**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure sufficient staff to meet the needs of the residents timely. This has the potential to affect all 58 residents currently residing at the facility. Findings include: 1. R13's admission Record documents an admission date of 2/9/25 with diagnoses including in part: altered mental status, anxiety disorder, diabetes, disorder of muscle, unsteadiness on feet, other lack of coordination, and unsteadiness on feet. R13's MDS dated [DATE] documents a BIMS of 14, indicating R13's cognition is intact. On 8/26/25 at 11:54 AM, R13's was sitting in his wheelchair in the doorway to his room with his call light on, this surveyor asked if his call light had been on a while, and he stated yes it has been. The call light was already on when the observation began. During constant observation, R13's call light was answered by V3 (Corporate Nurse) at 12:16 PM. 2. R8's admission Record documents an admission date of 9/11/23 with diagnoses including in part: diabetes, anxiety, chronic obstructive pulmonary disease, chronic pain syndrome, nicotine dependence cigarettes, and difficulty in walking. R8's MDS dated [DATE] documents a BIMS of 15, indicating R8's cognition is intact. R8's current Care Plan documents R8 uses tobacco with interventions including in part: orient R8 to smoking times and procedures. On 8/26/25 at 10:57 AM, R8's call light was on, and he stated he turned his call light on about 30 minutes ago about 10:30 AM because that was the smoking time for residents. There was a digital clock with large print that was next to R8's bed that he looked at when he stated what time he put his call light on. R8 stated it can take an hour at times to get his call light answered because there isn't enough help. On 8/26/25 at 11:49 AM, R8 is still in bed, stated he is still waiting for someone to get him up. V1 (Administrator) came to the room to answer the call light and stated he would go find the sit to stand to get him up. On 8/26/25 at 12:31 AM, R8 was still in bed. R8 stated V1 told him again that he was going to get the sit to stand and find the Certified Nursing Assistants (CNA) to get him up. R8 stated he has now missed the 10:30 AM smoke break. R8 said he thinks the next one is after lunch around 1:00 PM. 3. R3's admission Record documents an admission date of 8/7/25 with diagnoses including in part: cellulitis of buttock, muscle weakness, unsteadiness on feet, cognitive communication deficit, reduced mobility, need for assistance with personal care, and dementia severe. R3's MDS dated [DATE] documents a BIMS of 13, indicating R3's cognition is intact. R3's current Care Plan documents R3 has a selfcare deficit with interventions including in part: assist with meals as needed. On 8/26/25 at 12:38 PM, R3 was lying in bed with her lunch tray sitting on the bedside table, next to the bed. The tray was untouched. This surveyor asked R3 if she was hungry and she said yes, this surveyor told R3 her lunch was sitting beside the bed for her. On 8/26/25 at 1:33 PM, R3 was lying in bed with her lunch try sitting on bedside table next to bed, tray is untouched. On 8/26/25 at 1:38 PM, This surveyor asked R3 if she needed assistance eating and she replied Yes. On 8/26/25 at 1:42 PM, R3's V7 (Family Member) and V6 (Speech Pathologist/Director of Rehab) went into R3's room and V6 told V7 that R3 wasn't having a very good day today. On 8/26/25 at 1:47 PM, V6 stated R3 doesn't usually need assistance eating but she isn't having a very good day today, so she was going to try and get her to eat some. On 8/26/25 at 2:02 PM, V8 (CNA) stated R3 usually feeds herself but she has been struggling lately and hasn't been eating much. V8 stated she hasn't checked on her since her tray was delivered because she has been shaving 3 other residents and hasn't had time. 4. R11's admission Record documents an admission date of 12/5/23 with diagnoses including in part: fracture of lower end of right tibia, obesity, chronic pain syndrome, primary osteoarthritis, muscle weakness, other abnormalities of gait and mobility, unsteadiness son feet, and need for assistance with personal care. R11's MDS dated [DATE] documents a BIMS of 15, indicating R11's cognition is intact. The same MDS documents R11 is dependent for chair/bed-to-chair transfers. The MDS documents depends as, helper does all the effort and resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On 8/26/25 at 9:20 AM, R11 stated she is a mechanical lift now because she fell about 2 months ago while being transferred and broke her knee. R11 stated she usually has a long wait for her call light to be answered, sometimes 30 minutes or longer and stated she has urinated on herself before because she had to wait so long. On 8/26/25 at 12:40 PM, R11 said the CNAs usually get her up with one assist using the mechanical lift. On 8/26/25 at 12:40 PM, V4 (CNA) stated she got R11 up today with the mechanical lift by herself. This surveyor asked V4 why she did it by herself and V4 stated because there wasn't anyone else to help. 5.R12's admission Record documents an admission date of 7/18/25 with diagnoses