nurse Consultant WW on 10/7/22 at 2:39 p.m. revealed they were unaware of any concerns with wound care not being completed. The DON and Senior Nurse Consultant WW stated they had been short staffed like everywhere else. They stated they were trying of offer bonus/incentives to get more staff and had not been using agency staffing. They said that the wound care nurse had been pulled a lot to work as a staff nurse, but they thought the other nurses were providing wound care. They stated they expected staff nurses to complete wound care if Wound Care Nurse OO was not available. An interview with the Administrator on 10/7/22 at 2:11 p.m. revealed he was aware of the facility's staffing concerns but they did not hire agency staffing because corporate staff said it cost too much money. He was aware that due to staffing issues the DON and Wound Care Nurse OO had been working as floor nurses instead of their normal job duties. 2. A review of the Face Sheet indicated R#12 had diagnoses including diffuse traumatic brain injury. A review of the quarterly MDS dated [DATE] indicated R#12 had a BIMS of two, which indicated severe cognitive impairment. The assessment revealed R#12 required extensive assistance of one staff member for dressing, toileting, and personal hygiene. A review of R#12's care plan, revised 8/24/22, indicated the resident was at risk for a decline in activities of daily living (ADL) related to the resident's cognition and required staff assistance with ADLs. The facility developed an intervention that required staff to assist the resident with ADLs, including the assistance of one staff for toileting, incontinence care, dressing, bathing, and grooming. A review of a facility's Grievance/Complaint Form: Healthcare Centers, dated 7/6/22, indicated R#12's family member called to file a grievance in response to other family members who were very upset after visiting R#12 over the weekend (7/2/22-7/3/22) and finding the resident dirty, ungroomed, and in dirty clothes. The family member stated R#12 was always very well put together and conscious of [the resident's] appearance. The form indicated facility steps taken to investigate the grievance included showering R#12, clipping and cleaning the resident's nails, shaving, and changing R#12 into clean clothes. The form concluded, Grievance confirmed. A review of the Daily Census Report indicated the census on Saturday, 7/2/22, was 92 residents, and the census on Sunday, 7/3/22, was 93 residents. On 10/7/22 at 1:01 p.m., the surveyor and HR/Staffing personnel XX reviewed the Daily Nursing Staff Forms and the Export [NAME] Punch Audits, a log of employee time clock information, for 7/2/22 and 7/3/22. According to the staffing information, on 7/2/22 on the 7:00 a.m. to 3:00 p.m. shift, two CNAs worked on each of the two facility floors. On 7/2/22, on the 3:00 p.m. to 11:00 p.m. shift, for the first floor, one CNA worked the entire shift, and a second CNA reported to the first floor at 7:00 p.m. On the second floor, two CNAs worked until 7:00 p.m., one of the CNAs left at 7:00 p.m., leaving one CNA working. On 7/2/22, from 11:00 p.m. to 7:00 a.m., there were two CNAs on each floor. Further review of staffing information revealed on 7/3/22, there were two CNAs on each of the two facility floors from 7:00 a.m. to 3:00 p.m. On the 3:00 p.m. to 11:00 p.m. shift, one CNA worked the first floor, one CNA worked the entire 3:00 p.m. to 11:00 p.m. shift on the second floor, and two other CNAs working five hours total. Five CNAs worked on the 11:00 p.m. to 7:00 a.m. shift on 7/3/22. 3. A review of R#144's 5-Day scheduled, discharge MDS, dated [DATE], revealed the facility admitted the resident on 7/19/22 and discharged the resident on 7/23/22. The MDS revealed the resident had diagnoses of cancer, anemia, heart failure, hypertension, renal insufficiency, and diabetes. R#144 had a BIMS score of 15, indicating intact cognition. According to the MDS, R#144 was occasionally incontinent of bowel and bladder. The assessment further revealed R#144 required limited assistance from one staff member with bed mobility, transfers, personal hygiene, toileting, dressing, walking in the room, and locomotion on the unit. A review of a facility's Grievance/Complaint Form: Healthcare Centers, dated 7/20/22, indicated a family member found R#144 in urine. The grievance summary indicated the family member had arrived before the staff could get to the resident. On 10/7/22 at 10:44 a.m., an interview with R#144's family member revealed the resident was at the facility for rehabilitation, but the resident was found on day one soaked, sitting in [their] own urine. The family member stated R#144 needed help getting to the bathroom, and that was the very reason the resident went to the facility. The family member stated they got the resident out of the facility as soon as they could. It was unacceptable that someone did not assist the resident. On 10/7/22 at 1:01 p.m. a review of the Daily Nursing Staff Forms dated 7/20/22 and reconciliation of the Export [NAME] Punch Audits for 7/20/22, with HR/Staffing personnel XX revealed on 7/20/22, on the 7:00 a.m. to 3:00 p.m. shift and the 3:00 p.m. to 11:00 p.m. shift, there were two CNAs on each floor. On 7/20/22, on the 11:00 p.m. to 7:00 a.m. shift, there were five CNAs in the facility. 