**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R238's diagnosis located under the Profile tab of the electronic medical record (EMR), revealed R238 was admitted to the facility on [DATE] with diagnoses which included blindness in both eyes. Review of R238's Care Plan located in the EMR under the Care Plan tab and last revised 04/21/25, revealed R238 was at risk for falling, due to history of falls, cognitive impairments, decreased safety awareness, required assistance of daily living (ADL) related to impaired mobility, blindness, vascular dementia, pacemaker, difficulty walking, muscle weakness, and incontinence of bowel and bladder. Review of R238's admission MDS with an ARD of 04/21/25 and located under the RAI (Resident Assessment Instrument) tab, revealed R238 had a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated R238 was cognitively impaired. Further review of this MDS revealed R238 was, vision severely impaired, dependent for eating, and required substantial maximum assist for toileting and personal hygiene. During an observation on 04/28/25 at 9:56 AM, R238 was observed lying in his bed pulling at his briefs stating pee, poo. His call light was lying in the bed to the right of him. When asked if he could push the call light for assistance, R238 did not know where his call light was and was unable to see due to blindness. He patted on the bed, feeling for the call light and was unable to retrieve it or push to call for help. This surveyor pushed the call light at 9:58 AM and at 10:16 AM a Client Transport Aide came to the room and spoke with R238 briefly, then went for assistance. During an observation on 04/29/25 at 2:30 PM, R238 was asleep in his bed, the call light and a hand bell were observed on the nightstand and out of the resident's reach. During an interview on 04/29/25 at 2:16 PM, the DON confirmed that was she not aware that R238 was unable to use his call light and all staff were responsible for answering all lights and ensuring call lights were in reach of the residents and able to use. Based on observations, resident and staff interviews, and policy review, the facility failed to ensure the call devices used were tailored to meet the individual physical needs of the residents and failed to respond promptly to the call system for two residents, (Resident (R) 25 and R238), out of a sample of 51 residents. This failure placed R25 and R238 at risk of experiencing unmet care needs. Findings include: Review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs, revised 12/02/23 stated, It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center. The call light system procedure included the following: .Essentia Points .Unless indicated in the care plan, each patient/resident, when in their room or in bed, must have the call light placed within reach at all times, regardless of staff assessment of patient/resident's ability to use it. When the patient/resident is in bed, the call bell should be fastened to the side rail he/she is facing. When out of bed, call bell is to be draped across the bed, so it is accessible from wheelchair or bedside chair only. 1. Review of R25's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R25 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a brain disorder that appeared early childhood and permanently affects body movement and muscle,) contracture to bilateral knees, ankles, and respiratory failure. Review of R25's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25, located in the RAI [Resident Assessment Instruments] tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated he was moderately cognitively impaired. During an observation on 04/27/25 at 12:03 PM, R25 was lying on the bed. Both of his arms and hands were contracted and resting on his chest. R25 had a call bell placed about eight inches away from his head on the left side rail. He was unable to reach it. When asked, R25 kept shaking his head to express no that he could not press the call bell to get help, and he kept nodding his head to express yes, that he needed help and O2. During this interview with R25, this surveyor called for Certified Nursing Assistant (CNA) 5 to come to R25's room to assist R25. CNA5 confirmed that R25 did not have the ability to press the call bell and there was no call pad or any other type of call device that R25 could use to ask for help. During an interview on 04/27/25 at 12:05 PM, CNA6 confirmed that R25 had no ability to use the current call bell on his bed and there was no other call device that R25 could use to ask for help. During an observation and interview on 04/28/25 at 4:15 PM, R25 was observed on the bed with his bilateral arms rested on top of his chest outside of the cover. R25 could only move his head and neck. R25's call bell was placed on his bed sheet on top of his left knee location. The unit manager (UM) 5 walked into R25's room and moved R25's call bell from the top of his bed sheet near his left knee to near R25's left side of the bed, near his left side bed rail. When asked if R25 could press that call bell, the UM5 said, No. At the same time, when asked R25 if he could press this call bell, R25 shook his head, expressing that he could not. UM5 said he was not sure if the facility had another type of call device for R25. Observation on 04/29/25 at 9:30 AM, UM5 walked into R25's room and there was no suitable call device R25 could use to call for help. During an interview on 04/29/25 at 02:16 PM, the Director of Nursing (DON) stated that depending on the resident's needs, we could use a call pad or call bell. Observation on 04/30/25 at 8:45AM, walked into R25's room with UM5 and a small palm size call pad was placed under his right forehead. When asked, R25 expressed no by shaking his head that he could not press the new call pad. When asked, R25 showed how he pressed the new call pad. R25 tried to put pressure on the new call pad located under his right forehead head by turning his head to his right side and left trying very hard to hit the call pad, and he could not always hit the small call pad to activate the call light alarm. When R25 finally made the call pad activated by showing a green light on the control panel to the wall at the head of the bed, there was no sound or indicator to alert R25 to stop hitting the call pad. R25 just keep turning his head left and right and trying to activate the call light.

Based on observations, resident and staff interviews, and document review, the facility failed to create a homelike environment by ensuring resident rooms were clean or in good repair for four residents (Resident (R) 125, R106, R98, and R56) in the sample of 51 residents. Findings include: Review of the facility's undated admission Agreement revealed residents' rights: The Facility desires to provide the Resident with a homelike environment. 1. Observation on 04/27/25 at 10:50 AM of R125's room revealed the molding under the wall mounted air unit was peeled back with approximately 15 inches of it protruding into the room and exposing wood underneath. Paint was missing in spots around the bathroom door frame. During an interview on 04/27/25 at 10:50 AM, R125 reported the room did not look homelike. 2. Observation on 04/27/25 at 12:44 PM of R106's room revealed an area of the wall where the outer layer of drywall was missing in patches with the largest two areas measuring approximately six to eight inches by five inches. During an interview on 04/27/25 at 12:45 PM, R106 stated the room was not homelike. It doesn't look nice. During an interview on 04/30/25 at 10:34 AM, the Maintenance Director stated all the rooms were scheduled to be remodeled. The Maintenance Director verified that some areas had not been remodeled and may not look homelike. During an interview on 04/30/25 at 3:40 PM, the Director of Nursing (DON) stated she expected rooms to look homelike and molding to not be sticking out. During an interview on 04/30/25 at 6:33 PM, the Administrator stated the remodeling was expected to start on the fourth floor by the end of May 2025, and to the fifth floor after that, with completion anticipated for the end of the year. 3. During an observation on 04/27/25 at 3:25 PM, R98 and R56's bathroom had a black mold-like color throughout the edge of the ceiling and the cream color tiles on the wall-to-wall edge at the corner facing the bathroom entrance. The bathroom smelled damp and moldy. R98 and R56 both stated the moldy smell was not pleasant, and when they expressed their concerns to the facility care staff, the staff told them they were under renovation on the other floors, and soon the facility will be going to renovate their floor. R89 stated but they did not send any staff to clean it. Observation of R98 and R56's shared bathroom with the housekeeping supervisor (HSKS) and the Maintenance Director (MD) on 04/30/25 at 8:51 AM revealed a white colored mold-like area on the wall near the toilet area just under the ceiling. The HSKS stated that it was about four inches wide, and there were multiple grey/dark water drip marks and brown rusting-like water drip marks on the area between the edge of the ceiling and the wall. The ceiling had three areas that had dried water leak marks. The MD stated the name of the company had recently conducted mold inspection services around end of last year. The Administrator provided a copy of an Invoice from the company, dated 11/21/24 which indicated Mold Remediation-Kitchen and Dining. During an interview with the Administrator on 04/30/25 at 10:33AM, when asked if the mold service was conducted in other areas in the facility outside of the kitchen and dining area. The Administrator stated, No, the company did not inspect the facility's other areas including residents' rooms and bathrooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R197's undated Face Sheet located under the Resident tab of EMR revealed R197 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure and encounter for orthopedic aftercare, cognitive communication deficit. R197 was discharged to an assisted living facility on 04/09/24. Review of R197's Grievance/ Complaint Form: Health Center, dated 10/23/24, provided by the Administrator, documented there was a late grievance received by the facility Administrator on 10/23/24 after R197 was discharged on 04/09/24. The Grievance form documented the following: wound RP [responsible party] not informed. fall-p't [patient] trapped by male nurse. showers. feeding. weight lost. Resident RP reported issues to [R197's Insurance company name] .forward concerns to facility. Review of R197's Grievance/ Complaint Form: Health Center, dated 10/23/24 under the Summary documented the following: no male was assigned to Resident during stay. Res. (resident) did have fall on 4/21 from bed unwitnessed. So, it was not during care. wt [weight] 191 upon admission appetite . Res feed self. bed baths given. nurse notifies son who was present upon admission of wound status. During an interview on 04/30/25 at 9:47 AM, the Administrator stated on 10/3/24 she received a call from R197's insurance company stating R197's family member filed a list of complaints for abuse and neglect concerns as follows: A male care giver dropped R197 on the floor caused bruise. Someone force fed R194. Lost weight thirty pounds (lb.). Never received a bed bath or shower. Developed a Pressure Ulcer. The Administrator stated that the facility collaborated with R197's insurance company to investigate the case, which was unsubstantiated. When asked about the reporting process for suspected abuse or neglect, the Administrator stated that she would report such incidents to the State immediately. However, in this particular case, since abuse was unsubstantiated and the resident had been discharged from the facility several months ago, she felt there was no need to report it to the state. Instead, she conducted her own investigation and logged the case as a grievance. Based on staff interviews, record review, and facility policy review, the facility failed to report allegations of abuse in a timely manner for two (Residents (R) 202 and 197) of six residents reviewed for abuse out of a total sample of 51 residents. This failure that allegations of abuse would not be reported increased the risk for abuse to continue. Findings include: The facility's Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy, revised 07/29/19, states, The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious bodily injury . 1. Review of the Face Sheet in the electronic medical record (EMR) Resident tab R202 was admitted to the facility on [DATE] for rehabilitation following a left below the knee amputation. