**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident remained free of sexual abuse. This applies to one of three residents (R5) in the sample of eight reviewed for abuse. Findings include:The facility face sheet for R5 shows diagnoses to include dementia and psychosis. The facility assessment dated [DATE] shows R5 to have severe cognitive impairment and requires maximum staff assistance with her activities of daily living, and uses a wheelchair for ambulation.The facility face sheet for R4 shows diagnoses to include Parkinson's Disease, depression and psychotic disorder. The facility assessment dated [DATE] shows R4 to be cognitively intact and requires supervision for his activities of daily living and uses a wheel chair for his ambulation. The facility state report dated 8/9/2025 shows an incident between R4 and R5 while in the dining room of the facility. A staff observed the two residents sitting closely to each other and the male residents (R4) arm was moving back and forth over the female residents (R5) lap. The staff then went and separated the residents and noticed R5's pants were unbuttoned and R4 left the area immediately after being asked what was going on. On 8/20/2025 at 11:00 AM, V4 Certified Nursing Assistant (CNA) said she was walking past the dining room and noticed R4 and R5 sitting real close to each other and R4 had his hand over R5's lap and was moving his hand back and forth. V4 said she walked into the dining room and asked R4 what he was doing. V4 said R4 backed up quickly and nearly fell out of his wheelchair and denied doing anything. V4 said she looked over at R5 and noticed her pants were unbuttoned. V4 said when she turned her attention back to R4, he was gone. V4 said she took R5 from the dining room and took her to the nurse and told them what she had seen. On 8/20/2025 at 11:10 AM, V3 Registered Nurse (RN) said V4 came to him with R5 and told him that R4 and R5 were seen sitting very close to each other and R4's hand was moving over R5's lap and R5's pants were unbuttoned. V3 said he immediately called the Administrator and the Director of Nursing and assessed R5 for any harm.On 8/20/2025 at 1:30 PM, V1 Administrator said he was notified of the incident the day it happened, and he notified the police right away. V1 said R4 was placed on a one-to-one observation and will remain on one until an alternate living arrangement can be made. The care plan for R4 dated 3/25/25 shows R4 was showing interest in a female peer and would sit outside her room and try to enter her room. Interventions were put into place. On 6/24/25 R4's care plan was updated to show the potential to be inappropriately touching another female resident. R4's care plan was updated again with new interventions put into place. (A state report dated 6/24/25 shows this was R5. An investigation was completed and could not be substantiated.)The undated facility policy for abuse prevention shows each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone including other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to perform thorough pressure ulcer assessments and initiate a baseline care plan for a resident admitted to the facility with a pressure ulcer for 1 of 1 residents (R1) reviewed for pressure ulcers in the sample of 4. Findings include: R1's Facesheet dated 4/24/25 showed she was admitted to the facility 10/28/24 with diagnoses to include, but not limited to: COVID-19, generalized muscle weakness, hypothyroidism, diabetes, gastro-espophageal reflux disease (GERD), unspecified cirrhosis of the liver, and gout. R1's Nursing admission Assessment completed dated 10/28/24 showed she had pressure to her sacrum. This document did not provide any further description or measurements of R1's pressure ulcer to her sacrum. R1's Progress Notes did not contain a detailed pressure ulcer assessment for R1's initial pressure ulcer and weekly assessment. R1's Electronic Medical Record (EMR) did not contained a thorough initial or weekly assessment of R1's pressure wound to her sacrum. R1's Skin Check Weekly dated 10/28/24 showed R1 had an open area to her sacrum, but there was no further assessment of the wound (i.e. measurements, appearance, wound bed, wound edges, drainage, etc.) R1's Physician Order Sheet dated 4/24/25 showed there was an order for a wound care consult dated 10/28/24 and orders for wound care to the scarum dated 10/28/24. R1's Skin Integrity Care Plan wasn't imitated until 11/4/24 (8 days after admission) and the related to details were not completed. This care plan showed interventions to include: Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. On 4/25/25 at 1:43 PM, V7 (Registered Nurse - RN) said the floor nurse completes an admission assessment on all new admits. V7 said the wound care process had changed about a month ago. V7 said in October 2024 the floor nurse would do an initial skin assessment and chart any findings. V7 stated, If there was a wound, then the nurse should describe it to the best of her ability. Now we don't stage pressure wounds and we have to notify the Wound Care Nurse (WCN). The WCN will complete a detailed assessment. The floor