4. A review of an anonymous complaint revealed on 2/6/22, the complainant visited the facility and found an unnamed resident in a mess. The complaint alleged only one CNA was working the floor. On 10/5/22 at 3:02 p.m., an interview with HR/Staffing personnel XX revealed she was responsible for making the staffing schedules. She stated staffing was determined by resident census. HR XX stated the census on 2/6/22 was 94. Referring to the Daily Nursing Staff Form, dated 2/6/22, HR XX stated that while she would have wanted three CNAs on each floor per shift, the facility had two CNAs on each floor per shift. A follow-up interview with HR XX on 10/7/22 at 1:46 p.m., revealed after reviewing the Export [NAME] Punch Audit dated 2/6/22, she confirmed that one of the CNAs listed on the Daily Nursing Staff Form dated 2/6/22 had called out from work and only one CNA worked on the second floor for the 7:00 a.m. to 3:00 p.m. shift. Continued interview on 10/5/22 at 3:02 p.m., HR XX stated three staff members (Restorative CNA AAA, Recreation/Activity Staff BBB, and Medical Records CCC) who primarily served in other roles were also certified and were at times pulled from their primary duties to fill staffing needs. However, a review of the Export [NAME] Punch Audit and the Daily Nursing Staff Form revealed no documented evidence the three staff members had worked as a CNA. During an interview on 10/5/22 at 2:44 p.m., CNA EEE stated the weekends were understaffed. CNA EEE stated more staff were needed so they could get to everyone. An interview with CNA DD on 10/6/22 at 2:10 p.m. revealed there were not enough staff to care for residents. She stated sometimes there were one or two CNAs to provide care for 50 residents. During an interview on 10/7/22 at 5:41 a.m., CNA DDD stated at times the resident load was too much. CNA DDD stated they usually started waking residents at 3:00 a.m. to begin providing morning care so there would be time to get it could get done. CNA DDD stated there were not enough staff during the week nor on weekends to provide resident care, and sometimes the care did not get done. An interview with CNA UU on 10/7/22 at 5:50 a.m. revealed at times the resident load was too much, and they had to wake residents early to get the morning care completed. During an interview on 10/7/22 at 6:08 a.m., CNA RR stated there were not enough staff during the week nor on the weekends, sometimes resulting in a lack of incontinent care and overall patient care. An interview with LPN CC on 10/5/22 at 4:00 p.m. revealed that the previous weekend (10/1/22-10/2/22), one CNA was responsible for caring for 50 residents. She stated they were always short staffed, and the DON was working as a staff nurse all the time. An interview with CNA FFF on 10/6/22 at 2:25 p.m. revealed she thought they needed to hire more staff because she felt like they could do a better job caring for residents if they had more CNAs and nurses. During an interview on 10/7/22 at 1:53 p.m., with the DON/ RN BB and Senior Nurse Consultant (NC) WW stated she would like to see four CNAs scheduled on each floor for the first shift, three CNAs on each floor for second shift, and five to six CNAs working third shift. The DON stated the census for the second floor on 2/6/22 was 46 and one CNA was not enough. The DON stated she would have liked to have had more staff to care for residents on 7/3/22 on the 3:00 p.m. to 11:00 p.m. shift and on 7/20/22. On 10/7/22 at 2:40 p.m., the Administrator stated the facility tried to meet and exceed the state requirements for staffing. The Administrator stated the facility was staffed according to the census. The Administrator stated the residents on the second floor of the facility had a higher acuity, which was considered when scheduling staff. Further interview with the Administrator revealed when the resident census ran in the 90s, he liked to have four or five CNAs on each floor for each of the 7:00 a.m. to 3:00 p.m. and 3:00 to 11:00 p.m. shifts. The Administrator did not comment about one CNA assigned to care for 46 residents, but stated staffing was an ongoing issue everywhere.

Based on observation, document review, and interviews, the facility failed to prohibit the Director of Nursing (DON) from serving as a charge nurse for eight of 18 days reviewed when the facility's census was greater than 60 residents and there was no staffing waiver in effect. Findings included: During an observation on 10/3/22 at 9:48 a.m., the DON was observed working a medication cart and administering mediations to residents. A review of a Census Daily Detail by Name Report: All Units for 10/3/22 indicated the census of the facility was 90 residents. During an interview on 10/5/22 at 3:07 p.m., the Human Resources (HR) Director, HR XX, stated when the DON worked on the floor, the DON did so as a charge nurse. HR XX stated that, as a charge nurse, the DON was responsible for a medication cart and the administration of medications to residents. HR XX reviewed Daily Nursing Staff Forms with the surveyor and confirmed the DON was scheduled and worked as a charge nurse on 9/20/22 during the 7:00 a.m. to 7:00 p.m. shift, on 9/21/22 during the 7:00 a.m. to 3:00 p.m. shift, on 9/26/22 during the 7:00 a.m. to 7:00 p.m. shift, on 9/27/22 during the 7:00 a.m. to 3:00 p.m. shift, on 9/29/22 during the 7:00 a.m. to 7:00 p.m. shift, and on 9/30/22 during the 7:00 a.m. to 7:00 p.m. shift. According to HR XX, the DON was scheduled as a charge nurse during the 7:00 a.m. to 7:00 p.m. shift on 10/3/22, but another nurse came into work and relieved the DON of that duty. Per HR XX, on 10/4/22, the DON worked a medication cart until another nurse relieved the DON of that duty. HR XX reported the DON was scheduled to work as a charge nurse because two nurses had been on vacation, one of which came back to work that day, on 10/5/22, and the other nurse resigned, which caused staffing issues. A review of a Census Daily Detail by Name Report: All Units report revealed on 9/20/22, the facility's