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/24 revealed R202 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Review of a facility reported incident form, dated 12/09/24, revealed that on 12/07/24 at 2:30 AM R202 had a large bowel movement and was assisted with incontinence care by Certified Nursing Assistant (CNA) 10. The report indicated that following the care episode, R202's family member contacted the facility on 12/07/24 after being told by R202 that the CNA10 was rough and rude. Per the report CNA10 spoke with the resident's family member on 12/07/24 and advised in detail that the resident had a large bowel movement, and she took care to be sure to clean the resident thoroughly to avoid the possibility for a urinary tract infection (UTI). Review of the investigation revealed CNA10 did not feel that the family was alleging abuse. Review of a complaint filed by R202's representative revealed that the facility was notified of concerns regarding rough care provided to R202 on the morning of 12/07/24. Per the complaint, the complainant felt the facility did not take their concerns seriously and on 12/08/24 they presented in person to the facility. The complaint indicated that the complainant spoke with Unit Manager (UM) 3 who was to document and report their concerns. UM3 was interviewed on 04/29/25 at 2:10 PM, and she stated that she reported the incident to the Administrator immediately, as with any allegation of abuse. During an interview with the Administrator on 04/29/25 at 1:45 PM, she stated that she reported the allegation as soon as it was reported to her and suspended CNA10 on 12/09/24. She was also asked about her investigation, and she stated that interviews with the resident by law enforcement revealed that R202 felt CNA10 was wiping her aggressively and was unprofessional and cruel but made no mention of abuse of any kind. The Administrator stated that she interviewed CNA10 and LPN7, who was also present during R202's incontinence care. CNA10 disputed being rude or unprofessional and that she never intended to be rough with the R202, but wanted to make sure the resident was clean. LPN7 stated that she did not hear CNA10 say anything unprofessional and did not believe she was being rough with the resident. The Administrator added that she interviewed the other residents on CNA10's assignment and they did not indicate any concerns. Her conclusion was that there was no evidence that abuse occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI), the facility failed to complete a significant change Minimum Data Set (MDS) assessment following a decline in a resident's status for one of eight residents reviewed for a change in condition (Resident (R) 120) out of a total sample of 51 residents. This failure placed the residents at risk for unmet care needs. Findings include: Review of the RAI dated 10/01/24 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed a significant change in status MDS assessment must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting'; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. the nursing home may take up to 14 days to determine whether the criteria are met. Review of the Face Sheet tab of the electronic medical record (EMR) revealed R120 was admitted to the facility on [DATE]. R120 was in the hospital from [DATE] to 02/25/25 and had a diagnosis of fracture of unspecified part of the neck of right femur (hip fracture). Review of a quarterly MDS with an Assessment Reference Date (ARD) of 11/28/24 and located in the RAI tab of the EMR revealed R120 received supervision or touching assistance for eating, oral hygiene, toileting, showering/bathing, upper and lower body dressing, hygiene, rolling side-to-side, transferring, and walking up to 50 feet. Review of an Observation Detail List Report dated 02/18/25 and located in the Observations tab of the EMR revealed R120 fell on [DATE] at 2:30 AM in her bathroom. R120's usual ambulatory status was independent. Review of a hospital Discharge Summary dated 02/25/25 and located in the Documents tab of the EMR revealed R120 had a right femoral fracture and underwent surgery on 02/21/25. Review of a quarterly MDS with an ARD of 02/28/25 and located in the RAI tab of the EMR revealed R120 had an impairment in functional range of motion in one lower extremity. R120 required substantial/maximal assistance for eating, oral hygiene, upper body dressing, personal hygiene, and rolling side-to-side. R120 was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and transfers. R120 was unable to walk. Review of the RAI tab revealed no significant change MDS assessment completed following the fall with hip fracture. During an interview on 04/30/25 at 8:46 AM, Certified Nursing Assistant (CNA) 7 reported R120 required substantial/maximal assistance for upper body dressing with the CNA doing most of the work. R120 was unable to assist much with lower body dressing and required substantial assistance of one or two staff to transfer. During an interview on 04/30/25 at 9:29 AM, Licensed Practical Nurse (LPN) 1 reported R120 was independent and very self-sufficient at the time of her fall. Since the fall, she had declined and mostly stayed in bed and needed staff to assist her with mobility. During an interview on 04/30/25 at 2:24 PM, the MDS Coordinator (MDSC) reported the quarterly assessment with an ARD of 02/28/25 was completed a few days after R120 returned from the hospital. It reflected a decline in activities of daily living (ADLs). R120 had been monitored after the assessment to see if her decline was self-limiting. After the observation period, when she continued to require more assistance, the facility should have completed a significant change MDS. During an interview on 04/30/25 at 3:40 PM, the Director of Nursing (DON) reported she expected completion of a significant change MDS when a resident declined from needing supervision assistance to requiring substantial/maximal assistance or being dependent on staff for ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to complete a discharge Minimum Data Set (MDS) assessment within 14 days of a resident's discharge and submit it to the Centers for Medicare and Medicaid Services (CMS) system for two out of 51 sampled Residents (R) (R 131 and R154) reviewed for MDS completion. This failure prevented the transmission and compilation of resident-specific information for payment and quality measure purposes. Findings include: Review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument RAI (Resident Assessment Instrument) Manual, dated 10/1/2024 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed discharge assessments were to be completed no later than the discharge date plus 14 calendar days. In addition, they were to be transmitted within 14 days of completion. 1. Review of R131's Face Sheet tab of the Electronic Medical Record (EMR) revealed R131 was admitted to the facility on [DATE] with diagnoses which included periprosthetic fracture around internal prosthetic left should joint. R131 discharged from the facility on 2/14/2025. Review of the Census tab of the EMR revealed R131 discharged on 2/14/2025 and did not return to the facility. Review of the RAI tab of the EMR revealed a discharge - return anticipated MDS with an assessment reference date (ARD) of 2/14/2025 had a status of in process. 2. Review of R154's Face Sheet tab of the EMR revealed R154 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis (bone infection) and diabetes. R154 discharged from the facility on 12/30/2024. Review of the Census tab of the EMR revealed R154 discharged on 12/30/2024 and did not return to the facility. Review of the RAI tab of the EMR revealed the last MDS assessment was an admission MDS assessment with an ARD of 12/13/2024. There was no discharge MDS. During an interview on 4/29/2025 at 1:13 pm, the MDS Coordinator (MDSC) reported discharge MDSs were to be completed within 14 days of the ARD, which was the discharge date , according to the RAI manual. The MDSC confirmed she did not see a discharge MDS for R154. A discharge MDS was initiated for R131 but not closed or transmitted. During an interview on 4/30/2024 at 3:40 pm, the Director of Nursing (DON) stated she expected MDS assessments to be completed and submitted timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual and review of the facility's policy titled, MDS Assessment Accuracy, the facility failed to code pressure ulcers on a Minimum Data Set (MDS) assessment for two of 11 Resident (R) (R194 and R98) reviewed for pressure ulcers. This had the potential to cause the residents to have unmet care needs. Findings include: Review of the RAI (Resident Assessment Instrument) Manual, dated 10/01/2024 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed . items on the assessment should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [interdisciplinary team] completing the assessment. Review of the facility's policy titled, MDS Assessment Accuracy revised 12/6/2022 revealed, Each ARD [Assessment Reference Date] will be chosen to capture services rendered and reflect an accurate clinical profile of each patient/resident. 1.Review of R194's Face Sheet tab of the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] and had a hospital stay from 7/17/2024 to 7/20/2024. R194 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction (stroke) and diabetes. Review of the hospital's Ticket to Ride document located in the Documents section of the EMR revealed R194 was admitted to the hospital on [DATE] with pressure injuries to the left medial ankle, left heel, right heel, and sacrum. Review of R194's admission Observation dated 7/20/2024 and located in the Observations section of the EMR revealed: Areas noted to coccyx area. Resident with skin alterations to [right] #1 digit and side of foot and notes area to 5th digit and side of foot, area noted to ankles, and heels with blacke [sic] tissue noted, elevated heels off bed. Review of R194's Skin Note dated 7/22/2024 and located in the Observations section of the EMR revealed: Left outer ankle noted with open area with slough noted to wound bed, left heel noted with DTI [deep tissue injury], left lateral foot near 5th digit open area, pink. Left great toe DTI. Left bunion noted with DTI. Right heel noted with DTI; Right ankle noted with redness. Review of R194's Order History located in the Orders section of the EMR revealed treatment orders for wounds to the left bunion, left great toe, left heel, left lateral foot near the 5th digit, outer ankle, and right heel and outer ankle, with start dates of 7/22/2024. Review of R194's Quarterly MDS assessment with an ARD of 7/24/2024 and located in the RAI section of the EMR for Section M (Skin Conditions) revealed R194 was at risk for pressure ulcer/injury but had no unhealed pressure ulcers/injuries. During an interview on 4/29/2025 at 1:18 pm, the MDS Coordinator (MDSC) stated that MDSCs reviewed EMR documentation, hospital records, and coding by wound nurses to determine if there were pressure ulcers. The MDSC reviewed the Skin Note dated 7/22/2024 and acknowledged the coding of DTIs. The MDSC stated the MDS assessment with ARD of 7/24/2024 should have coded the pressure ulcers/injuries. During an interview on 4/30/2025 at 3:40 pm, the Director of Nursing (DON) reported the expectation that MDS assessments are coded accurately. Pressure ulcers/injuries should be reflected to ensure treatment and interventions. 