including in part: displaced intertrochanteric fracture of left femur, anxiety, restlessness and agitation, major depressive disorder, dementia severe with other behavioral disturbance, and sensorineural hearing loss. R12's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 99 indicating the interview was not completed. The same MDS documents R12 is supervision or touching assistance for toilet transfer and sitting to standing. R12's current Care Plan documents R12 is at risk for fall with interventions including in part: call light within reach and observe for unsafe actions and intervene. The same Care Plan documents R12 has a self-care deficit with interventions including in part: assist with toileting and showers/bath. On 8/26/25 at 12:02 PM, constant observation, R12's bed alarm was going off at 12:02, R12 was yelling for help stating he needed to urinate and was going to urinate in his pants because he had to go so bad, there was no staff in the hallway. R12's call light was laying over the nightstand, out of reach. At 12:04 R12 reached for his trashcan and pulled it over to him, pulled down his pants and was trying to urinate in the trashcan, there was still no staff in the hallway until 12:08 PM. At 12:08 V5 (Activities Director) walked past R12's room then turned around and came back and told R12 she would get someone to help. At 12:09 V3 (Corporate Nurse) came down the hall to give this surveyor a document and heard the bed alarm and went into R12's room to assist. V3 came out of the resident's room and was asked who would have answered that bed alarm if she wasn't coming to find this surveyor and V3 stated I would hope the staff would.6. R4's admission Record documents an admission date of 9/30/24 with diagnoses including in part: atherosclerosis of aorta, difficulty in walking, other abnormalities of gait and mobility, history of falling, and tobacco use. R4's MDS dated [DATE] documents a BIMS of 08, indicating moderately impaired cognition. On 8/26/25 at 8:47 AM, R4 stated call light wait time can be long at times. R4 stated I am concerned if there was a real problem I might be dead before they get to me to answer my call light. On 8/26/25 at 11:04 AM, V9 (CNA) stated she feels like residents to not get the care they when they are short staffed, and V9 stated she feels like they are short on staff now. V9 stated they only have 4 CNA's working today and she doesn't think that is enough. V9 stated she can't always get to the residents right away when they need something. On 8/26/25 at 11:06 AM, V10 (CNA) stated she feels like residents are not getting the care needed when they are short staffed, and she stated there is only 4 CNAs working today and she doesn't think that is enough. V10 stated she doesn't think she is able to provide the best care when they don't have enough CNA staff, and she feels that is true right now. V10 was asked about 2 call lights that were currently on, and she stated they are on all the time, but we have higher priority things that need done right now. On 8/26/25 at 11:56 AM, V4 (CNA) stated there are days they have enough staff and days they don't. V4 stated weekends seems to be worse. V4 stated there are times she can't give showers due to not enough staff. V4 stated she feels like residents are not getting the care needed on days they are short staffed because they might not get their showers. V4 stated there are only 4 CNAs working today. On 8/26/25 at 1:13 PM, V1 (Administrator) stated there is someone from the management team here during the day 7 days a week, but not at night unless it is needed. V1 stated ideal staffing is 6 CNAs from 6am-2pm, 5 CNAs from 2pm-10pm, and 4 CNAs from 10p-6a. V1 stated they are having some difficulties with staffing right now due to staff being out with COVID. V1 stated the CNAs shifts were switched to 12 hour shifts to help cover. V1 stated all mechanical lift transfers should be completed using 2 staff assist. A facility document titled Daily Census dated 8/25/25 documents total number of residents that reside in the facility is 56. A facility policy titled Staffing dated October 2017 documents under Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment and under Policy Interpretation and Implementation: 5. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain and implement physician orders for wound care for 1 (R1) of 3 residents reviewed for wound care in the sample of 9. The findings include: R1's admission Record documented R1 was admitted to this nursing home on 9/20/2022 with diagnosis of stroke with right sided paralysis. R1's Minimum Data Set (MDS) dated [DATE] documents R1 had a Brief Interview for Mental Status (BIMS) score of 01, indicating R1 has severe cognitive impairment. This MDS also documented R1 has one Stage IV Pressure Ulcer that was present on admission. R1's admission assessment titled Admit/Readmit Screener, dated 4/26/25 documented R1 was admitted via wheelchair from hospital and had a pressure area to his coccyx. There were no measurements or description of the wound documented on the Admit/Readmit screener or the nurse progress notes. R1's Order