census was 94 residents; on 9/21/22, the facility's census was 94 residents; on 9/26/22, the facility's census was 93 residents; on 9/27/22, the facility's census was 94 residents; on 9/29/22, the facility's census was 95 residents; on 9/30/22, the facility's census was 93 residents; and on 10/4/22, the facility's census was 90 residents. During an interview on 10/6/22 at 2:21 p.m., the DON reported the facility was short of staff and when there was no one available to cover the medication cart, she worked the medication cart as a charge nurse. During an interview on 10/6/22 at 2:39 p.m., the Administrator stated there was a shortage of staff everywhere, so the DON sometimes manned the medication cart when there was no one else to do so. The Administrator explained he had lost two nurses earlier in the year, and two more nurses had been on extended vacations. According to the Administrator, he had been offering incentives for staff, even out of his own pocket. The Administrator stated he tried to follow the regulations, but he also had to make sure the residents got their medications on time. During a follow-up interview on 10/7/22 at 4:54 p.m., the DON confirmed she had been scheduled as a charge nurse on 9/20/22, 9/21/22, 9/26/22, 9/27/22, 9/29/22, 9/30/22, 10/3/22, and 10/4/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews and review of the policy titled Resident Trust Policy, the facility failed to provide quarterly financial statements for two of two cognitively intact residents (R) reviewed that had a trust fund account managed by the facility (R#14, R#61). The facility managed 93 resident trust fund accounts. Findings include: Review of the facility policy titled Resident Trust Policy dated September 2009, revealed number 6. Quarterly statements will be provided in writing to the resident or the resident's responsible representative within 30 days after the end of the quarter. 1. Record review for R#14 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, which indicates the resident is cognitively intact. Interview on 7/21/19 at 12:53 p.m., R#14 revealed she does not receive a quarterly statement for her trust fund account that the facility manages. Review of printed Resident Fund Management Service dated 7/24/19 at 10:21 a.m., revealed on page three (3), R#14 has an active trust fund account that is managed by facility. 2. Record review for R#61 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 15, which indicates the resident is cognitively intact. Interview on 7/22/19 at 11:13 a.m., R#61 revealed she does not receive a quarterly statement for her trust fund account that the facility manages. Review of printed Resident Fund Management Service dated 7/24/19 at 10:21 a.m., revealed on page two (2), R#61 has an active trust fund account that is managed by facility. Interview on 7/23/19 at 4:55 p.m. with Accounts payable/Financial Counselor, responsible for the resident trust fund accounts, stated during the admission process, the residents are given the choice to have the facility manage a trust fund for their money. If the resident elects the facility to manage their trust fund, an agreement is signed and she sets up the account. She stated that residents are informed they have access to their money 24 hours per day. She further stated that she gives the residents quarterly statements in person within the month after the quarter ends, if the resident is their own responsible party. She stated the residents sign a ledger to acknowledge receipt of their quarterly statement. She confirmed the facility was managing resident trust for both R#14 and R#61. She further stated she was unable to find any documentation that R#14 or R#61 had acknowledged receiving their quarterly statement for the past four quarters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interviews, the facility failed to provide supervised smoking for one resident (R#7) reviewed for smoking. The sample size was 55. Findings include: Review of the facility policy titled Smoke Free Policy with a revised date of 11/5/18, revealed the policy statement to be as of January 1, 2015, smoking is not allowed on the healthcare center premises by visitors, partners or patients/residents. Smoking will only be allowed in outdoor designated areas for those residents grandfathered in prior to January 1, 2015. Procedure bullet 10: when the patient/resident is identified as needing supervision, the supervision shall be provided by a partner who is physically present in the designated smoking area for all residents who need supervision based on their Smoking Observation Form or electronic documentation. Review of the clinical record for R #7 revealed resident was admitted to the facility on [DATE] with diagnosis of but not limited to mood disorder, muscle spasms, anemia, peripheral vascular disease (PVD), chronic obstructive pulmonary disease (COPD), depression, amputation of both legs, hyperlipidemia, tobacco use, neuropathy, diabetes (DM). The resident's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section J revealed resident was a current smoker. Review of facilities Smoker Worksheet, revealed R#7 name was on the list of identified smokers in the facility. Review of Smoking Observation Form documented that residents were to be assessed on admission, re-admission, or with a significant change. Review of Quarterly Smoking Observation Form for R#7, dated 3/12/19 and 7/22/19, revealed question one: Does the resident smoke? Yes column is checked. Question two: Does the resident have a past history of smoking? Yes column is checked. Supervision will be required at all designated smoking times when the patient/resident