2. Review of R98's Face Sheet located under the Resident tab of the EMR revealed R98 was originally admitted [DATE] and readmitted to the facility on [DATE] with diagnoses including diabetes and multiple sclerosis (chronic and unpredictable neurological disorder that affects the brain, spinal cord, and optic nerves.) Review of R98's Wound Management Detail Report, dated 12/26/2024, located in the EMR under Wound Management, revealed R98 developed a new unstageable pressure ulcer on 12/26/2024, the size was measured at 3.5 centimeters (cm) x 4.5 cmx 0.2 cm. Review of R98's Medication Administration Report (MAR) located in the Resident tab of the EMR under Report included documentation that revealed R98 was receiving wound care of Medi Honey (honey) (honey) gel; 80 %, once a day on Monday, Wednesday, and Friday for pressure ulcer of sacral region, unstageable. Start date on 12/26/2024, discontinued on 2/17/2025. Review of R98's Quarterly MDS with an ARD of 1/9/2025, located in the RAI tab of the EMR, documented under Section M-Skin Conditions the MDS documented No, R98 did not have any unhealed pressure ulcer in any stage. Interview on 4/29/2025 at 1:15 pm, with the MDS Coordinator (MDSC) reviewed R98's EMR and stated the facility first identified R98's new pressure ulcer was on 12/26/2024. The MDSC confirmed that R98's pressure ulcer was unstageable and later became a stage III. The MDSC said R98 continued to receive pressure ulcer treatment from 12/26/2024 until it was healed on 3/10/2025. The MDSC confirmed R98's quarterly MDS assessment dated [DATE], was documented incorrectly and that it should have indicated one unhealed unstageable pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled, Care Plans, the facility failed to ensure a baseline care plan was created within 48 hours of admission for one of 51 sampled Residents (R) (R192) reviewed for baseline care plan. This failure had the potential for the residents to have unmet care needs. Findings include: Review of the facility's policy titled, Care Plans dated 7/27/2023 revealed, Upon a new admission. A baseline care plan will be developed .The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. Review of R192's Electronic Medical Record (EMR) admission Record located under the Profile tab indicated R192 was admitted to the facility on [DATE] with a diagnosis of: Orthopedic aftercare following surgical amputation (amputation of Left Lower Leg), Type II Diabetes Mellitus (too much sugar in the blood) End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids) and Peripheral vascular Disease (reduced circulation of blood to a body part). Review of R192's EMR indicated R192's Care Plan located under the Admission tab was created on 5/15/2024. During an interview on 4/29/2025 at 1:40 pm with the Director of Nursing (DON) she stated that she was not aware R192 did not have a baseline care plan but indicated the Admitting Nurse initiates the baseline care plan. The DON stated the baseline care plan was to occur within 48 hours of admission and that R192 should have had one created prior to 5/15/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility's policy titled Care Plans, the facility failed to develop a comprehensive care plan for one of 11 Residents (R194) reviewed for pressure ulcers. This had the potential to cause the residents to have unmet care needs. Findings include: Review of the facility's policy titled Care Plans revised 7/27/2023 revealed: Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS schedule, following the completion of the assessment. Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. Care plans will be updated by nurses, Case Mix Directors [CMD], or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. Review of R194's Face Sheet tab of the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] and had a hospital stay from 7/17/2024 to 7/20/2024. Further review revealed that R194 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction (stroke) and diabetes. Review of the hospital's Ticket to Ride document located in the Documents section of the EMR revealed R194 was admitted to the hospital on [DATE] with pressure injuries to the left medial ankle, left heel, right heel, and sacrum. Review of R194's admission Observation dated 7/20/2024 and located in the Observations section of the EMR revealed: Areas noted to coccyx area. Resident with skin alterations to [right] #1 digit and side of foot and notes area to 5th digit and side of foot, area noted to ankles, and heels with blacke [sic] tissue noted, elevated heels off bed. Review of R194's Skin Note dated 7/22/2024 and located in the Observations section of the EMR revealed, Left outer ankle noted with open area with slough noted to wound bed, left heel noted with DTI [deep tissue injury], left lateral foot near 5th digit open area, pink. Left great toe DTI. Left bunion noted with DTI. Right heel noted with DTI; Right ankle noted with redness. Resident has pressure reduction boots and was encouraged to wear them or to float heels while in the bed. Review of R194's Order History located in the Orders section of the EMR revealed treatment orders for wounds to the left bunion, left great toe, left heel, left lateral foot near the 5th digit, outer ankle, and right heel and outer ankle, with start dates of 7/22/2024. Review of R194's Care Plan located in the RAI section of the EMR revealed a problem area, Resident is at risk for pressure ulcers dated 11/25/2023 with approaches which included keep bony prominences from direct contact with one another with pillows, foam wedges, keep resident off bony prominences, conduct a systematic skin inspection weekly paying attention to the bony prominences, use boots or pillows to relieve pressure on the heels, and turn and reposition every two hours. The Care Plan failed to reflect any actual pressure ulcers or approaches. During an interview on 4/29/2025 at 10:42 am, Wound Nurse (WN) 1 stated she tried to care plan wounds when residents were admitted or re-admitted from the hospital with wounds. During an interview on 4/30/2025 at 10:16 am, WN1 reported the R194's Care Plan was not correctly updated when he returned from the hospital with identified pressure ulcers. During an interview on 4/30/2025 at 3:40 pm, the Director of Nursing (DON) reported everything related to pressure ulcers was expected to be care planned with interventions which were in place to ensure proper care.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs, the facility did not ensure that two of the 51 sampled Residents (R) (R98 and R151) received nail care. This failure had potential to increase the risk of infectious disease and nail damage for R98 and R151. Findings include: Review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs, revised 12/2/2023 stated It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center. 1. Review of R98's Face Sheet located under the Resident tab of the Electronic Medical Record (EMR) revealed R98 was admitted to the facility with diagnoses that included but not limited to diabetes and multiple sclerosis (chronic and unpredictable neurological disorder that affects the brain, spinal cord, and optic nerves.) Review of R98's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/2025 located in the RAI [Resident Assessment Instruments] tab of the EMR, for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact; Section GG (Functional Abilities and Goals) revealed, R98 was dependent on staff for ADLs and for personal hygiene including combing hair, washing, drying hands, and nail care. Review of R98's Care Plan located in the residents EMR under RAI tab revealed for ADL Functional care plan, dated 10/8/2021, included the following interventions: Daily grooming- hair, skin, nails. Observation on 4/27/2025 at 2:46 pm revealed, R98's fingernails were observed longer than one centimeter (cm) past her fingertips. R98 said that the podiatrist had come to trim her toenails. However, there was a designated nail day activity every Monday for filing fingernails, but she had not received assistance to get out of bed to attend. R98 stated she had repeatedly asked the Certified Nursing Assistant (CNA) to trim her fingernails, but the CNAs always told her they could not trim her fingernails because she had diabetes. Observation and interview on 4/29/2025 at 9:22 am with Unit Manager (UM) 2 in R98's room confirmed that R98's fingernails were too long and should be trimmed. UM2 explained that the podiatrist only trims resident's toenails. CNAs were responsible for trimming residents' fingernails unless the residents had diabetes, in which nurses would handle the trimming. During an observation and interview on 4/29/2025 at 9:52 am, with Licensed Practical Nurse (LPN) 2 revealed, R98's fingernails on right hand were examined. The length of the longest overgrown fingernail that needed trimming was measured at one centimeter (cm) on her little finger while the shortest was measured at 0.4 cm on her thumb. LPN 2 then measured all R98's fingernails on her left hand. The length of the longest overgrown fingernail that needed trimming was measured at 1.2 cm on her fourth finger, and the shortest was measured at 0.4 cm on her fourth finger. LPN2 stated she was not sure who was responsible for trimming the fingernails of a resident with diabetes. 2. Review of R151's Face Sheet located under the Resident tab of the EMR revealed R151 was admitted to the facility with diagnoses that included but not limited to hemiplegia (paralysis on one side of the body) following a stroke. Review of R151's Quarterly MDS with an ARD of 2/27/2025, located in the RAI tab of the EMR, for Section C (Cognitive Patterns) revealed, a BIMS score of six out of 15 which indicated she was severely cognitively impaired; Section GG (Functional Abilities and Goals) revealed, R151 required partial/ moderate assistance for personal hygiene including combing hair, washing, drying hands, and trimming nails. Review of R151's Care Plan located in the residents' EMR under RAI tab revealed for ADL Functional dated 11/3/2024, included the following interventions: Set up for ADL's, assist with bathing, dressing, personal hygiene and oral hygiene daily and prn. Observation on 4/27/2025 at 1:47 pm revealed R151's right fingernails were long and dirty, with dark gray, dirt-like stains on the edges of her fingers and beneath her overgrown nails. Observation and interview on 4/29/2025 at 9:13 am with LPN2 confirmed that R151's fingernails appeared long and yellowish, with black and grayish discolorations that resembled dirt. LPN2 then measured the fingernails on R151's right hand; The length of the longest fingernail that needed trimming was measured at 0.4 cm on her middle finger, and the shortest was measured at 0.3 cm on her little finger. LPN2 then measured the fingernails on R151's left hand. The length of the longest overgrown fingernail that needed trimming was measured at 0.5 cm on her fourth finger, while the shortest was measured at 0.4 cm on her little finger. When asked, LPN2 was not sure who was responsible to trim diabetic residents' fingernails and if the podiatrist trim them. During an interview on 4/29/2025 at 9:21 am, UM2 confirmed that R151's fingernails were too long and should be trimmed. UM2 stated that for diabetic residents, the nurse would be responsible for trimming their fingernails. For residents without diabetes, the CNA would take care of the trimming. UM2 further stated that the podiatrist was only responsible for toenail care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, and a review of the facility's policy, the facility failed to administer long-acting insulin in accordance with physician orders for two residents (Resident (R) 436 and R98) out of 51 sampled residents. This failure had the potential to have adverse effects on residents if their insulin was not given or their dose was reduced without a physician's order. Findings include: 1. Review of R436's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R436 was admitted to the facility on [DATE] with diagnoses including diabetes. Review of R436's Medication Administration Report (MAR) located in the Resident tab of the EMR under Report revealed the nursing staff documented R436's blood glucose (BG) as low at 123 and 142. The nurse withheld R436's insulin Lantus (long-acting insulin) without a physician's order as follows: Physician's order: Lantus Solostar U-100 Insulin (long-acting insulin) pen 100 units/ml (3ml), give 10 units subcutaneous once a day in the morning for long-term drug therapy. Start date 3/28/2025. MAR documented on 4/1/2025 at 6:00 am: Not Administered: Due to Condition Comment: 123 [BG]. MAR documented on 4/2/2025 at 6:00 am: Not Administered: Due to Condition Comment: 142 [BG]. 