Summary Report with active orders as of 5/30/25 documented there were no orders for wound care from 4/26/25 until 5/2/25. R1's Treatment Administration Record (TAR) dated 4/1/30-4/30/25 indicated there were no treatments ordered for R1's coccyx wound to be done beginning on 4/26/25. The same TAR dated 5/1/25-5/30/25 documented a treatment to begin on 5/2/25 of cleanse area to sacrum (coccyx) then apply manukah honey absorbent dressing and cover with silicone border dressing every night shift for wound care. On 6/3/25 at 11:23am, V11 (Licensed Practical Nurse/LPN) said he was working on 4/26/25 when R1 returned to the facility from the hospital. V11 said that R1 had a wound on his sacrum/coccyx upon re-admission. V11 said all he was told from the out of state hospital that R1 was discharged from was that R1 had a non-blanchable area to coccyx. V11 said the wound had a wadded up dressing on it and the middle was deeper. V11 said he wasn't sure about the stage of the wound. V11 said they started off with Silvadene and calcium alginate dressing. V11 said that he believes either the doctor or the nurse practitioner okayed the calcium alginate, he does not remember. V11 said he did pass it on in report and thinks he wrote it on the 24-hour shift report. V11 said that V9 (Registered Nurse/RN) was helping him since he was new to the facility. On 6/3/25 at 2:55pm, V7 (LPN/Infection Preventionist/IP) said that R1 came back to the facility on 4/26/25 with the sacrum/coccyx wound. V7 said that the nurse that admitted R1 should have documented a wound note with measurements and R1 would have been seen the following Thursday. V7 said she was not notified about the wound on the sacrum/coccyx until 4/28/25. V7 said she got the order for treatments on the coccyx wound on 5/2/25. On 6/4/25 at 9:35am, V10 (RN) said she worked day shift on 4/27/25. V10 says it's usually after around 10am when she starts her treatments. V10 said that R1 did not have a treatment on the TAR to be done. V10 said she knew he came back with a wound and when she saw there was not a treatment, she knew it had to be cleaned. V10 said she went with what the wound doctor always orders which is cleanse, apply Silvadene, calcium alginate and cover with dry dressing. On 6/4/25 at 10:03am, V8 (RN) said that R1 had an area on his behind and when she looked at the TAR there was no treatment listed on there. V8 said she would never leave a wound without a dressing, and they had been putting Silvadene, calcium alginate and dry dressing on it. V8 said she does not remember if it was on the 24-hour report sheet or not. On 6/4/25 at 11:08am, V5 (Physician) said he thought he remembered staff calling for wound orders. V5 said he figured he would go ahead and do something until the wound physician could see R1. V5 said he thought he ordered calcium alginate with dry dressing, which is what wound care generally does. V5 said he does not remember which nurse called him. On 6/4/25 at 11:15am, V9 (RN) said she was told about R1's wound and did look at it. V9 said she put a treatment on it, cleansed, applied Silvadene, calcium alginate and a dry dressing. V9 said it was very hectic and she may have not put a note in on it. V9 said she also put in the order, she just wanted to put something on it. V9 said she didn't remember which doctor ordered it. On 6/5/25 at 11:46am, V14 (RN) stated that she worked the night of 4/26/25 after R1 had returned from the hospital earlier that day. V14 said there was no open area on R1's coccyx before he went to the hospital. V14 said she tries to do her treatments in the evenings after her medication pass, but V11 (LPN) took care of it on days so she didn't have to do it. V14 said an order will show on the TAR if she has to do one, but this happened with R1 a long time ago. V14 then said that an order did pop up for R1 to cleanse, apply Silvadene cream and apply calcium alginate and cover the wound with dry dressing. V11 said if the order was not put in, it would not show up for her to do. V14 said that usually it goes on the 24-hour shift report, but she does not remember if she put it on there or not. V14 said she also worked on 5/1/25 and she did a treatment on R1's wound but does not remember if it showed on the TAR for her to do. V14 said that R1 was able to make his needs known. V14 said she got to where she could understand R1, or he would shake his head yes or no. Facility Policy labeled Telephone Orders (undated) documents Verbal telephone orders may only be received by licensed personnel (e.g. (for example) RN, LPN, pharmacist, physician). Orders must be reduced to writing by the person receiving the order and recorded in the resident's medical record. Facility Policy labeled Medication Orders (undated) documents Treatment Orders- When recording treatment orders, specify the treatment, frequency and duration of the treatment. Facility Policy labeled Pressure Ulcers/Skin Breakdown- Clinical Protocol (undated) documents Assessment and Recognition In Addition, the nurse shall describe and document/report the following: Full Assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.