observation identifies any potential hazard risk, as evidenced by any boxes checked Yes. Patient/resident smoking status upon observation: Supervised Smoker. Review of document titled Smokers in the Facility undated, provided by facility, revealed that R#7 name was on the document. Review of document titled Smoking Location of the Facility undated, provided by the facility, revealed the court yard on the first floor as the designated smoking area. Based on review of R#7's comprehensive care plan a provided, resident is a current smoker and wished to continue to enjoy smoking with supervision, initiated on 3/12/19 and revised on 7/22/19. Observation on 7/21/19 at 2:00 p.m., resident was observed smoking in the designated smoking area (court yard on first floor). He was smoking one cigarette and holding a second cigarette in his hand. He was wearing a smoking apron. There was no evidence of any staff members present during the smoking period. Surveyor remained with resident until he was finished smoking. Interview on 7/21/19 at 2:00 p.m. with R#7, stated he smokes by himself most of the time, but staff give him cigarettes and light them for him, and then they leave. Observation on 7/21/19 at 2:10 p.m., staff member GG removed resident smoking apron, upon re-entry into facility. Staff member stated that he just gets the cigarettes from the nurses station and lights them for resident and puts the apron on and takes it off. He asked surveyor Is someone supposed to be outside with him when smoking? Interview on 7/23/19 at 8:45 a.m. with housekeeping aide HH, stated she was asked to start sitting with resident today, during the 8:30 smoking break. Interview on 7/23/19 at 1:21 p.m with Admininistrator, stated the facility is a non-smoking facility, but there is one resident who was grandfather in. He stated that there is not a formal schedule as to who is supposed to attend smoke breaks with the resident. He further stated that staff from housekeeping, dietary, activities and nursing are supposed to supervise the resident during smoke breaks. He further stated that he makes sure someone is with resident while smoking. On the weekends and when he is not in facility, he stated it is the responsibility of the Nursing Supervisor to ensure a staff member is with resident during smoke breaks. When questioned about Sunday episode when resident was observed in courtyard smoking unsupervised, he responded that the weekend Supervisor called out on Sunday, and he does not know who would or should have made sure the resident had supervision for smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for resident R#304 revealed she was admitted to the facility on [DATE]. She readmitted to the facility on [DATE] with diagnoses including but not limited to: congestive heart failure, chronic obstruction pulmonary disease, hypertension, major depression, chronic pain syndrome. Record review for R#304 admission Minimum Data Set (MDS) assessment dated [DATE] which documented a BIMS summary score of 15, indicating cognitively intact. An interview and observation on 7/22/19 at 9:53 a.m. R#304 did not have a water pitcher in the room. The resident revealed that they she has liquids on the meal tray and she saves the liquids to have to drink throughout the day. An observation on 7/22/19 at 3:42 p.m. R#304 had no water pitcher visible. An observation on 7/23/19 8:42 a.m. R#304 had no water pitcher visible. An observation on 7/23/19 at 9:07 a.m. R#304 sitting up in bed eating breakfast noted one glass of water on tray. no water picture visible. An observation on 7/23/19 at 10:54 a.m. of two certified nursing assistant (CNA) KK and PP passing ice, water, and juice on first floor hall A. The CNA KK entered R#304 room and came out no ice, water, or juice was provided to R#304. An interview was conducted on 7/23/19 at 11:03 a.m. with R#304. The resident revealed the staff came in and ask her did she have a pitcher for ice water and she informed them she did not have one. Resident revealed the staff told her they would get a water pitcher for her. An interview was conducted on 7/23/19 at 11:48 a.m. with CNA KK regarding provided hydration to the residents in the facility. The CNA revealed when passing hydration to the residents the residents are asked if they would prefer Ice, water, and/or juice. The CNA also revealed Ice, water, juice is passed/offered to the residents each shift and at the resident request. The CNA revealed If the resident does not have a pitcher one will be provided. An interview was conducted on 7/23/19 at 12:15 p.m. with PP CNA. The CNA revealed she assisted with passing ice water on C hall and was aware that R#304 did not have a pitcher. The CNA revealed she did not provide a pitcher to R#304 and was not sure if the CNA KK provided the residents with a pitcher. An observation on 7/23/19 4:42 p.m. R#304 had no water pitcher visible. An interview was conducted 7/23/19 at 4:55 p.m. with the Administrator and the Senior Nurse Consultant LL. The Senior Nurse Consultant confirmed that R#304 did not have a pitcher at her bedside. Both the Administrator and Senior Nurse Consultant revealed that their expectations are that the ice water is passed to all residents to ensure that they stay hydrated. Review of the facility policy titled Hydration: Dietary Service. with a revised date of 10/18/17 revealed: Each resident/patient will be provided a drinking glass and water pitcher in their room unless they are on fluid restriction. Water pitchers are filled with ice/water at least but limited to twice per day. Based on observation, interviews, record review and review of the facility policy Hydration: Dietary