2. Review of R98's undated Face Sheet located under the Resident tab of the EMR revealed R98 was admitted to the facility on [DATE] with diagnoses including diabetes. Review of R98's MAR located in the Resident tab of the EMR under Report revealed the nursing staff documented R98's BG low at 186, 103, and 197. The nurse withheld R98's insulin Lantus (long-acting insulin) or reduced its dose to half of the ordered dose without a physician's order as follows: Physician's order: Lantus Solostar U-100 Insulin (long-acting insulin) pen 100 units/ml (3ml) give 10 units subcutaneous once a day at bedtime for diabetes. Start date 1/27/2025. MAR documented on 2/17/2025 at 9:00 pm: Not Administered: Other Comment: 186 [BG]- 5 units given. MAR documented on 2/25/2025 at 9:00 pm: Not Administered: Other Comment: 103 [BG]. MAR documented on 2/27/2025 at 9:00 pm: Not Administered: Other Comment: [given] Previous shift. MAR documented on 4/4/2025 at 9:00 pm: Not Administered: Other Comment: 197 [BG] - 5 units given. MAR documented on 04/24/25 at 9:00 PM: Not Administered: Other Comment: 5 units given. Further review of the MARs revealed each of the above entries was documented as Licensed Practical Nurse (LPN)8, who made the decision to either not administer or administer half the amount ordered of Lantus. During an interview on 4/29/2025 at 8:42 am, the Unit Manager (UM) 2 stated that staff should follow the physician's orders on when to hold Lantus. If there were no orders, the requirement was to hold Lantus when BG was equal to or lower than 150. Staff should also offer sugary drinks or snacks at the same time as holding the insulin. During an interview on 4/29/2025 at 3:00 pm, the Director of Nursing (DON) stated that UM2's statement of holding insulin Lantus when BG was equal to or lower than 150 was incorrect. She stated that Lantus was a long-acting insulin and that nurses should never hold it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to identify pressure ulcers and initiate treatment orders in a timely manner for one of 11 residents reviewed for pressure ulcers (Resident (R) 194) out of 51 total sampled residents. This had the potential for residents' pressure ulcers to decline. Findings include: Review of R194's Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] and had a hospital stay from 7/17/2024 to 7/20/2024. R194 had diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) and diabetes. Review of R194's Braden Scale for Predicting Pressure Sore Risk dated 6/27/2024 and located in the Observations section of the EMR revealed the resident scored at high risk for developing pressure ulcers. Review of a Skin Note dated 6/28/2024 and located in the Observations section of the EMR revealed R194 had no skin issues. No further Skin Notes were found from 6/28/2024 through when R194 went to the hospital for a planned surgery on 7/17/2024. Review of R194's Progress Notes section of the EMR revealed no documentation of any skin check from 6/28/2024 until the resident went to the hospital on 7/17/2024. There was no documentation of any existing pressure ulcers when R194 was discharged to the hospital. Review of the hospital's Ticket to Ride document located in the Documents section of the EMR revealed R194 was admitted to the hospital on [DATE] with pressure ulcers to the left medial ankle, left heel, right heel, and sacrum. During an interview on 4/28/2025 at 9:38 am, Family Member (F1) reported she met R194 at the hospital when he arrived there on 7/17/2024. The hospital staff removed his socks for a skin check, and R194 had wounds on both heels, above his buttocks, and on his left big toe, of which she was unaware. Review of R194's Progress Notes section of the EMR revealed an entry dated 7/20/2024 at 3:05 pm that he had returned from the hospital and had skin alterations. Review of R194's admission Observation dated 7/20/2024 and located in the Observations section of the EMR revealed: Areas noted to the coccyx area. Resident with skin alterations to [right] #1 digit and side of foot and notes area to 5th digit and side of foot, area noted to ankles, and heels with black tissue noted, elevated heels off bed. Review of R194's Skin Note dated 7/22/2024 and located in the Observations section of the EMR revealed: Left outer ankle noted with open area with slough noted to wound bed, left heel noted with DTI [deep tissue injury], left lateral foot near 5th digit open area, pink. Left great toe DTI. Left bunion noted with DTI. Right heel noted with DTI, Right ankle noted with redness . Review of R194's Order History located in the Orders section of the EMR revealed treatment orders for wounds to the left bunion, left great toe, left heel, left lateral foot near the 5th digit, outer ankle, and right heel and outer ankle, with start dates of 7/22/2024, two days after R194 returned from the hospital. The left bunion, left great toe, and right heel received skin prep. The left lateral foot and ankle had orders for hydrogel. Review of R194's Medication Administration Record (MAR) dated 7/1/2024 to 7/31/2024 revealed he had no treatment orders in place for his pressure ulcers from when he returned from the hospital on 7/20/2024 until 7/22/2024. Review of a wound nurse practitioner Progress Note Report dated 7/26/2024 and located in the Documents section of the EMR revealed R194 had a left heel in-house acquired deep tissue injury which measured 2.5 centimeters (cm) x 3cm x 0.3cm. R194 also had a left lateral ankle wound, in-house acquired, which was assessed as measuring 2.2 cm x 1.2 cm x approximately 0.3 cm and was 65% necrotic (dead) tissue. The note recorded, Both wounds are documented as in-house pressure areas as they were first discovered by hospital staff on 7/17 . During an interview on 4/29/2025 at 9:22 am, Certified Nursing Assistant (CNA) 1 stated CNAs check residents' skin with care and report anything of concern to the nurse. Skin concerns are also documented on shower sheets, which the nurse signs off. During an interview on 4/29/2025 at 9:32 am, Wound Nurse (WN) 2 stated that if a resident was admitted from the hospital with wounds, the floor nurse was to get treatment orders from the doctor. During an interview on 4/29/2025 at 10:25 am, Unit Manager (UM) 1 stated that the wound nurses obtain wound treatment orders. If there was no wound nurse available, the floor nurse was responsible for obtaining treatment orders from the physician. Skin checks were expected to be done at least weekly and documented in the Observations section of the EMR. The shower sheets were just a tool, but UM1 stated he would check if any still existed for R194. UM1 was unable to locate any shower sheets for R194. During an interview on 4/29/2025 at 10:42 am, WN1 stated that if a resident was admitted from the hospital with wounds, the floor nurse was to get treatment orders from the doctor if no orders were provided by the hospital. The floor nurses completed weekly skin assessments, and CNAs were to notify nurses of any skin changes. The wound nurse practitioner did not follow wounds that were only getting skin prep as a treatment. During an interview on 4/30/2025 at 10:16 am, WN1 stated that, from what she observed on 7/22/2024 after R194 returned from the hospital, the nursing staff should have noticed the wounds and addressed them before he went to the hospital. Orders should be in place promptly after identifying a wound and not two days later. WN1 reviewed R194's EMR and stated there were no orders from 7/20/2024 to 7/22/2024 and no documentation of wounds prior to him going to the hospital, but from what she saw on 7/22/2024 and from the hospital records, the wounds appeared to be there when he left (for the hospital). During an interview on 4/30/2025 at 3:40 pm, the Director of Nursing (DON) reported she expected a wound nurse to assess and obtain treatment orders within 24 hours of a wound being identified. Review of the facility's Pressure Injury Prevention Program revised 3/18/2021 stated: . Documentation of pressure injuries should be completed in the resident's [EMR] . Monitor the skin of all at-risk residents daily during ADLs [activities of daily living] and report any abnormal findings to the Charge Nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide restorative nursing services for one of two residents (Resident (R) 98) reviewed for position and mobility out of a total sample of 51 residents. This failure had the potential to negatively affect Resident 98's ability to perform activities of daily living (ADL) and place R98 at risk of ADL decline. Findings include: Review of the facility's policy titled, Restorative Nursing Program, revised 11/4/2021, included the statement as follows: It is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and maintaining optimal physical, mental, and psychological functioning and wellbeing of the patient/resident. Restorative nursing program is under the supervision of a Registered Nurse (RN) or a Licensed Practical Nurse (LPN), and restorative nursing services are provided by Restorative Nursing Assistants (RNAs), Certified Nursing Assistants (CNAs), and other qualified staff. Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible .Active Range of Motion (AROM) - exercises performed by the resident, with cueing. supervision, or physical assistance by the staff. Review of R98's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R98 was admitted to the facility on [DATE] with diagnoses including diabetes and multiple sclerosis (MS: chronic and unpredictable neurological disorder that affects the brain, spinal cord, and optic nerves.) Review of R98's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/2025, located in the RAI [Resident Assessment Instruments] tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of fifteen out of 15 which indicated she was cognitively intact. R98 had an impaired range of motion (ROM) on both sides of her upper and lower extremities. R98 was dependent on staff (the staff does all the effort) for toileting, bathing, lower body dressing, putting on and taking off footwear, personal hygiene, sitting to lying, chair to bed to chair transfer, and shower transfer. R98 did not walk and was dependent on staff to wheel her as she was not able to wheel herself. Review of R98's Care Plan located in the resident's EMR under RAI tab revealed that for the ADL Functional care plan, dated 10/8/2021, included the following interventions: - Total lift with 2-person assists for transfers. - PT/ OT/ST to evaluate and treat as warranted. Review of R98's Care Plan located in the resident's EMR under RAI tab revealed that for the Nutritional Status care plan, dated 10/8/2021, included the following interventions: - Increase physical activity/exercise as tolerated. The assigned discipline included Restorative Nursing. During an observation on 4/27/2025 at 3:10 pm, R98 stated she had MS and she could move her left leg a bit, but she could not move her right leg at all. R98 said she did not receive any of the range of motion services. During an interview on 4/29/2025 at 4:57 pm, the Director of Rehabilitation (DOR) stated that R98 was on physical therapy (PT) from 10/27/2024 to 12/5/2024 and on occupational therapy (OT) from 10/27/2024 to 12/2/2024. The DOR stated the therapy department had referred R98 to the Restorative Nursing Program. The DOR provided a record for R98's PT and OT discharge summary, and he pointed out where it documented the following: 1. On page four of the PT Discharge Summary, Date of Service: 10/27/2024-12/5/2024, under Discharge Recommendations and Status: - Restorative Program Established/Trained = Restorative Range of Motion Program, Restorative Bed Mobility Program. - Range of Motion Program Established / Trained: Patient is currently able to move feet up and down, raise arms above head, and raise arms straight out from shoulders, and tier is progressive and with Restorative Nursing Program, patient will be able to move feet up and down, raise arms above head and raise arms straight out from shoulders by performing the following Restorative Nursing interventions: active ROM, encourage resident to participate, face the resident in order to observe for signs of fatigue or discomfort, introduce self and explain procedure and refer to PT/OT as needed. - Bed Mobility Program Established / Trained: Patient is currently able to move from a lying position to a sitting position,, move from a sitting position to a lying position, and pull self up in bed, and tier is progressive and with Restorative Nursing Program, patient will maintain/prevent decline of current status, as demonstrated by the ability to move from a lying position to a sitting position, move from a sitting position to a lying position and pull self up in bed by performing the following Restorative Nursing interventions: assist resident to turn from side to side, provide a verbal prompt to assist with lying down from a sitting position, provide verbal prompts to assist with moving up in bed, provide verbal prompts to sit up from a lying position and provide verbal prompts to assist patient with turning from side to side. - Prognosis: . Good with consistent staff follow-through. 