nurse should provide measurements, location of the wound, and a basic description of the wound and any drainage. (The surveyor directed V7 to review R1's admission Assessment and asked what R1's wound looked like.) There is no way to know what it looked like because it just says pressure. (The surveyor asked V7 if she saw any detailed Wound Assessment for R1's sacral pressure wound.) I don't see anything here. V7 said proper documentation of the wound assessment is an important for tracking the wounds progress and ensuring continuity of care for the R1. V7 said she is unsure who initiates the baseline care plan for residents. V7 stated, I think MDS (Minimum Data Set) does that? I really can't speak on it. I don't remember every doing that. On 4/25/25 at 2:00 PM, V4 (WCN) said she started with the facility around the third week of February 2025. V4 said she was not working at the facility when R1 was there. V4 said all new admissions should have an initial skin assessment. V4 said if it is during them week, the nurse will notify her if there is a wound and she usually does a thorough wound assessment within 24 hours. V4 said the floor nurse can provide a basic description, including the location, size, appearance of the wound and if there is any drainage. V4 said the initial wound assessment is important to track the wounds progress, determine if the treatments regimen needed to be altered, and to prevent the risk of infection. The surveyor showed V4, R1's admission assessment dated [DATE] that showed, pressure, to the sacrum and R1's Skin Assessment Weekly dated 10/28/24 that showed R1 had an open area to her sacrum. The surveyor asked V4 if R1's documentation provided the proper assessment details of a pressure wound. V4 replied, Absolutely not. The baseline assessment is very important, so everyone knows the starting point. V4 said a proper wound assessments includes: measurements; location; description of the wound bed and wound edges; staging for pressure ulcers; and a description of drainage. V4 said if R1 had a pressure wound on admission, then R1 should have had a baseline care plan initiated within 24 hours to address R1's individualized care needs. V4 said the Care plan is a tool to communicate the R1's care needs to the care team. On 4/25/25 at 2:21 PM, V2 (Director of Nursing - DON) said she did not recall R1, but she was looking through R1's record for Skin Assessments. R1 provided the Skin Assessment Weekly dated 10/28/24 (showing an open wound to R1's sacrum, but no further description of the wound). V2 said there should be a detailed initial pressure ulcer assessment and weekly pressure ulcer assessment. V2 said based the information documented, there was no way to know what R1's sacral pressure ulcer looked like. V2 said the facility does not use shower sheets and she had reviewed all the possible places the nurse should have documented a thorough wound assessment. V2 said she could not locate one. V2 said a baseline care plan should be initiated within 24-48 hours of admission. V2 said R1's admission Assessment showed she had pressure to her sacrum, so R1's care plan should have reflected there was a skin integrity concern. V2 stated, I do see a wound care consult ordered. There isn't usually a Wound Care consult unless the resident had a wound. The whole thing is very confusing. The facility's Pressure Injury Assessment and Treatment Policy dated 1/2025 showed, The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified alterations in skin integrity, pressure injuries, and the prevention of acquiring additional alterations in resident skin integrity . General Guidelines: A. The pressure injury treatment program should focus on the following strategies: a. Evaluating the resident, understanding current risk level, and/or the status of existing skin alteration and/or pressure injuries .Documentation: The following information should be recorded in the resident's electronic medical record. A. Document type of wound and location: a. Stage of the wound in pressure. b. Use anatomical location in description. B. Partial thickness or Full thickness. C. Wound measurements: a. Head to toe (Length). b. Left to right (Width). c. Depth. D. Undermining, tunneling, or sinus tract: a. Clock method (12 o'clock represents residents head, 6 o'clock represents resident's feet. E. Exudate (Drainage): a. Type. b. Color. c. Amount. d. Odor. i. Absence or presence of odor and describe the smell. F. Wound bed: a. Adherence of tissue (slough or eschar). b. Types of tissue visualized in wound bed. c. Amount of visible tissue: i. Describe in percentage amounts tissue types that make up the wound bed. ii. Can you use the clock system to describe location of varying tissue types. d. Debris or foreign bodies. G. Describe wound edges: a. Definition (defined or undefined). b. Attachment. c. Border shape. d. Maceration, epibole, fibrotic, callused etc. H. Describe Peri-Wound (Surrounding tissue). I. Describe any indications of possible infection. J. Pain: a. Causative factors. b. Duration. c. Intensity. d. Intervention for pain relief and effectiveness. K.Document interventions for healing .