Service. The facility failed to provide hydration (ice/water) at the bedside for two of fifty-five sampled residents, (R) (R#61 and R#304). Findings include: 1. Review of the clinical record for R#61 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to atherosclerotic heart disease, chronic obstructive pulmonary disease (COPD), hypertension (HTN), hyponatremia, Spondylosis, depression, history falls and neuropathy. The resident's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Interview on 7/22/19 at 11:20 a.m. in R#61 room, she stated she rarely gets fresh ice water. No visible water pitcher in R#61 room. Observation on 7/23/19 at 8:05 a.m., there is no visible water pitcher or drinking cup on residents side of the room. Observation on 7/23/19 at 3:06 p.m., resident sitting at her beside. She stated that no-one brought her any ice water today. There is no visible water pitcher or water cup on her over bed table. Interview on 7/24/19 at 8:26 a.m. with R#61, stated she was given a pitcher of ice water today, when she hasn't had a pitcher for ice water in a long time. She could not remember exactly how long it has been since she had ice water. Interview on 7/24/19 at 9:34 a.m. with Certified Nursing Assistant EE stated that she passes ice twice daily on her shift. She further stated that she offers R#61 ice water everyday, but resident refuses and throws her water pitcher in the trash.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure that privacy curtains were clean and provided full visual privacy, which included a total of six of 119 beds on one of two units. The facility census was 108 residents. Findings include: Observation on 7/21/19 at 2:16 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/21/19 at 3:33 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/22/19 at 10:53 a.m., revealed in room [ROOM NUMBER], bed A and bed B had no privacy curtain at all. Observation on 7/22/19 at 11:04 a.m., revealed in room [ROOM NUMBER], privacy curtain on bed B dirty with dried food particles. Observation on 7/22/19 at 12:11 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/23/19 at 11:55 a.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Interview on 7/24/19 at 10:05 a.m. with Housekeeping Aide DD, stated she inspects the privacy curtains daily to make sure they are clean. She stated if the privacy curtains need to be changed, she notifies the floor tech, to take down to be laundered. She stated she was not sure if there was a routine schedule for laundering the privacy curtains. She stated that she has not noticed any privacy curtains that were too short or missing in any of the rooms on A-Hall. Interview on 7/24/19 at 6:05 p.m. with Housekeeping Supervisor, stated her expectation is that the housekeeping aides look at the privacy curtains every day. If a curtain is identified as being dirty, they are to notify the floor tech to remove the curtain and replace it with a clean one. She stated there is not a routine schedule of laundering the privacy curtains. She further stated that if the housekeeping staff are checking the privacy curtains daily, she is not sure how there could be a room that didn't have a curtain at all, or some rooms with short curtains in the middle.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in seven resident rooms (rooms 200, 201, 203, 206, 209, 210, 227), common shower room and supply storage room, on one of two units. The census was 108. Findings include: Observation on 7/21/19 at 11:20 a.m., revealed on second floor, A Hall supply/storage fluorescent room light out, making room dark during retrieval of supplies. Observation on 7/21/19 at 11:30 a.m., revealed in room [ROOM NUMBER] light bowl sitting on sink counter; ripped wallpaper strip above bed A; peeling particle board on sink counter; hole in ceiling, between two beds, with electrical face plate partially covering opening; hole in ceiling tile in bathroom, approximately two inches in diameter; light in bathroom missing globe fixture; hole in ceiling tile in bathroom, approximately one inch circular around sprinkler head. Observation on 7/21/19 at 12:51 p.m., revealed in room [ROOM NUMBER], electrical outlet in wall with broken face plate. Observation on 7/21/19 at 12:55 p.m., revealed in room [ROOM NUMBER], a hole in ceiling tile in bathroom, approximately two inches in diameter; call light reset button missing on wall unit; chair rail missing around room on bed B side of the room. Observation on 7/21/19 at 2:16 p.m., revealed in room [ROOM NUMBER], hole in ceiling, between two beds, with electrical face plate partially covering opening. Observation on 7/21/19 at 2:18 p.m., revealed common shower room on second floor, with strong, unidentifiable and gagging odor. Observation on 7/22/19 at 11:04 a.m., revealed in room [ROOM NUMBER], bathroom had very strong urine odor; male urinal in clear plastic bag hanging on grab bar, with dark discolored ring around urinal opening. Observation on 7/22/19 at 12:11 p.m., revealed in room [ROOM NUMBER], hole in ceiling, between two beds, with electrical face plate partially covering opening. Observation on 7/23/19 at 11:55 a.m., revealed in room [ROOM NUMBER], chair rail around the beds, missing chunks of wood, exposing splintered wood rail. Interview on 7/24/19 at 5:26 p.m., with Maintenance Director, stated that each nurses station has a notebook that staff members fill out a hand written work order for items or concerns needing maintenance repair. He stated that he checks the notebooks 3-4 times per day. He further stated he prioritizes items/concerns that relate to resident care. During walking rounds, he verified concerns identified during survey.