2. On page three of the PT Discharge Summary, Date of Service: 10/27/2024-12/2/2024, under Discharge Recommendations and Status: - Restorative Program Established/Trained = Restorative Range of Motion Program. - Range of Motion Program Established / Trained: BUE [bilateral upper extremities] AROM [active range of motion] in all planes as tolerated with resistance. During an interview with the Director of Nursing (DON) and the Unit Manager (UM) 2 on 4/29/2025 at 5:00 pm, UM2 stated that R98 was not currently in the restorative nursing program. She thought R98 had just been discharged from the PT and OT recently. UM2 stated she would review the referral and place R98 in the restorative nursing program. Upon record request on 4/29/2025 at 5:00 pm, the DON confirmed that no documentation indicated that R98 was receiving restorative nursing ROM as per the therapists' referral. The DON stated she was overseeing the restorative program, and R98 was never enrolled and received ROM since both PT and OT had discontinued their services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to have physician orders and an indication for an indwelling catheter for one (Resident (R) 85) of three residents reviewed for urinary catheters out of a total sample of 51 residents. This failure increased the risk of urinary catheters being implemented without an acceptable indication. Findings include: Review of the Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R85 was originally admitted to the facility on [DATE]. An observation of R85 on 4/27/2025 at 10:09 am revealed the resident in bed resting. On the right side of the resident's bed, hung a catheter bag, covered in a blue privacy bag. Review of the Minimum Data Set (MDS), located in the EMR under the RAI tab, with an Assessment Reference Date (ARD) of 3/3/2025, indicated that R85 had an indwelling catheter and Brief Interview for Mental Status (BIMS) of five out of 15 indicating severely impaired cognition. Review of the Progress Notes from 1/23/2025 at 7:08 am revealed the resident was not voiding and a straight catheter was ordered. A subsequent note at 6:55 pm revealed the resident still had not voided unassisted and the Nurse Practitioner (NP) ordered an indwelling catheter. A review of R85's physician's orders, found under the Resident tab, revealed no order for the use and care of a catheter. A review of R85's Care Plan revealed a focus that indicated the resident had an indwelling urinary catheter, dated 3/13/2025. The goal for this care plan focus was for R85 to not exhibit signs of infection or urethral trauma using approaches that included changing the catheter bag as needed, changing the catheter per the physician's order, and providing catheter care every shift and as needed. During an interview with the Director of Nursing (DON) on 4/29/2025 at 2:44 pm, she confirmed that there were no orders for the use of a catheter or for catheter care for R85. The DON verified that a resident who had a catheter should have orders indicating diagnosis and need for use and orders for care of the catheter. A policy for the use of catheters was requested, and the DON stated that the facility did not have a policy but did have a procedure for catheter care. The first two steps of the procedure include: 1) Identify resident; and 2) Verify orders. During an interview on 4/30/2025 at 9:23 am, Registered Nurse (RN) 4 verified there was no order for the catheter but stated that the staff followed standards of care and the care plan when providing catheter care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to obtain and document weight for one of nine residents (Resident (R) 197) reviewed for nutrition out of a total of 51 sampled residents. This failure had the potential to place R197 at risk of weight loss if the weight was not obtained and monitored in a timely manner to provide accurate information for nutrition need calculation. Findings include: Review of the facility's policy titled, Weight Monitoring Program, revised 6/2/2023, documented New Admissions. Initial weight and height will be obtained and documented on the Yearly Weight Record Form within 24 hours of admission to the healthcare center. New admissions will be weighed weekly for four weeks and/or until weight is stable. Review of R197's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R98 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure and pneumonia. R197 was discharged to an assisted living facility on 4/9/2024. Review of R197's Care Plan located in the resident's EMR under RAI tab revealed that for Psychosocial Well-Being care plan, dated 3/22/2024, included the intervention of Monitor for decreased intake, weight loss, and social isolation. Review of R197's Care Plan located in the resident's EMR under RAI tab revealed that for the Nutritional Status care plan, dated 3/29/2024, included the intervention of Monitor/record weight. Notify MD and family of significant weight change. Review of R197's weight report located under the Resident tab of the electronic medical record (EMR) revealed R197 had only one weight recorded on 3/20/2024 when R197 was admitted . R197 was 191 pounds (lbs.) During an interview on 4/30/2025 at 11:51 am, the DON stated there was no second weight measured for R197. The DON verified that since R197 was newly admitted , his weight should have been taken once a week for four weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review, the facility failed to ensure documentation of assessment prior to, and upon return from, dialysis and failed to ensure communication forms used between the facility and the dialysis center were completed for one of two residents reviewed for dialysis (Resident (R) 106) out of 51 sampled residents. This had the potential to affect the health of residents receiving dialysis. Findings include: Review of the facility's policy titled, Dialysis Care Pre and Post Dialysis, revised 8/22/2022, revealed the use of a Dialysis Center Communication Form. The policy documented the procedure that facility staff were to take and record the resident's blood pressure and pulse, and observe shunt access prior to and upon return of the resident's transport to and from dialysis. Review of R106's Face Sheet tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease and dependence on renal dialysis. Review of R106's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/06/25 and located in the resident's EMR RAI tab revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated severely impaired cognition. R13 received dialysis. Review of R106's Care Plan located in the RAI section of the EMR revealed a problem area dated 11/19/2024, potential for complications related to hemodialysis. Approaches included: Communication with dialysis center regarding medication, diet, and lab results. Coordinate care with dialysis center .Observe vital signs before and after dialysis. Review of the Orders tab of R106's EMR revealed orders dated 3/13/2025, Dialysis: Communication book sent with resident to dialysis .Dialysis: Monitor and record blood pressure and pulse before and after dialysis twice a day on Tuesdays, Thursdays, and Saturdays. Review of R106's Vitals tab of his EMR as well as the April 2025 Medication Administration Record (MAR) located in the Reports tab of the EMR and the Progress Notes tab of the EMR revealed only one set of vital signs were recorded on: 4/1/2/2025, 4/3/2025,4/08/2025, 4/15/2025, 4/19/2025, 4/22/2025, and 4/29/2025 and no pre- or post-dialysis vital signs were recorded on 4/5/2024 and 4/24/2025. Review of R106's Documents tab of his EMR revealed one Dialysis Center Communication Form for April dated 4/5/2025. On it was documented pre-dialysis vital signs, but no post-dialysis vital signs. Review of a Dialysis binder located at the nurse's station for R106 revealed no completed communication forms in it from April 2025. A file basket at the desk contained communication forms for three residents, which included R106. It included Dialysis Center Communication Forms dated 4/8/2025, 4/10/2025, 4/12/2025, 4/15/2025, 4/17/2025, 4/24/2025, 4/26/2025, and 4/29/2025. These forms included pre- and post-dialysis vital signs, but there were no forms for 4/1/2025, 4/3/2025, 4/19/2025, and 4/22/2025 when two sets of vital signs were not recorded in the EMR. In addition, the bottom part of the form, which was labeled To be completed by Dialysis Center and included pre- and post- dialysis weights, vascular access condition, new physician orders, and any occurrence during dialysis treatment, was not completed on the forms dated 4/8/2025, 4/24/2025, 4/26/2025, and 4/29/2025. During an interview on 4/29/2025 at 1:45 pm, Wound Nurse (WN) 2 stated dialysis residents took their dialysis binders with them to and from dialysis. Upon return to the facility, the binder was checked to see if any communication needed follow-up from the dialysis center. Nurses checked vital signs and the vascular access site pre- and post-dialysis and documented them in the EMR. During an interview on 4/29/2025 at 4:06 pm, the Unit Manager (UM) 1 verified the missing Dialysis Center Communication Forms for R106, and stated he would check if medical records had any more. UM1 reported that the dialysis center was bad at times at filling out the bottom portion of the forms. UM1 stated he had called them to obtain weights in the past. During an interview on 4/30/2025 at 3:40 pm, the Director of Nursing (DON) reported she expected staff to check a resident's blood pressure and pulse before and after they received dialysis. The DON expected the nurses to fill out the communication forms with current orders, labs, concerns, and vital signs, and the dialysis center to fill out their section of the form. If the dialysis center did not fill out the form, she expected the facility to call the dialysis center.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and a review of the facility's policy, the facility failed to adequately label insulin pens and failed to properly dispose of expired medication in the designated disposal container for one of the four medication carts (MC) that were observed during medication administration on [DATE]. This failure had the potential to increase the risk of medication administration errors and posed a potential biohazard. Findings include: Review of the facility's policy titled, Medication Storage in the Healthcare Centers, revised [DATE], stated Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Types of medications and routes of administration are stored based on package type .Medication labeled for individual patients/residents .in closed and labeled containers. During the fourth-floor medication administration observation on [DATE], at 8:37 AM, Licensed Practical Nurse (LPN) 2 assigned to medication cart (MC) 1 was administering insulin to Resident (R) 151. 1. LPN2 checked R151's insulin order using the facility's tablet and confirmed that the order was to administer 10 units of Novolog FlexPen U-100 Insulin subcutaneously. LPN2 prepared Novolog FlexPen U-100 Insulin and went into R151's room, primed two units of Novolog FlexPen U-100 Insulin wasted and prepared ten units of insulin NovoLog pen and then administered it to R151 on her left lower abdomen. LPN2 returned to her MC1 and placed the Novolog FlexPen U-100 Insulin into the first drawer of the MC1 to the right side of the drawer. Observed there were a total of four insulin pens placed next to each other without any labels indicating the name of residents and the instruction of administering orders as follows: NovoLog. Lantus. Aspart. Tresiba. Upon observation, it was unclear to the surveyor which pen belonged to which resident. During an interview on [DATE] at 8:42 AM, LPN2 stated she had a total of four residents on her assignment on the MC1 who were receiving insulin and each of the residents' insulin pens was different. R151 was the only resident on her assignment with the MC1 receiving Novolog, so she knew which pen belonged to which resident. LPN2 stated she was the only nurse other than the Director of Nursing (DON) who had access to that medication cart so she was familiar with which resident received which insulin by the physician orders. LPN2 further stated she did not know who removed the name label from those four insulin pens. She stated that resident's names should be marked or labeled on pens. On [DATE] at 2:22 PM, the DON stated that the insulin pens should be labeled. 2. Review of the facility's policy titled, Disposal of Medications, revised [DATE], stated Medications which have expired, been discontinued, or remain in the healthcare center after a patient/resident's discharge shall be removed from active stock and placed in disposal. To ease with the drug destruction process .Pharmacy Services will implement the use of a collection receptacle kiosk. Non-controlled medications no longer needed in the healthcare center will be removed from the medication cart and logged on to the Certificate of Inventory and Destruction Form for Reverse Distribution. The nurse will place the medication in the collection receptacle. kiosk and initial next to the medication on the log that the medication was placed into the kiosk. During a medication administration observation on [DATE] at 9:06 AM, LPN2 emptied an entire Nephro-Vite bottle into the Sharp's container on the right side of her MC1. When questioned about this action, LPN2 explained that the bottle of Nephro-Vite had expired. She stated that the facility did not provide a designated waste medication container for each MC. She stated she had been instructed to dispose of all waste medications, other than narcotics, in the Sharp's container. During a follow-up interview on [DATE] at 2:22 PM, the DON stated that wasted medications should be placed in the medication dispensing box on the second floor. She stated that all nurses knew this procedure and clarified that the box was designed for deposits only and could not be removed. The DON stated that disposing of wasted medications in the Sharp's container was unacceptable.