4. On 10/16/22 at 12:25 PM, V12 (Dietary) stated, we are going to have to use disposable bowls and small bowls for the desserts because we do not have enough of the regular ones. On 10/16/22 between 12:25 PM to 1:50 PM the side salad, the diced tomato salad, and the sliced cucumbers were served in disposable bowls and the pear cobbler and the sliced pears were served in disposable small bowls to R2, R3, R4, R5, R6, R7, R8, R9, R13, R14, R15, R16, R17, R19, R22, R24, R26, R27, R28, R30, R33, R34, R36, R38, R39, R40, R42, R43, R44, R45, R47, R48, R49, R50, R52, R55, R56, R58, R59, R110, and R211. On 10/16/22 at 1:10 PM, V12 (Dietary) stated, We need some disposable spoons and knives, I don't have any left for the rest of the trays and four residents were served with plastic ware before they stopped serving lunch and washed some spoons so that non disposable spoons could be used. On 10/16/22 between 1:10 PM and 1:15 PM R38, R52, R43 and R5 were given disposable spoons and knives. On 10/17/22 between 12:00 PM and 1:15 PM, the creamed corn and the tropical fruit were served in disposable bowls to R2, R3, R4, R5, R6, R7, R8, R9, R13, R14, R15, R16, R17, R19, R22, R24, R26, R27, R28, R30, R33, R34, R36, R38, R39, R40, R42, R43, R44, R45, R47, R48, R49, R50, R52, R55 ,R56 R58, R59, R110, and R211. On 10/19/22 at 1:00 PM, R38 received her whole lunch on disposable ware. On 10/19/22 at 1:45 PM, V27 (Dietary) stated, R38 was served on disposable ware due to we did not have any regular dishware left. Small disposable bowls are used for desserts due to not having enough bowls to serve with and large disposable bowls are used sometimes because we don't have enough bowls to use either. Sometimes we do run out of regular silverware and have to use disposable. On 10/17/22 at 12:30 PM, R13 was sitting at a table with two other residents that were eating, he did not have his lunch yet and was heard repeating, please come to me, at 12:50 PM R13 wanted to go back to his room and was observed waving his arm towards any staff that came by him. At 12:59 PM, R13 received his lunch, the other two residents at his table had already finished their lunch and left the table. 5. On 10/17/22 at 12:20 PM, V22 (Laundry Aide) pushed a soiled linen cart through the middle of the dining room while residents were being served their noon meal. Soiled linen was stacked up approximately three feet above the lid of the soiled linen cart and a sheet was covering it. V22 had her hand raised above her head and resting on the sheet covering the pile of soiled linen while she pushed the soiled linen cart. Residents were being served lunch at the time the soiled linen cart was being pushed through the dining room. Multiple residents were seated at tables in the dining room while the cart was pushed through the dining room and about half of the residents were eating their meal. Based on observation and interview, the facility failed to provide dining experience in a manner that maintains or enhances each resident's dignity for 41 of 41 residents (R2- R9, R13-R17, R19, R22, R24, R26-R28 ,R30, R33, R34, R36, R38-R40, R42-R45, R47-R50, R52, R55 ,R56 R58, R59, R110, R211) reviewed for dining in a sample of 55. On 10/16/2022 at 11:45am, residents were observed gathered in the dining room for the noon meal. On 10/16/2022 at 10:30am, V1 (Administrator) said the facility starts serving the residents their noon meal at 12:00pm. 1. On 10/16/2022 at 12:42pm, the first tray was observed being sent out of the kitchen to be served to a resident on the hall. R17 was quietly seated in the dining room, at the same table as R30 and R56. At 12:45, V56 received her tray while R17 and R30 remained waiting for their meal to be served. At 12:55pm, R17 began shouting I ' m hungry, can I have something to eat? and Please give me something to eat. and continued to cry out for her meal until she was served at 1:12pm. R56 was observed offering some of her food to R17 in an attempt to calm R17 down. At the table next to R17, R3 was served his meal at 12:42pm, while R45 and R59 continued to wait. At 12:59, R59 received his tray while R45 continued to wait to be served. R59 and R3 finished their meal and left the table before R45 was served at 1:10pm. While waiting R45 began to yell at staff to inquire about where his food tray was and that he had been forgotten, but staff would not stop to assist him with his question. 