Based on observation, staff interview, and review of facility provided data, the facility failed to ensure kitchen staff were wearing hair protectors in the food preparation area. In addition, the facility failed to ensure the dish machine room was safe and sanitary; specifically, free from broken floor tiles and free from dirty water containing food debris accumulating on the floor. This practice had the potential to affect 103 residents receiving an oral diet. The census was 108 residents. The findings include: An initial tour of the kitchen was conducted on 7/21/19 at 11:20 a.m. with [NAME] CC, Kitchen Aide BB, and Kitchen Aide AA, the Food Service Manager (FSM) was unavailable. The kitchen staff was observed in the process of cooking and preparing for the lunch meal. A small amount of food debris was observed on kitchen floor tiles, walls were clean. The dish machine wash and rinse cycle was tested twice by a Kitchen Aide with two (2) small batches of dirty dishes. The wash and rinse cycle were within required range for a low temperature machine. The floor drain in the dish machine room was not draining water. Floor tiles around the drain area in the middle of the floor, appeared loose, and broken. A large amount of cloudy pooled water containing food debris was noted in the middle of the room, approximately five (5) inches deep at the drain site. Water was also observed pooled over two black rubber safety mats. A brief interview was conducted with Kitchen Aide AA on 7/21/19 at 11:50 a.m. during the tour in the dish machine room, where she confirmed the floor drain has not been draining right for some time that maintenance was aware of it. A second tour of the kitchen was conducted on 7/22/19 at 4:00 p.m. with the FSM, where she confirmed there were broken tiles and water pooling around the drain area in the dish machine room, she confirmed maintenance was aware of the drainage problem. During the continued tour, [NAME] MM was observed working in the kitchen, on the dinner meal preparation, without a beard net. The staff's beard, mustache and goatee facial hair were uncovered. An interview was conducted with the Maintenance Director (MD) on 7/23/19 at 16:40 p.m. where he stated that a local plumbing company came out on Thursday. He explained the first he knew about the drain problem was on Wednesday. The plumber snaked the drain on Thursday, but it didn't work. He confirmed loose and broken tiles but did not know how long the problem was there. He stated that on Friday they were supposed to have the jetting of the drain conducted by the plumbing company, but he could not come, he called to say he was sending a subcontractor, but confirmed it wasn't done. The MD confirmed they would wet vac the area. Observation of the drain area with the MD reveals a larger pooled area from what was observed on 7/21/19, the water appearing cloudy, with food debris. Two safety mats located along the side of the dish machine were covered with water. A request was made from the MD for a copy of the work orders and/or invoices for plumbing repairs. During a brief observation in the kitchen on 7/23/19 at 12:48 p.m. [NAME] MM was observed in the lunch meal tray line dishing up food items with a hair protector/net on, a beard guard on that covered his lower beard, however, facial hair in the goatee and mustache areas were not covered. A brief interview was conducted on 7/23/19 at 4:00 p.m. with Nurse Consultant LL during the request for the facility policy regarding kitchen staff attire, to include hair requirements. The Nurse Consultant confirmed the kitchen staff know that hair and beard nets are an expectation, that all hair needs to be covered. A review was conducted of the provided facility policy titled, Dietary Partner Hygiene and Dress Code, revised date, 6/2016. Policy Statement: it is the policy for partners working in the Dietary Department to dress in a manner appropriate for preparing, handling and serving food that prevents contamination and spread of bacteria. Scope: This applies to all dietary partners, and any person(s) who handles and serves food employed by the facility. Hygiene: No. 2 documented- hair is covered with hair net and/or cap. Facial hair is completely covered with a hair net or beard guard. A review was conducted of two (2) facility provided plumbing invoices. The invoice date of 4/2/19, note documentation reflects- jet service related to the kitchen sink floor was backing up. The line was jetted and it was discovered to have a separation down the line. The line needs to be dug up and repaired. The invoice date of 7/18/19, documentation note reflects- jet service for the kitchen line floor drain by the dishwasher was snaked first and cleared up of a cup and knife. It was still backing up when it had to be jetted and cleared, 30-day warranty.

Based on observation and staff interviews, the facility failed to ensure the sanitary handling of used cooking oil/refuse, and failed to ensure that kitchen staff had adequate accessibility to the grease trap grounds area for disposal. The census was 108 residents. Findings include: An initial tour of the kitchen was conducted on 7/21/19 at 11:20 a.m. with [NAME] CC, Kitchen Aide BB, and Kitchen Aide AA, the Food Service Manager (FSM) was unavailable. The kitchen staff was observed in the process of cooking and preparing for the lunch meal. The latest health inspection dated 7/12/19, was posted, documenting a score of 98%. Food prep areas, kitchen equipment and food storage areas were observed to be clean and in order. The initial tour continued to the loading dock area, dumpster area, and the grease trap area with Kitchen Aide BB. The back door was closed to the kitchen. During the observation of the walk-through area to the outside, used as a pass through to the kitchen back door, revealed seven (7) dead insects and a box-like mouse trap. At 12:00 p.m. while the tour continued outside, near the dumpster area, Kitchen Aide BB explained they dump the grease and oil in the grass behind the dumpster. The grease trap container was observed located behind a six (6) foot fence. The fence door was unlatched; however, the Kitchen Aide was unable to open the gate fully, less than 1.5 feet. A large number of weeds and Kudzu vines were surrounding the grease trap container and the surrounding area. The grease trap container was observed to be the size of a tall, large barrel-type trash receptacle with a lid. Several broken wheelchairs were noted under the Kudzu vine, along with other old equipment not fully visible under the vines. The weeds and vines prevented access to the grease trap container to observe it more closely. A second tour of the kitchen was conducted on 7/22/19 at 4:00 p.m. with the FSM, where she confirmed that the fryer oil is changed on