Based on observations, staff interviews, and review of the facility policy titled, Procedure: Blood Glucose Monitoring, the facility failed to ensure infection control practices were followed during a blood glucose (BG) check for one of two residents (Resident (R) 151) observed during medication administration observation. These failures placed all the residents who received a BG check and insulin from the medication cart at risk of contracting infectious diseases. Findings include: Review of the facility's undated policy titled, Procedure: Blood Glucose Monitoring, under Considerations, stated An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses (HBV [hepatitis B ], HCV [hepatitis C], and HIV [human immunodeficiency virus]) through contaminated equipment and supplies that are shared (e.9., blood glucose meters, fingerstick devices, insulin pens). The current FDA [Food and Drug Administration], /CDC [Centers for Disease Control and Prevention] recommendation is to use a separate blood glucose meter and spring-loaded lancet (if used) for each resident. During the fourth-floor medication administration observation on 4/28/2025, at 8:37 am, a BG check observation for R151 was conducted with Licensed Practical Nurse (LPN) 2. LPN2 performed hand hygiene and gathered the supplies needed for the BG check, which included a bottle of BG test strips, four small packs of alcohol pads, a shared-use glucometer, and lancets. LPN2 entered R51's room with all the supplies in her hands and placed them directly on R151's bed sheet without using a protective barrier. The BG check was performed, revealing a BG level of 128. After completing the check, LPN2 left R151's room and placed the BG test strips bottle into the first drawer of the medication cart, without sanitizing it. LPN2 then checked R151's insulin order using the facility's tablet and confirmed that the order was to administer 10 units of Novolog insulin subcutaneously. She prepared the Novolog insulin pen and returned to R151's room. Again, LPN2 placed the insulin pen and alcohol wipes on R151's bed sheet without a barrier. After positioning R151, she administered the insulin to the left lower abdominal area. LPN2 exited R151's room after administering the injection and placed the contaminated Novolog insulin pen back in the first drawer of the medication cart, without sanitizing it. This pen was placed next to the insulin pens of three other residents. On 4/28/2025 at 8:42 am, LPN2 was asked about this situation. LPN2 acknowledged that she could have placed the BG check supplies in a cup or placed a barrier between the supplies and R151's bed. LPN2 stated that she did not do so. She also stated that she could have wiped the bottle of test strips and R151's insulin pen with sanitizing wipes before putting them back in the medication cart, as it had been lying on R151's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and a review of the facility's policy, the facility failed to ensure medication was refilled before the medication ran out and over-the-counter medication was available for one of six residents (Residents (R) 129) observed during the medication administration and two residents (R436 and R98) out of a total of 51 sampled residents. This failure had the potential for adverse effects if medications were not administered due to a lack of timely refills or short supply. Findings include: Review of the facility's policy titled, Ordering Medications from the Pharmacy, revised [DATE], stated The healthcare center will transmit physician orders to the pharmacy using facsimile or other technology in order to receive medications on a timely basis. Facilities with EMAR: All orders will be entered into the system and transmitted to pharmacy. The policy under Reordered Medications (Refills) section stated some of the requirements as follows: Medication orders requiring refill are recorded on a Medication Reorder Sheet. Medication carts should be checked for additional available punch cards prior to reordering. Medications should be reordered four (4) days in advance of need in order to maintain an adequate supply on hand. Schedule II controlled substances should be reordered seven (7) days in advance of need. 1. During a medication administration observation on [DATE] at 9:06 am, Licensed Practical Nurse (LPN) 2 emptied an expired bottle of Nephro-Vite into the biohazard container on the medication cart one. LPN2 stated she would look for a new bottle of Nephro-Vite for R129 from the fourth-floor medication storage room. Observation conducted with LPN2 in the fourth-floor medication storage room revealed that a new bottle of Nephro-Vite was unavailable for R129. LPN2 stated she would hold the Nephro-Vite temporarily and look for it later. During a follow-up fourth-floor medication storage room observation on [DATE] at 9:12 am with Unit Manager (UM) 2, UM2 confirmed that there was no Nephro-Vite available. UM2 stated that if over-the-counter medications were unavailable in the medication storage room, nurses would look for them on other medication carts or in the medication storage room on another floor. 2. Review of R436's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R436 was admitted to the facility on [DATE] with diagnoses including lung cancer and brain cancer. Review of R436's Medication Administration Report (MAR) located in the Resident tab of the EMR under Report revealed that the nursing staff had not administered medications because the medications were unavailable. Examples include the following: Atorvastatin (for high cholesterol) tablet 20 milligram (mg), give one tablet by mouth at bedtime for long-term drug therapy, start date [DATE]: [DATE] at 9:00 am: Not Administered: Drug/Item Unavailable. Pantoprazole (for acid reflux) tablet, delayed release 40 mg, give one tablet by mouth once a day for long-term drug therapy. Start date [DATE]. [DATE] 9:00 am and [DATE] 9:00 am: Not Administered: Drug/Item Unavailable. [DATE] 9:00 am: Not Administered: Drug/Item Unavailable Comment: Not available. Levetiracetam (seizure medication) tablet 500 mg, give one tablet by mouth twice a day for long-term drug therapy. Start date [DATE]. [DATE] 5:00 pm: Not Administered: Drug/Item Unavailable. Tamsulosin (treats symptoms of enlarged prostate) capsule 0.4 mg, give two capsules by mouth nightly at bedtime for long-term drug therapy. Start date [DATE]. [DATE] at 9:00 am: Not Administered: Drug/Item Unavailable. B Complex w-Vit C: Take one tablet by mouth daily for long-term drug therapy. Start date [DATE]. [DATE] 9:00 am: Not Administered: Other Comment: Other. [DATE] 9:00 am: Not Administered: Drug/Item Unavailable Comment: Y. 3. Review of R98's undated Face Sheet located under the Resident tab of the EMR revealed R98 was admitted to the facility on [DATE] with diagnoses including diabetes, multiple sclerosis (a chronic and unpredictable neurological disorder that affects the brain, spinal cord, and optic nerves). Review of R98's MAR located in the Resident tab of the EMR under Report revealed that the nursing staff did not administer medications because the medications were unavailable. Examples include the following: Tizanidine (muscle relaxant) capsule 4 mg, give one capsule by mouth at bedtime for pain. Start date [DATE]. [DATE] 9:00 pm: Not Administered: Drug/Item Unavailable. [DATE] 9:00 pm: Not Administered: Drug/Item Unavailable Comment: 2525 Venlafaxine tablet extended release 24 hr 150 mg, give one tablet by mouth one time a day for major depressive disorder. Start date [DATE]. [DATE] 9:00 Am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, and [DATE] 9:00 am: Not Administered: Drug/Item Unavailable, [DATE] 9:00 am: Not Administered: Drug/Item Unavailable. [DATE] 9:00 am: Not Administered: Drug/Item Unavailable. [DATE] 9:00 am, [DATE] 9:00 am, [DATE] 9:00 am, and [DATE] 9:00 am: Not Administered: Drug/Item Unavailable. During the fourth-floor medication administration observation on [DATE] at 8:42 am with UM2, when asked, UM2 stated if there was no medication available for the resident, the staff would contact the pharmacy first to confirm if the medication would be delivered that day and if not, the facility had an emergency medications machine on the 3rd floor, the staff would go there to get the medication, except for the narcotic control medications. UM2 stated that for the narcotics medication, the nurse needed to call the resident's physician to obtain an order and contact the pharmacy. UM2 said that if the emergency medications machine had no medication, the nurse would contact the resident's physician for further instructions. During the interview on [DATE] at 3:00 pm, the Director of Nursing (DON) reviewed R98 and R436's MARs and confirmed all the medication documentation in the MARs, including the blank areas, documented not administered, or medication not available. During this interview on [DATE] at 3:00 pm, the DON stated it was unacceptable that some of the medications that were not given or not available as documented in the MAR were over-the-counter in-house medications. The DON stated the facility had plenty of them in stock. She expected the nurse to contact the physician if the medication was unavailable or not given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure an application for Preadmission Screening and Resident Review (PASRR) Level I that included a diagnosis of schizophrenia was submitted prior to or on admission to the facility for evaluation and determination of specialized services for one of 43 sampled Residents (R) (R32). This failure had the potential for residents with mental disorders not to receive identified specialized services. Findings include: Review of R32's Face sheet revealed she was admitted to the facility with diagnoses that include but are not limited to schizophrenia, unspecified. Review of R32's most recent annual Minimum Data Set (MDS) dated [DATE] revealed: Section A- Identification Information: no PASRR Level II; Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition; Section D-Mood: Total Severity score of 0 (zero); Section E-Behavior: no behaviors indicated. Review of R32's care plans included but not limited to: (Resident Name) at risk for potential decline with her psychosocial wellbeing mood and depression indicators related to schizophrenia with remaining LTC (Long Term Care) in facility with start date of 2/4/2022; (Resident Name) has impaired decision making and impaired memory at times related to Schizophrenia, psychotropic medication with start date of 2/15/2022. Review of R32's medications included but not limited to: seroquel (quetiapine) 100 milligram (mg); one tablet by mouth at bedtime for dermatillomania (a mental health condition where a person compulsively picks or scratches their skin, causing injuries or scarring); Zoloft (sertraline) 50 mg one tablet by mouth at bedtime for treatment of depression. Review of R32's medical record revealed an approved PASRR Level I dated 9/21/2021, however there was no primary diagnosis of serious mental illness, developmental disability, or related condition indicated. Review of R32's medical record revealed that R32 was not receiving psychiatric services. Review of the facility list of residents and status of the PASRR Level II indicated R32's PASRR Level II was pending. Interview on 3/2/2024 at 1:03 pm with Social Service Director (SSD) EE revealed she reviewed new admissions to ensure they have a PASRR Level I in place. She verified that R32 did not have a Level II PASRR but did have the diagnoses that would trigger a Level II. She revealed she did not know how it was missed when she was admitted to the facility. She verified R32 did not receive any type of psychiatric services. SSD EE stated they were in the process of auditing all residents with qualifying diagnoses to ensure Level I screenings were submitted. She reported she had completed one for R32 and provided a copy of the PASRR Level I dated 3/2/2024. Review of a PASRR Level I for R32 dated 3/2/2024 revealed a status of pending and indicated a primary diagnosis of serious mental illness, developmental disability, or related condition that included a diagnosis of schizophrenia, residual type. Interview on 3/3/2024 at 8:30 am with the Administrator revealed her expectations of staff were to review and ensure PASRR Level I screenings were completed accurately prior to residents' admission and resubmit them as needed. She reported that staff had recently received training from corporate on the PASRR process. The Administrator revealed the facility did not have a policy for PASRR and that they follow the State guidelines.