Based on observation, interview, and record review the facility failed to ensure dietary staff are properly trained. This has the potential to affect all 73 residents in the facility. Findings include: Facility Data Sheet dated 4/15/25 shows the facility has a total census of 73 residents. On 4/15/25 at 12:10 PM, V1 (Interim Administrator) said the facility does not currently have any residents that receive a tube feeding or have an order of NPO (nothing by mouth). On 4/15/25 at 8:30 AM, V1 said the facility does not currently have a dietary manager and V8 (Former Dietary Manager) left approximately two to three weeks ago. On 4/15/25 at 11:00 AM, V11 (Regional Director of Operations- Kitchen) said he and his company have been overseeing the facility since July or August of 2024. V11 said the facility is responsible for hiring and training their own in-house employees including dietary aides, cooks, and a dietary manager. V11 said his company provides the facility access to a menu program that provides menus, recipes, tray tickets, policies and procedures, and education material. Since V11 has been working with the facility, V11 said there have been four dietary managers that V11 has helped train and the longest employed manager stayed for approximately two to three months. On 4/15/25 at 10:50 AM, V4 (Cook) said V8 was providing training to the newly hired employees, including V6 (Dietary Aide). V4 does not provide any training unless V4 were asked to train employees. On 4/15/25 at 12:55 PM, V3 (Assistant Administrator) said when V8 left, V1 and V3 started assuming some of V8's operational duties to ensure the kitchen was able to provide the residents with meals with no concerns. V3 said to train the newer employees, V3 is having more senior workers, like V7 (Dietary Aide) provide training to the newer employees. On 4/15/25 at 10:06 AM, V7 said she has been working at the facility for almost two years. On 4/15/25 between 9:15 AM and 9:30 AM, V7 was doing dishes at the dish machine. V7 started by handling dirty trays from breakfast with gloves on, placing the dirty plates and utensils onto a dish rack, and run the dish rack through the dish machine. When the dishes were finished being washed and sanitized, V7 removed the rack from the dish machine and continued this process until there was no more room on the out-feed table to place racks of clean and sanitized dishes. Without removing the gloves from handling the dirty dishes, V7 proceeded to empty the dish racks with clean and sanitized dishes and started to put them away. On 4/15/25 at 9:22 AM, V6 said she started working at the facility on 4/14/25. V5 (Dietary Aide) was training V6 how to clean up the beverage carts after breakfast. V5 instructed V6 to take a clear, two-inch pan full of ice and water, dump the ice and water into a nearby sink, then dip the pan into the third sink (sanitizer sink) of the three-compartment sink. V5 and V6 repeated this process for a total of four pans. None of the pans were left in the sanitizer sink for at least one minute. After the pans, V5 and V6 began emptying coffee pitchers from breakfast. V5 told V6 that the middle sink in the set-up and ready three-compartment sink was known as the dumping sink where employees discard leftover liquids from cups and pitchers before washing them. V5 asked V7 if that was correct and V7 agreed. When V5 asked V4, V4 said that the middle sink was not for dumping discarded liquids into and was for rinsing already washed dishes. On 4/15/25 at 10:50 AM, V4 said staff should wash hands when going from dirty dishes to clean dishes. Facility did not have a policy and procedure related to required dietary staff training. Facility Dish Machine Operation policy (no date) states, The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food . 7. Follow the procedure for proper preparation and loading of dishes into the dishwashing machine. The standard sequence is as follows: c. Stack dishes in racks using correct procedure for that style rack . f. Use clean, washed hands to pull out clean racks, and allow to air dry before putting dishes away for storage .