2. On 10/16/2022 at 1:22pm, R9 was observed wandering about the dining room in her wheelchair. R9 was observed eating food from the other resident's plates who had finished and left the dining room. V11 (Certified Nursing Assistant/CNA) also observed R9's activities. V11 was asked if R9 had been served yet and V11 did not know. V12 (Dietary Aide) said R9 had not been served yet. V12 was told about R9 eating off other residents plates due to be hungry and how much longer until R9's tray was served. V12 replied R9 does that all the time and her behavior was typical. Before being served her own meal tray, R9 was observed finishing a half eaten chicken salad sandwich which had first been served to R19. R9 had dropped a large chunk of sandwich onto the floor. R9 was observed picking the sandwich off the floor and eating it. V11 was observed watching R9 along with the surveyor. V11 was asked about R9 eating off the floor, but V11 did not attempt to stop R9 nor attempt to redirect R9 in any way. V11 would only answer (R9) had not been served her meal yet. 3. On 10/16/2022 at 1:06pm, R49 was observed sitting with two of her family members. All three were waiting to be served. R49 and her guests patiently waited to be served while all other members of the table were served, had eaten and left the table. R49 and her guests were finally served at 1:26pm.

Based on interview and record review the facility failed assistance with bathing for to 12 of 17 residents (R8, R18, R29, R31, R32, R36, R41, R49, R50, R51, R54, R57) reviewed for dependent care in a sample of 55. Findings included: On 10/17/2022 at 9:30am, V1 (Administrator) presented a facility document titled Resident Census and Condition. This document showed the facility has a census of 61 residents and of the 61 residents 59 of them require assistance of one or two staff for transferring and 42 residents require the assistance of 1 or 2 staff for personal hygiene needs. 1. On 10/18/2022, the shower schedule for the the evening shift of 10/17/2022 was reviewed with V6 (Corporate Administrator). R41, R18, R36, R50, R26, R44, R49, R7 and R8 were all scheduled to receive their showers per this schedule. V6 was asked to provide documentation of who received their scheduled shower on the evening of 10/17/2022. V6 provided a document titled Complete Care Details a summary lookback for 10/17/2022 for all units which listed the resident's who were bathed that day. This list documented 4 residents (R24 (not scheduled), R26, R44 and R7) received showers. This list showed R41, R18, R36, R50, R49 and R8 did not receive their showers as scheduled. V6 said she did not know why all the residents who were scheduled did not get showered. On 10/20/2022 at 11:00am, V32 (CNA/Certified Nursing Assistant) said she worked the evening shift on 10/17/2022 and she gave showers to R44, R24 and R26, which she documented. V32 said she was not sure if any other showers were given that evening. 2. On 10/18/2022 at 9:00am, R36 said she was scheduled to get a shower on the evening of 10/17/2022 and she wanted her shower, but no one came to give her one. R36 said she misses a lot of showers because there is not enough staff to give her one. R36 said she needs extensive assistance for all personal hygiene tasks. On 10/19/2022 at 10:00am, R36 said she still had not received a shower and it had been over a week since she was last showered. R36's medical records under MDS (Minimum Data Set) dated 9/11/2022 documents R36's BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating R36 is cognitively intact and under section G of the MDS it documented R36 needs physical help in part for bathing. 