Saturday. The cooking oil in the fryer appeared clean upon observation. Tour of the back door walk through area was observed to be free of dead insects. Tour of the outside grease trap area, revealed the fence gate to the grease trap area could be opened half-way, some of the weeds near the gate were observed to be stomped down. The FSM explained they are not using the grease trap, that the weeds are too high, they have saved the oil. Observation revealed two large uncovered metal pots containing dark colored cooking oil, was stored under the warming oven on the floor tile, located next to the gas stove. The FSM stated another place like on the back covered porch area, or in the walk thru area would be better place to store it. The back-porch area is open on one side, and is an area where the oxygen tanks are stored. A brief interview was conducted with the Administrator on 7/23/19 at 8:45 a.m. in his office, where he explained that the facility utilizes two community organizations that they donate equipment to. The organization will pick up discarded equipment quarterly that might be used for parts; that items that need to be fixed are kept in the maintenance shed. During an interview on 7/23/19 at 4:30 p.m. the Maintenance Director (MD) was asked who was responsible for the area around the grease trap. The MD explained that he was just told about it yesterday afternoon, that the facility's landscaping contractor will be called, they will have them cut them (the weeds) back. He stated the landscaping crew was due out this week. He confirmed he did not know how long the grease trap area has looked that way. He confirmed old wheelchairs were put out there by therapy for repurposing, an outside company was to pick up them for repurposing, stating that the equipment out there, are not fixable items. The MD also confirmed the weeds and Kudzu are thick, as tall as four (4) feet high in places, and confirmed that he had looked yesterday. He also confirmed they have a pest control contractor that comes out frequently, the last time was on 7/17/19, that they have a running contract with them. He again confirmed the responsibility for the weeds is the landscaping company. A request was made from the MD for a copy of the pest control policy and a policy for grease trap maintenance. The MD stated he did not have a policy to ask the FSM, that she may have one. An observation was conducted on 7/23/19 at 11:30 a.m. with the FSM present, for the lunch meal pureed food process, with [NAME] CC. During this time, the two metal pots of old cooking oil were no longer observed under the warming oven. The FSM confirmed the oil was put in the trap, with help last night. On 7/23/19 at 12:30 p.m. during observation of food temperature testing with the FSM, she confirmed there is no facility policy for the dumpsters and grease trap, or cooking oil disposal. An interview and tour of the grease trap area was conducted on 7/24/19 at 9:10 a.m. with the Rehab Director (RD). During the tour of the grease trap area behind the gate, she explained that the old rehab equipment is given to maintenance to take to the shed. She confirmed that no one in her department placed the broken wheelchairs and other items out there. She explained what the process for old and broken equipment to be removed is; that they fill out a maintenance request, in the shared maintenance log book located on each nursing unit. Then maintenance picks up the equipment, then fixes the equipment, if possible. The RD confirmed the staff in her department do not take away equipment, that she doesn't know what happens to unusable equipment, their department only gets back usable, fixed equipment. The RD then walked to the nurse's station to the maintenance book and pointed to a recent request dated 7/16/19 for a resident wheelchair that was broken and needed replaced. The Maintenance Request form had a date of 7/16/19 and a note documenting replaced brakes.

An interview was conducted on 7/22/19 9:29 a.m. with D regarding sufficient staffing. She revealed the facility does not have enough staff. D revealed she was incontinent of both bowel and bladder and had to wait over an hour for staff to come and provide incontinence care. D revealed she will place her light on and it may take up to an hour. D revealed on 11p.m.-7a.m. there is one CNA for the entire hall. During initial screening on 7/22/19 at 11:54 a.m., with resident #23, stated that there is not enough staff to put him to bed when he wants to go to bed. He has to sit for hours in wheelchair, waiting for someone to put him back to bed. During initial screening on 7/22/19 at 1:45 p.m. with resident #24, stated that there is not enough staff to change his diaper but once per shift. He further stated staff come in and turn off his call light, without asking him what he needs. He stated that he does not get up out of bed, because there is not enough staff to put him back to bed, causing him to sit up longer than he desires. Interview on 7/21/19 at 1:45 p.m., with Certified Nursing Assistant (CNA) FF, stated that she was called in today to help work on the floor. She stated that she does get pulled to work on the floor at times, when they are short staffed. She stated that she will work some extra hours when they ask her too. Interview on 7/21/19 at 2:48 p.m. with CNA II, stated she has 28 residents to care for today, because they are short staffed. She stated she normally would have help on the A Hall and she would have about 15 residents. She stated that today, she is on the floor by herself. Interview on 7/24/19 at 9:34 a.m. with CNA EE, stated that she has on average of 10-12 residents per shift. She stated that when staff call in (a lot on weekends), then she will have about 18 residents by herself. She stated that she does work extra shifts, when she is able, working about six extra shifts per month, sometimes they are double shifts. Interview on 7/24/19 at 10:05 a.m. with Housekeeping Aide DD, stated that she has helped the residents with requests, when she sees that the staff are busy helping others. She stated she answers call lights and will get residents drinks and snacks when they ask. Based on observation, review of facility records, and resident and staff interview, it was determined that the facility failed to provide staff in sufficient numbers to care for the needs of seven Residents (R) #13 , R A, R B, R C, R#23, R#24, R D on two of two units as identified in resident and facility assessments. Findings include: A review of the Facility Assessment dated June 2019 revealed that the facility cared for a very high percentage of residents that required the assistance of two-plus persons with daily care such as bed mobility, transfers, toilet use, and dressing. The assessment also documented that the