Based on observation, interview, and record review the facility failed to ensure correct food service scoops were used to serve mashed potatoes. This has the potential to affect all 73 residents in the facility. Findings include: Facility Data Sheet dated 4/15/25 shows the facility has a total census of 73 residents. On 4/15/25 at 12:10 PM, V1 (Interim Administrator) said the facility does not currently have any residents that receive a tube feeding or have an order of NPO (nothing by mouth). On 4/15/25 at 11:40 AM, V4 (Cook) said the food supplier did not bring the lunch meal on time to serve the country fried steak on Monday. V4 said for lunch on 4/15/25 they will be serving country fried steak with gravy, mashed potatoes, gravy, and a breadstick. V4 said V4 and other cooks usually get the scoops set up and ready for serving and the dietary aides will serve lunch. V4 showed this surveyor where the binder was that listed the portion and scoop sizes to use for each meal and stated that the dietary aides also know where it is and have access to it when needed. On 4/15/25 at 11:25 AM, V4 placed a green handled number 12 scoop (which provides 2 2/3 ounces) into the mashed potatoes. On 4/15/25 at 11:38 AM, V7 (Dietary Aide) started service, providing one scoop of mashed potatoes to every single plate. Facility diet spreadsheet shows the portion size for mashed potatoes is 4 ounces. On 4/15/25 at 11:47 AM, V11 (Regional Director of Operations- Kitchen) said the menus and recipes should be followed, including using the appropriate scoop listed. If the menus are followed as written, the nutritional needs of the residents should be met. Facility Standardized Recipes policy (no date) states, Standardized recipes will be used for all menu items, including pureed and therapeutic diets . 1. Each standardized recipe will include the following: . g. Serving sizes.

Based on observation, interview, and record review the facility failed to ensure employees practiced safe food handling practices resulting in risks of cross-contamination. This has the potential to affect all 73 residents in the facility. Findings include: Facility Data Sheet dated 4/15/25 shows the facility has a total census of 73 residents. On 4/15/25 at 12:10 PM, V1 (Interim Administrator) said the facility does not currently have any residents that receive a tube feeding or have an order of NPO (nothing by mouth). 1. On 4/15/25 between 9:15 AM and 9:30 AM, V7 (Dietary Aide) was continually observed doing dishes at the dish machine wearing gloves. V7 started by breaking down breakfast trays, discarding food debris and waste, and placing all trays, plate tops, cups, and utensils into dish racks. When the dish rack was full, V7 would place the dish rack into the dish machine and pull down the handle to run the automatic run cycle. When the cycle finished, V7 would pull the dish rack out of the dish machine and place the rack on the out-feed table to dry. V7 continued this process until the out-feed table became full with clean and sanitized dish racks. After handling the dirty dishes and without changing gloves or washing hands, V7 proceeded to remove the clean and sanitized dishes from the dish racks and put the clean and sanitized dishes away. On 4/15/25 at 10:50 AM, V4 (Cook) said all employees should wash hands after handling dirty dishes before touching clean and sanitized dishes. Facility Dish Machine Operation policy (no date) states, The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food . 7. Follow the procedure for proper preparation and loading of dishes into the dishwashing machine. The standard sequence is as follows: c. Stack dishes in racks using correct procedure for that style rack . f. Use clean, washed hands to pull out clean racks, and allow to air dry before putting dishes away for storage . 2. On 4/15/25 at 9:03 AM, V4 started washing pots and pans in the three-compartment sink. V4 would use the first sink to wash all items with soap and water, the second sink to rinse with plain water, and the third sink to sanitize with a pre-diluted mixture of water and sanitizer. V4 washed a total of 7 pans, placed them in the middle sink to rinse, and dipped the pans into the third sanitizing sink for less than ten seconds each before placing them to the side to air dry. On 4/15/25 at 9:22 AM, V5 (Dietary Aide) and V6 (Dietary Aide) were cleaning up the beverage carts that were sent to the units for breakfast. V5 grabbed a clear two inch pan filled with ice and water and brought it to the dish machine area to show V6 how to clean the pans. V5 dumped the ice and water into a nearby sink, then proceeded to dip the clear pans into the third, sanitizer sink and immediately pulled them out and placed them to air dry. V5 and V6 continued this process with four clear pans and some coffee pitchers. On 4/15/25 at 10:50 AM, V4 said all items placed in the sanitizer sink should remain submerged for at least one minute for them to be fully sanitized. 3. On 4/15/25 at 10:12 AM, a visibly soiled food service scoop was stored inside the bulk flour storage bin, resting inside of the flour. On 4/15/25 at 10:50 AM, V4 said scoops should not be stored inside of bins. Facility provided Utensil Storage policy (no date) states, Employees will store utensils, tableware, and equipment according to the following guidelines . 