Based on observations, staff interviews, and review of the facility policies titled, Foodborne Illness, Patients/Residents' Personal Food', and Labeling, Dating, and Storage, the facility failed to properly thaw frozen foods by not allowing running water to overflow to prevent potential harmful particles/bacteria to run freely. The facility also failed to ensure resident nourishment refrigerators and freezers were clean, resident foods were labeled and dated, as well as food items discarded past the use by date. The deficient practice had the potential to affect 170 residents receiving an oral diet. The facility census was 174. Findings include: Review of the facility policy titled Foodborne Illness revealed under Procedure, 2. Foods will be used before the expiration date, use by date, best by date, and sell by date indicated on the food item. Foods not used prior to the expiration date, use by date, best by date, or sell by date must be discarded. 7. Meats will be thawed and cooked to appropriate internal temperatures to prevent foodborne illness. Thaw meats under refrigeration at or below 41 degrees Fahrenheit in a drip proof container or submerged in a solid bottom pan under cold running water. Review of the facility policy titled Patients/Residents' Personal Food revealed under Procedure, 4. Food item(s) will be labeled with the resident's name, contents, the date it was prepared if known and a discard/use by date. 6.All food items requiring refrigeration must be labeled and dated. 8. Nursing/housekeeping partners will be responsible for the disposal of outdated foods maintained in the patient/resident's room and those stored in the nursing unit's nourishment refrigerators/freezers. Review of the facility policy titled Labeling, Dating, and Storage revealed it applies to all Dietary partners employed by the company. The policy stated under Procedure, 1. Food and beverage items will have an identifying label as well as a received date and opened date, as applicable; for items prepared onsite, a 'used by' date will also be indicated. Observation on 3/1/2024 at 9:05 am of the food preparation sink revealed Dietary [NAME] (DC) AA thawing frozen fish filets. The sink had two compartments, the left side contained frozen fish filets that were submerged in water but had no running water and the water was not overflowing into a drain. DC AA was in the process of placing additional frozen fish filets inside the right-side sink compartment, the faucet was running cold water, however the water in the sink was not overflowing to have potential particles flow freely. Interview on 3/1/2024 at 9:05 am, DC AA revealed that the fish filets are usually thawed in the refrigerator overnight, but the cook did not take them from freezer the day before and put them in refrigerator. DC AA stated that she was in a hurry to get the fish thawed and did not place it in a container to have the water overflow. Interview on 3/1/2024 at 9:05 am with the Dietary Manager (DM) confirmed that the water the frozen fish filets were submerged in was not overflowing to remove potential particles. The DM stated that they thaw food items mainly using the refrigerator. Staff should take food items out of the freezer the day before, which did not get done. Observation on 3/2/2024 at 8:55 am of the fifth-floor resident nourishment room revealed a standard refrigerator with a top/upper freezer. Observation of the refrigerator revealed six, 4-ounce containers of name brand strawberry yogurt with use by date of 2/16/2024. Also, in this refrigerator were six, 8-ounce cartons of 2 percent milk with a use by date of 2/29/2024. Observation of the inside upper freezer revealed a brown substance that appeared to be melted chocolate ice cream, splashed and splattered throughout the entire inside of the freezer, covering the bottom, sides, ceiling, and inside door. There was an area on the bottom the size of 6 inches x 8 inches of the brown substance. Interview on 3/2/2024 at 8:55 am the DM confirmed that the six yogurt cups had use by date of 2/16/2024 and six milk cartons had a use by date of 2/29/2024. The DM revealed he was unsure which department should ensure food items past the use by date should discard the items. The DM confirmed that the upper freezer had a large amount of a splashed/splatted brown substance covering the entire inside top, bottom, and sides. The DM revealed he was not sure which department was responsible for cleaning the inside of the refrigerator or freezer. Interview on 3/2/2024 at 8:55 am with Housekeeper BB revealed that housekeeping was not responsible for cleaning the inside or outside of the resident nourishment room refrigerator or freezer. Housekeeper BB revealed nursing was responsible. Interview on 3/2/2024 at 9:00 am with Registered Nurse Unit Manager CC confirmed that the resident nourishment upper freezer was not clean and had a brown substance splatter throughout. Unit manager CC revealed that nursing was responsible for cleaning the inside of the resident refrigerator and freezer. Unit Manager CC indicated that staff should be cleaning up food spills as they occur. Observation on 3/2/2024 at 9:10 am of the fourth-floor resident nourishment room revealed a standard refrigerator with upper freezer. The refrigerator revealed six, 4-ounce cartons of name brand strawberry yogurt with use by date of 2/16/2024. Interview on 3/2/2024 at 9:00 am with the DM, he confirmed that the yogurt containers had a use by date of 2/16/2024. The DM revealed that he would have to ask the Executive Dining Director (EDD) who was responsible for discarding food items past the use by date in the resident nourishment rooms. Observation on 3/2/2024 at 9:10 am of the third-floor resident nourishment room revealed a standard refrigerator with upper freezer. Continued observation revealed a rectangle shaped plastic food container with a red lid with no label or date. There was also a white rectangle plastic food container with a clear plastic lid with no label or date. On the bottom shelf of the refrigerator was a white frosted plastic grocery bag containing four stalks of celery with no label or date. Further observation of the refrigerator revealed a sign taped to the front door which stated, Food items should be labeled with the resident's name, content, and date. All food will be discarded after 48 hours. Interview on 3/2/2024 at 9:10 am with the DM, he confirmed that both plastic food containers and plastic bag of celery stalks had no label or date. The DM revealed that all food items stored in a refrigerator should have a label and date. The DM revealed that nursing was responsible for ensuring foods are labeled and dated. Interview on 3/2/2024 at 9:15 am with Licensed Practical Nurse (LPN) DD revealed that nursing staff are responsible for making sure resident foods in the resident nourishment room are labeled, dated, and discarded if needed. Observation on 3/2/2024 at 9:20 am of the second-floor resident nourishment room revealed a standard refrigerator with upper freezer. Continued observation revealed a white colored plastic bag with a plastic circular food container with no label or date. Also in the refrigerator was a brown colored plastic grocery bag containing multiple food items with no label or date. Interview on 3/2/2024 at 9:20 am with the DM, he confirmed both the white plastic bag and brown plastic bag containing food items had no label or date, but should have. Interview on 3/2/2024 at 9:30 am with the Executive Dining Director (EDD) revealed that dietary staff stock and place food items in the resident nourishment refrigerators and the EDD expects dietary staff to check expiration/use by dates of food items supplied by dietary and discard as needed. The EDD revealed that resident food items stored in the resident nourishment refrigerators need to have a label and date and if not, dietary staff are expected to alert nursing staff, and for nursing staff to label and date the food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that one of 16 sampled residents (R) (R#35) was provided Activities of Daily Living (ADL) care related to incontinence care. Findings include: A review of the clinical record revealed R#35 was admitted to the facility on [DATE] with a diagnosis to include but not limited to sepsis, cellulitis of left lower limb, chronic respiratory failure with hypoxia, COPD, unspecified abnormalities of gait and mobility, pressure ulcer of sacral region, stage four. During an interview on 6/21/22 at 9:00 a.m., R#35 stated that the staff only changes her once per shift. She stated that she wets the bed and needs to be changed more frequently. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that R#35 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment in cognitive skills for daily decision making. The resident was assessed in Activities of Daily Living (ADL) functional status to require the total dependence of two staff with toileting. R#35 was assessed to be always incontinent of bowel and bladder. A review of the Care Area Assessment (CAA) summary revealed R#35 triggered urinary incontinence on the MDS assessment requiring further evaluation of urinary continence. A review of the care plan (created 2/11/21) for R#35 revealed is at risk for pressure ulcers related to incontinence of bladder. The goal established included R#35 wounds will improve within three months. Interventions included staff to provide R#35 with incontinence care after each incontinent episode. A review of progress notes dated 6/3/22 at 4:15 p.m. revealed that R#35 bed sheets were wet, and that the resident had to be changed by the activity assistant (Certified Nursing Assistant (CNA) BB) and the Hospice Aide due to no CNA's on the floor during shift change. The resident advised that she had not been changed since 1:00 p.m. and her bed sheets were wet. During an interview with Unit Manager (UM) on 6/22/22 at 11:15 a.m., she revealed that staff are expected to round on each resident every two hours. Sometimes residents have to wait for incontinence care, but the staff will explain to the resident the need to have to wait.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to obtain a Physician's Order for oxygen use, including the frequency of use and flow rate for one of 57 sampled residents (R) (R#281). Findings include: A review of R#281's clinical record revealed that she was admitted on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, depression, and anxiety. An observation of R#281 on 6/21/22 at 1:59 p.m. revealed that she had oxygen tubing attached via nasal cannula and the oxygen flow rate was at two liters per minute via an oxygen concentrator. An observation of R#281 on 6/22/22 at 8:29 a.m. revealed that oxygen was in use via nasal cannula at a flow rate of two liters per minute via an oxygen concentrator. During an observation of R#281 on 6/22/22 at 1:00 p.m., she was in therapy gym and was noted with oxygen via nasal cannula in use via oxygen tank. A review of an admission Minimum Data Set (MDS) assessment revealed that R#281 was marked as receiving oxygen. A review of R#281's Physician's Orders revealed that there was no order written for the resident to receive oxygen. Further review of Physician's Orders revealed that an order for oxygen was written on 6/23/22: oxygen at two liters per minute via nasal cannula to keep oxygen as needed for low oxygen saturation and shortness of breath. During an interview on 6/22/22 at 8:32 a.m. with Licensed Practical Nurse (LPN) AA, they stated that R#281 had oxygen via nasal cannula in use at two liters per minute. LPN AA revealed that nursing staff does not date oxygen tubing and that oxygen tubing is changed weekly. LPN AA verified that there was no order for the resident to have oxygen. She further revealed that there was no oxygen care plan. During an interview with Director of Nurses (DON) on 6/23/22 at 11:38 a.m. they stated that there should be an order for oxygen use, not only for the flow rate but also if the oxygen should be continuous or used as needed. DON further revealed that if a resident is transported to the facility, then nursing staff should verify oxygen orders and if no orders for oxygen are in the medical chart, then the nurse should contact the physician to clarify the need for oxygen. During continued interview, she verified that there was no order for oxygen on R#281's chart. Review of Procedures: Oxygen Administration (undated) revealed: Procedure: 2. Verify orders 7. Adjust device to ordered level 8. Apply device to resident.