facility had high percentages of residents with cognitive impairments and behavioral health needs that impacted resident care. A review of the facility's Alphabetical census of residents dated 7/21/19 revealed that there were 106 residents onsite - 55 on the 200 Hall and 51 on the 100 Hall. A review of the Daily Staffing Schedule for 7/21/19 revealed two nurses and two certified nursing assistants (CNAs) were scheduled to care for residents on the 200 Hall, and an equivalent number on the 100 Hall. Observation on 7/21/19 at 11:30 AM of the staff on the 200 Hall confirmed that two CNAs were available to provide care to the 55 residents on that hall. During an observation on 7/22/19 at 11:15 a.m., the family of Resident #13 was seen to arrive at the facility for a visit. A few minutes into the visit, one of the family members was observed to remove a manicure set from her bag and proceed to trim the nails of the resident. The resident's nails were observed to be about a centimeter long. During an interview with the family member, at the time of this observation it was revealed that she trims his nails during her weekly visits because the staff are busy and not able to get to it. During a group interview on 7/23/19 at 11:10 a.m. with members of the resident council it was revealed that residents were dissatisfied with the number of staff available on the various shifts to care for their needs. Resident (R) A said sometimes staff say there are not enough of them available to get her roommate up. When this happens, her roommate remains in bed. Resident A also said that, during meal services, the CNAs come to the residents' rooms and turns off their call lights, telling them that staff will return to assist them when they are done with serving the meal. When this happens, she must wait a long time for assistance if she needs to go to the bathroom. During such waits, she sometimes wets herself. Other times, she is left in the bathroom and it is the nurse who comes after a considerable amount of time to get her off the potty. A review of the most recent minimum data set (MDS) assessment for Resident A revealed a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 indicates a resident is cognitively intact. The assessment also documented that this resident needed extensive assistance of two-plus persons for activities of daily living (ADLs) such as transfers, bed mobility, toilet use, and personal hygiene. A review of the most recent minimum data set (MDS) assessment for the roommate of Resident A revealed the roommate was assessed as having a severe cognitive deficit and needed extensive to total assistance with ADLs such as transfers, dressing, and toilet use. Resident B said, during the same interview, that it sometimes take more than an hour for staff to respond to her call for assistance to be taken to the bathroom. The resident said she takes a water pill, so when she (I) need(s) to go, she (I) need(s) to go, and she has accidents when she must wait an hour or more for staff to respond to her call. A review of the most recent MDS assessment for Resident B revealed a BIMS score of 15 revealing the resident to be cognitively intact. The resident was assessed as needing extensive assistance with transfers, dressing, toilet-use, and personal hygiene. During the same group interview, Resident C said that he did not believe that staff was simply reluctant to come when the residents called. Instead, he believed that they are short-staffed. Thus, when the staff took a long time to respond to the residents' call lights, it meant they were with another resident. Resident C said there was usually only one CNA on each hallway. Sometimes, the nurse would come in, turn his call light off, and say she is working with another resident and would be back when she could. He said he receives the care he needs, it just takes much longer than is warranted. Resident A said this state of affairs has existed for several months. A review of the most recent MDS assessment completed for Resident C revealed a BIMS of 15, indicating that he was cognitively intact. Resident C was assessed as needing extensive assistance with bed mobility, transfer, eating, and toilet use. During an interview on 7/24/19 at 3:36 p.m. with CNA MM, it was revealed that she normally works the 3:00 p.m. to 11:00 p.m. (evening) shift, and was one of four CNAs scheduled and available to work on the 200 Hall that evening. The CNA said three of those four CNAs had also worked during the previous shift and was held over to work on the evening shift. CNA MM said the evening shift usually had four CNAs, but occasionally five were scheduled. However, though rare, sometimes there were only two. If only two CNAs are scheduled to provide care on that hall, then the nurses are expected to help with providing showers etc. On the weekends, staff are expected to pick up extra shifts so that there is not less than four CNAs on the evening shift. During an interview on 7/24/19 at 5:11 p.m., CNA NN revealed she has been responsible for the daily scheduling of nurses and CNAs for the facility since May 2019. CNA NN said she schedules staff for each day/each shift based on the daily census. Depending on that census, the minimum number of CNAs she will schedule on the day and evening shifts are four on each hall; the minimum amount for the night shift are three on each floor/hall. However, 4-5 CNAs are usually scheduled on each floor/hall on the day shift and 3-4 on the evening shift. On the night shift, she usually schedules 2-3 CNAs on each floor/hall. The numbers are the same 7 days a week. When there are call-outs for the CNAs, she tries to replace them with part-time staff. If she is not able to replace them with part-time staff, then the nurses are expected to help. Sometimes she will fill in on the shift for a CNA who cannot come in. For example, she was scheduled as one of the five CNAs, scheduled to work the 100 hall/first floor on that shift. CNA NN admitted that, of the five CNAs scheduled for the upstairs (200) hall, three were CNAs from the previous shift who had agreed to work an extra shift that day. During an interview on 7/24/19 at 5:34 p.m. with CNA OO, it was revealed that five CNAs had indeed been scheduled for the 200 hall on the 3-11 shift that day. However, one of those scheduled CNAs was the activity director who was not, at the time, working on the floor. Another of the scheduled CNA was the medical records clerk who was also not working on the floor. CNA OO said the only CNAs working on the hall during the shift were three CNAs who were not listed on the original schedule provided by the facility, but who had worked during the previous shift and was then working extra hours. This CNA said many of the CNAs had worked extra shifts for several months