3. On 10/18/2022 at 12:15pm, R41 and R32 both alert to person, place and time were together in their room. Both said R41 was scheduled to get a shower the evening before (10/17/2022) but no one ever came and offered him to take a shower. Both said they are lucky to get even one shower a week and frequently don't get that because the facility is short of staff. R41's medical record under MDS under section G and dated 9/23/2022 documented R41 did not have the bathing activity occur or was provided by family 100 % in the previous 7 days. R32's most recent MDS documents R32 needs supervision with bathing. 4. On 10/18/2022 at 12:30pm, R57 said the facility does not have enough staff. R57 said he and others do not get showers when scheduled and they have to beg to get showered. R57 said this issue has been brought up several times in resident council meetings but nothing is ever done about it. R57's medical records under MDS section C and G and dated 10/7/2022 documented R57 has a BIMS of 14 indicating R57 is cognitively intact and requires total assistance with bathing. 5. On 10/18/2022 at 12:38pm, R54 said she does not get her scheduled showers and sometimes doesn't even get showered once per week. R54 said the facility needs more staff. R54's medical record under MDS section C and G, dated 10/05/2022 documents R54 has a BIMS of 14 indicating R54 is cognitively intact and needs physical help in part with bathing. 6. On 10/18/2022 at 12:42pm, R51 said the facility does not have enough staff to give showers and provide proper care to the residents. R51 said she does not get her scheduled showers and often does not get showered once per week. R51's medical record under MDS sections C and G and dated 10/12/2022 documented R51 has a BIMS of 15 indicating R51 is cognitively intact and requires total dependence with bathing. 7. On 10/17/2022 at 9:30am, R31 said there used to be 2 CNAs (Certified Nursing Assistants) assigned to work her hall on dayshift and on evening shift but for several weeks now there has only been one assigned. R31 stated she only gets a shower if she asks the staff for one otherwise she does not receive them. R31's medical records under tab titled MDS section C and G dated 9/16/2022 documented R31 has BIMS of 15 indicating R31 is cognitively intact and needs physical help in part with bathing. 8. On 10/17/22 at 10:33 AM, R29 stated that there is usually 2 CNAs working on her hall and lately there has only been 1 CNA working her hall. R29 stated that she needs 2 CNAs to get her out of bed. R29 stated she transfers using a patient lifting machine which takes 2 people to use and she must wait for another staff member to be found before she can be transferred or showered. R29's medical records under tab MDS sections C and G dated 8/31/2022 documented R29 has a BIMS of 15 indicating R29 is cognitively intact and needs extensive assistance of 2+ staff for transferring and is listed as total dependence of staff for bathing. On 10/18/2022 at 10:36am, V16 (Registered Nurse) said the facility is short staffed on all shifts especially CNAs (Certified Nursing Assistants). V16 said the residents in this facility are very elderly and need more assistance than a younger population would need. V16 said their skin is more fragile so staff cannot be rushed when caring for them because they can be injured more easily. On 10/18/2022 at 10:39am, V15, V17 and V18 (Certified Nursing Assistants) all said the facility is very short of staff and it is hard to complete all showers scheduled. V17 said she's worked at this facility for 2-3 years and she has always felt 3 care staff on the evening shift is not enough staff to provide all the care the residents need. V17 said it didn't used to be like that but has been for several months now. V15, V17 and V18 all said they can not complete the scheduled showers due to not having enough time or not enough staff, but they are doing the best they can.