Based on observation, interview, and record review the facility failed to ensure the kitchen was maintained in clean and sanitary condition. This deficient practice had the potential to affect all residents receiving an oral diet. As indicated on the facility's Form Centers for Medicaid and Medicare Services (CMS)-672, Resident Census and Conditions of Residents Form, the facility's census on 6/21/22, was 170 residents. Findings include: Review of the facility Cleaning Schedule Policy with an effective date of 9/1/01 and a revised date of 3/22/16 revealed it is the policy of the corporation that the Dietary Manager prepares a list of all cleaning tasks and posts them in the Dietary Department. It is the Dietary Manager's responsibility to develop and enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment. During the initial tour of the kitchen on 6/21/22 at 10:00 a.m. the floor was observed to have brown/black/and yellow stains throughout the kitchen with debris and was slick. The food warmer, just inside the door used to enter the kitchen from the dining room, was opened and the inside was observed to have debris and the inner part of the door was observed to have a thick yellow substance. The walls behind the warmer was observed to have a thick yellow substance that was dried and appeared in a streaking motion going down the wall. There was a prep table sitting next to the warmer with a sink that appeared clean. Underneath the table, on the wall, was a black substance. On the walls above the table was a thick yellow substance that was dry and appeared in a streaking motion going down the wall. In the floor underneath the table, near the sink, was a puddle of water. There was no mat noted in front of the sink to assist in preventing slippage of staff. The double door cooler near the table was observed to be clean on the outside and when opened the inside appeared clean. Observation of the floor in the dishwasher room revealed a water hose leaking water into the floor and the floor was standing full of water. There was no mat observed in the floor to prevent staff from slipping. The walls in the dishwasher room were observed to have a thick yellow substance that was dried an appeared in a streaking motion going down the walls. Observation of the cooking area revealed the floor was slick and there was a yellow and brown substance noted on the floor. The stove/oven was observed to have a thick brown and black substance on the front of the oven in a streaking motion. The stove eyes were black with debris noted and the oven, when opened, was observed to have a thick black, caked on substance, on the oven racks and inside the oven and on the inside of the oven doors. The fryer was observed to have a thick yellow substance, dried and in a streaking motion going down the outside of the fryer. Next to the fryer was a double oven that was observed to have a yellow and brown substance that was dried and appeared in a downward streaking motion on the outside of the oven. The inside of the double oven was observed to have a thick, black substance, on the oven racks and all inside the oven and on the inside of the oven doors. The wall behind the stove/oven, fryer, and double oven was observed to have a thick, brown substance that was dried and appeared in a downward streaking motion. Directly across from the stove/oven was a warmer. On the outside of the warmer was a yellow and brown substance that was dried and appeared in a downward streaking motion. Inside the warmer was a thick, black substance noted on the racks, all around the inside, and on the inside of the double doors. Behind the warmer the wall was observed to have a thick, brown, and yellow substance that was dried and appeared in a streaking motion down the wall. Adjacent to the warmer was a prepping table that was observed to be clean. Underneath the prepping table the wall was observed to have a black substance that reached all the way back to the warmer. The hood was noted to be clean and was last professionally cleaned in April 2022. Observation of the bakery area revealed all walls with a thick brown/yellow substance that was dried and appeared in a downward streaking motion. The prep table in the bakery area was observed to be clean. The floors had a brown/black substance and were slick with debris noted. There was a warmer noted in the bakery area with a thick brown and yellow substance observed on the outside that was dry and appeared in a downward streaking motion. Observation of the utensil, pots and pans storage area revealed the floor was wet, slick, and had a brown/black substance. The walls located behind the storage racks for the pots/pans/and utensils revealed a thick, yellow substance that was dried in a downward streaking motion. There was debris noted underneath the racks. Across from the pots/pans/and utensil racks was a prep table with a sink. There was a large water leak observed underneath the sink and the entire floor was standing with water and the wall under the table/sink was observed to have a black substance that ran the entire length of the prep table. The pipes under the sink had a thick brown substance noted on them. Across from the prep table was a double sink with garbage disposals. The garbage disposal in the first sink was observed to have a large amount of food in the bottom and there was a plunger observed in the sink. During this time an interview was conducted with the Dietary Manager, and she revealed the garbage disposal in the first sink was broken and stated she put in a work order, but nothing has been done about it yet but stated the garbage disposal in the second sink still works. Observation of the second sink garbage disposal revealed it was clean. The walls around the garbage disposal sinks were observed to have a thick brown and yellow substance that was dried and appeared in a streaking downward motion. Observation of the dry storage room revealed an Air Condition (AC) unit sitting in a pan that was full of water that was overflowing onto the floor and the entire dry storage room floor was standing in water. There was a pump noted sitting in the pan full of water next to the AC unit. The electric cord to the pump was laying over in the floor, in water, and plugged into the wall. The floor in the dry storage room was observed to have a brown and black substance caked on the floor with tiles that were chipped and broken. Base boards around the floor wall in the dry storage room were observed to have a black substance. Outside the dry storage room, to the immediate left, was a sink and eye wash station. The wall was observed to have a thick yellow substance caked on the wall and the garbage can had a thick white/gray substance dried on it in a downward streaking motion. Observation of cooler one revealed the floor had a black substance with debris all over the floor to include underneath the racks. Observation of cooler two revealed the floor had a black substance with debris all over the floor to include underneath the racks. The fan in cooler two revealed a thick fuzzy substance. Observation of Cooler/freezer three revealed the floor had a black substance with debris all in the floor to include underneath the racks. Observation of the ceiling tiles throughout the kitchen were observed and there were yellow and black stains noted on tiles and all vents in the ceiling was noted to have a thick fuzzy substance. During an interview on 6/21/22 at 10:30 a.m. with the Dietary Manager she revealed she has worked as the Dietary Manager in the facility since 2018. She stated it is the responsibility of the kitchen staff to keep the kitchen clean and the kitchen appliances clean and to see to it that everything is in good working order and added that it is her responsibility to schedule the cleaning and ensure that it is done. During this time the Dietary Manager toured the kitchen and observed areas found to be a concern and confirmed the kitchen was not clean and sanitary. She stated she has been very short staffed in the kitchen and that she has done the best she could with what she had to work with. During an observation and interview on 6/21/22 at 11:00 a.m. with the Administrator and the Corporate Clinical Nurse, in the kitchen, the Administrator revealed she came into the kitchen earlier this morning to speak with the kitchen staff, but she did not tour the kitchen for cleanliness or unsanitary conditions. All areas of concern were reviewed with the Administrator and the Corporate Clinical Nurse, and both revealed they will begin getting the areas clean immediately. During this time the Dietary Manager provided a copy of work orders since 2018 and the cleaning assignments for the kitchen for the last three months were requested. Review of the work orders revealed completed work by maintenance that included floor tiles/black mold 2/6/19, ceiling leak/floor tiles/black mold 2/6/19, water leak 3/4/19, paint walls in kitchen 3/28/19, replace ceiling tiles 3/28/19, missing floor tile 5/29/19, mold on ceiling 7/9/19, sink leaking 9/3/19, painting 10/8/19, sink leaking 10/28/19, soiled ceiling tile 10/15/20, leaking AC unit 10/21/20, AC unit leaking 2/24/21, repaint 4/27/21, ceiling leak 9/20/21, locate leak behind stove-standing water 10/7/21, multiple ceiling leaks 11/30/21, ceiling leak 12/9/21, garbage disposal not working 1/4/22, kitchen area sink leaking 1/16/22, sink leaking in pots and pan areas 2/1/22, ceiling leaks 3/31/22, AC leaking 4/14/22, mildew on fans in cooler 4/23/22. All tasks were documented as completed by maintenance. During a follow-up tour of the kitchen on 6/23/22 at 7:50 a.m. with the Administrator present some of the ceiling tiles had been replaced. During this time the Administrator revealed they ran out of ceiling tiles had not gotten all the ones that were soiled replaced. Observation of the stove/oven revealed it had been cleaned. All warmers and the fryer had been cleaned. All leaks had been fixed and there was no standing water in the floor. The walls that had a thick yellow substance dried in a streaking downward motion remained on the walls except for the walls behind the utensil, pots, and pans racks, and were observed to be clean. The garbage disposal in the first sink remained broken but was not being used. The walls under the prep tables with sinks were observed and had been cleaned with a small amount of black substance noted. The pump in the AC unit in the dry storage room was fixed, the water was no longer standing in the pan or on the floor. All coolers/freezers' floors and vents had been cleaned. Observation of all floors revealed they had been cleaned, were not slick, but the black and brown substance remained and there were broken and stained tiles in the dry storage room. During this time the Administrator revealed the kitchen looked much better and there was still a lot of work to do, and they would continue working on it until it was completely finished and cleaned up. During an interview on 6/23/22 at 1:30 p.m. with the Administrator she revealed she was completely embarrassed at the condition of the kitchen during the walk through the previous day with the surveyors. She stated she was not aware of the unclean and unsanitary conditions of the walls, stoves, sinks, garbage disposal, AC unit, and other concerns identified during the walk through and revealed the Dietary Manager was supposed to be keeping her informed of concerns by using an audit tool. She revealed she could not provide the cleaning schedules requested from the Dietary Manager the previous day and stated the Dietary Manager left her a letter of immediate resignation as of 6/21/22 and when she (the Dietary Manager) left she took cleaning schedules and other documentation with her. During this time the Administrator provided a copy of the police report she made about the missing documents. She stated the facility Quality Assurance Performance and Improvement (QAPI) program has a Performance Improvement Plan (PIP) in place related to the kitchen. During this time a copy of the Annual Nutrition Service Checklist - Action Plan May 2022 was provided by the Administrator and she revealed the Dietary Manager was supposed to be reporting back to her using the Plan for Food Nutrition Services audit tool but again stated the Dietary manager took the documentation with her when she left and there is no evidence of it. Review of another agency Inspection Report revealed the last inspection date for the facility was 5/29/19. Areas of concerns included but was not limited to observation of buildup of slime in the interior of the ice machine, torn and/or soiled floors/carpeting, tile missing on floor in kitchen area, presence of insects, rodents, and other pests. Review of the In-service Education Summary Form dated 6/15/22 with an In-Service Title: Dietary Infection Control revealed a topic that include but is not limited to, sanitation condition. Nine dietary staff were in attendance. The Dietary Manager's name did not appear on the list of attendees.