Based on interview, observation and record review the facility failed to provide the mechanical soft diet texture as directed by the menu/recipe for 7 of 19 residents (R17, R30, R24, R45, R37, R13, and R15) reviewed for dining in a sample of 55. Findings Include: 1. The Facility document titled, Diet Spreadsheet dated week 3, Day 15 documents: Dental Soft (Mech Soft) - Ground Chicken Salad Sandwich, Cheddar Macaroni Salad - No raw Veg (vegetables), Diced Tomato Salad - No Raw Veg (d/s), and Pear Cobbler. The facility document titled, Ground Chicken Salad Sandwich documents: 4. Portion #10 dipper chicken salad on 1 sl (slice) bread. Top with 2nd slice of bread. On 10/16/22 between 12:00 PM and 2:00 PM, R17, R30, R24, R45, R37, R13, and R15 were observed with and eating the mechanical soft textured diet for lunch. On 10/16/22 between 12:00 PM and 2:00 PM, R17, R30, R24, R45, R37, R13, and R15 were observed with chicken salad sandwiches served on toast. 2. The Facility document titled, Diet Spreadsheet dated week 3, Day 16 documents: Dental Soft (Mech Soft) - Ground Hamburger on Bun, Soft baked french fries, creamed corn, and soft canned diced fruit. The facility document titled, Ground Hamburger on Bun documents: Portion #10 dip ground beef onto each bun. Top ground beef with 1-2 ounces of prepared gravy, as needed, to serve the meat moist. On 10/17/22 between 12:00 PM and 1:30 PM, R17, R30, R24, R45, R37, R13, and R15 were observed with and eating the mechanical soft textured diet for lunch. On 10/17/22 between 12:00 PM and 1:30 PM, R17, R30, R24, R45, R37, R13, and R15 were observed with ground hamburger on a bun with no gravy. On 10/17/22 at 11:23 PM, V20 (Therapy Director/ Speech Language Pathologist) stated, the residents with the mechanical soft diet should not receive their sandwiches on toast, that would be considered a regular diet food item. The directions on recipe for the item should always be followed. On 10/20/22 at 1:00 PM, V8 (Dietary Manager) stated, she did not realize the chicken salad was suppose to be served on bread and that the hamburger for the mechanical soft diet was suppose to have gravy on it. R17's Physician order sheet for 10/01/22 with a start date of 05/28/22 documents a Mechanical Soft diet. R30's Physician order sheet for 10/01/22 with a start date of 07/05/22 documents a Mechanical Soft diet. R24's Physician order sheet for 10/01/22 with a start date of 08/26/22 documents a Mechanical Soft diet. R45's Physician order sheet for 10/01/22 with a start date of 08/26/22 documents a Mechanical Soft diet. R37's Physician order sheet for 10/01/22 with a start date of 06/28/22 documents a Mechanical Soft diet. R13's Physician order sheet for 10/01/22 with a start date of 10/04/21 documents a Mechanical Soft diet. R15's Physician order sheet for 10/01/22 with a start date of 03/09/20 documents a Mechanical Soft diet.

Based on interview and record review the facility failed to have sufficient number of nursing staff to provide nursing and related services to meet the activity of daily living needs of the residents who reside there. This failure has the potential to affect all 61 resident who reside in this facility. Findings included: On 10/17/2022 at 9:30am, V1 (Administrator) presented a facility document titled Resident Census and Condition. This document showed the facility has a census of 61 residents and of the 61 residents 59 of them require assistance of one or two staff for transferring and 42 residents require the assistance of 1 or 2 staff for personal hygiene needs. On 10/17/2022 at 3:30pm, V2 (Director of Nursing) said the CNAs (Certified Nursing Assistants) typically work 8 hours shifts which include 6am to 2pm for dayshift, 2pm to 10pm for evening shift and 10pm to 6am for night shift. After reviewing the evening shift schedule for 10/17/2022, V2 verified the facility had on schedule, 3 CNAs (V17, V31 and V32) and V30 NA (Nursing Assistant). V2 said she felt that was enough staff to provide care to all the residents who resided at this facility. On 10/18/2022, the shower schedule for the the evening shift of 10/17/2022 was reviewed with V6 (Corporate Administrator). R41, R18, R36, R50, R26, R44, R49, R7 and R8 were all scheduled to receive their showers per this schedule. V6 was asked to provide documentation of who received their scheduled shower on the evening of 10/17/2022. V6 provided a document titled Complete Care Details a summary lookback for 10/17/2022 for all units which listed the resident's who were bathed that day. This list documented 4 residents (R24 (not scheduled), R26, R44 and R7) received showers. V6 said she did not know why all the residents who were scheduled did not get showered. On 10/20/2022 at 11:00am, V32 (CNA/Certified Nursing Assistant) said she worked the evening shift on 10/17/2022 and she gave showers to R44, R24 and R26, which she documented. V32 said she was not sure if any other showers were given that evening. On 10/18/2022 at 9:00am, R36 said she was scheduled to get a shower on the evening of 10/17/2022 and she wanted her shower, but no one came to give her one. R36 said she misses a lot of showers because there is not enough staff to give her one. R36 said she needs extensive assistance for all personal hygiene tasks. On 10/19/2022 at 10:00am, R36 said she still had not received a shower and it had been over a week since she was last showered. R36's medical records under MDS (Minimum Data Set) dated 9/11/2022 documents R36's BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating R36 is cognitively intact and under section G of the MDS it documented R36 needs physical help in part for bathing. On 10/18/2022 at 12:15pm, R41 and R32 both alert to person, place and time were together in their room. Both said R41 was scheduled to get a shower the evening before (10/17/2022) but no one ever came and offered him to take a shower. Both said they are lucky to get even one shower a week and frequently don't get that because the facility is short of staff. R41's medical record under MDS under section G and dated 9/23/2022 documented R41 did not have the bathing activity occur or was provided by family 100 % in the previous 7 days. R32's most recent MDS documents R32 needs supervision with bathing. On 10/18/2022 at 12:30pm, R57 said the facility does not have enough staff. R57 said he and others do not get showers when scheduled and they have to beg to get showered. R57 said this issue has been brought up several times in resident council meetings but nothing is ever done about it. R57's medical records under MDS section C and G and dated 10/7/2022 documented R57 has a BIMS of 14 indicating R57 is cognitively intact and requires total assistance with bathing. On 10/18/2022 at 12:38pm, R54 said she does not get her scheduled showers and sometimes doesn't even get showered once per week. R54 said the facility needs more staff. R54's medical record under MDS section C and G, dated 10/05/2022 documents R54 has a BIMS of 14 indicating R54 is cognitively intact and needs physical help in part with bathing. On 10/18/2022 at 12:42pm, R51 said the facility does not have enough staff to give showers and provide proper care to the residents. R51 said she does not get her scheduled showers and often does not get showered once per week. R51's medical record under MDS sections C and G and dated 10/12/2022 documented R51 has a BIMS of 15 indicating R51 is cognitively intact and requires total dependence with bathing. On 10/18/2022 at 12:48pm, R 11' s' family member said she feels the facility is short of staff and needs more. R11's family member said some times when she comes to see R11, R11 is soaked with urine and needs her whole bed changed and it takes a long time to get the call light answered. On 10/17/2022 at 9:30am, R31 said there used to be 2 CNAs (Certified Nursing Assistants) assigned to work her hall on dayshift and on evening shift but for several weeks now there has only been one assigned. R31 stated she only gets a shower if she asks the staff for one otherwise she does not receive them. R31's medical records under tab titled MDS section C and G dated 9/16/2022 documented R31 has BIMS of 15 indicating R31 is cognitively intact and needs physical help in part with bathing. On 10/17/2022 at 10:01 am, R55 who was alert to person, place and time said there used to be 2 CNAs on her hall but that has not happened for a very long time. R55 said she feels there are a lot of residents on her hall who require extensive assistance and must be transferred with the patient lifting machine, which requires at least two staff members to use. On 10/17/22 at 10:33 AM, R29 stated that there is usually 2 CNAs working on her hall and lately there has only been 1 CNA working her hall. R29 stated that she needs 2 CNAs to get her out of bed. R29 stated she transfers using a patient lifting machine which takes 2 people to use and she must wait for another staff member to be found before she can be transferred or showered. R29's medical records under tab MDS sections C and G dated 8/31/2022 documented R29 has a BIMS of 15 indicating R29 is cognitively intact and needs extensive assistance of 2+ staff for transferring and is listed as total dependence of staff for bathing. On 10/18/2022 at 10:36am, V16 (Registered Nurse) said the facility is short staffed on all shifts especially CNAs (Certified Nursing Assistants). On 10/18/2022 at 10:39am, V15, V17 and V18 (Certified Nursing Assistants) all said the facility is very short of staff. V17 said she's worked at this facility for 2-3 years and she has always felt 3 care staff on the evening shift is not enough staff to provide care. V17 said it didn't used to be like that but has been for several months now. V15, V17 and V18 all said they can not complete the scheduled showers due to not having enough time or not enough staff, but they are doing the best they can.