5. Cleaned and sanitized equipment and utensils should be handled in a way that protects them from contamination . 4. On 4/15/25 at 8:54 AM, there were eight serving pitchers in the reach in cooler that contained a variety of juices and lemonade that were not labeled or dated. On 4/15/25 at 9:26 AM, V5 and V6 were cleaning up the beverage carts that were sent to the units for breakfast. V5 told V6, We are supposed to label these (juice and milk pitchers). I don't know why they are not labeled. On 4/15/25 at 10:50 AM, V4 said all items in the fridge should be labeled and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure care was provided to a resident in a dignified manner for 1 of 3 residents (R3) reviewed for resident rights in the sample of 6. The findings include: On 1/8/25 at 10:12 AM, R3 was sitting up in bed. R3 said she had been on isolation for COVID. R3 said one night a CNA (Certified Nursing Assistant - V11) came in her room. R3 stated, I don't know her name, but I think [V1 - Administrator] knows it. I talked to her (V1) about it. Anyways, the CNA was changing me and I told her that I have pain in my knees and she needs turn me at pushing on my hips. She kept pushing on my legs and it hurt, so I was telling her not to touch my knees. She kept making comments that she had a headache and I was yelling. I wasn't yelling, but I was letting her know that she was hurting my legs. When she turned me, she made a comment about me being a very big girl. I know I'm overweight and I don't need to be reminded. I thought that was a rude comment. The CNA wasn't wearing a name tag, so I asked her what her name was and she told me, I don't have to tell you that. She never told me her name. I have the right to ask anyone who comes in my room to identify themselves. I just felt like she was terribly rude. The care was rushed, she wasn't listening to me, the fat comment, and then she refused to give me her name. I called the front desk and reported it to [V12 - LPN]. Then [V1 - Administrator] came to speak with me. [V1] told me that the CNA would not be coming back to the facility. R3's Face Sheet dated 1/7/25 showed she had diagnoses to include, but not limited to: polyosteoarthritis, generalized muscle weakness, COVID-19, lymphedema, history of cancer, obesity, irritable bowel syndrome, and schizoaffective disorder. R3's facility assessment dated [DATE] showed she was cognitively intact. R3's Psychiatry Initial Evaluation dated 12/3/24 showed, Resident reports being distrustful of unfamiliar staff. Recently experienced an episode of panic when evaluated by an unknown person . R3's Alteration in Pain Care Plan revised 4/17/24 showed, R3 has an alteration in comfort, pain associated with obesity, immobility, polyosteoarthritis, lymphedema and depression . Interventions: . R3 is able to: call for assistance when in pain, ask for medication, tell you how much pain she is experiencing, tell you what increase or alleviates pain . The facility's undated Investigative Summary showed on 12/29/24, R3 who is alert and oriented x 4 (to person, place, time, and situation) reported that a CNA on night shift did not speak to her respectfully. The agency CNA (V11) was not scheduled to return to the facility. According to the schedule the CNA was V11. This report showed R3 reported V11 was not wearing her name badge and refused to identify herself. R3 said V11 stated, I don't have to give you my name. R3 said V11 was very rude and made a comment about R3 being a big girl, during cares. The report showed R3 did not feel it was abuse, but it was rude and didn't want V11 provided further care for her. On 1/7/25 at 12:35 PM, V9 and V10 (CNAs) said the staff are supposed to wear their name badges at all times. V10 stated, They are part of our uniform. V9 and V10 said the agency staff rarely wear name tags. They said the facility had sticker name tags that can be filled out, when you forget your badge. They said if a resident asks your name, then you can't refuse to tell them. They said the resident's have the right to know who is providing care to them. On 1/7/25 at 3:11 PM, V3 (DON - Director of Nursing) said all staff should be wearing name badges at all times. V3 said the facility uses agency staffing for CNAs and nurses and there seems to be a problem with agency staff wearing a name badge. V3 stated, I've call [the agency] numerous times about their staff wearing name badges when working. The agency staff are always telling me they forgot it or they don't have one. It drives me nuts. We have sticker name badges at the Receptionist desk and they can write their name on it. There is no excuse to not have one. It is part of their uniform and they know it. If they don't wear a badge and a resident asks their name, then they should tell the resident their name. So the resident isn't afraid and knows that the person actually works here. This is the resident's home and they have the right to know who is providing their care. On 1/8/25 at 10:51 AM, V12 (LPN - Licensed Practical Nurse) said at the end of her shift on 12/29/24 she received a call from R3. V12 said R3 reported her CNA was very rude and mentioned something about R3's weight. The CNA (V11) said R3 was yelling at her, but R3 is usually pretty soft spoken. V12 said it was the end of the shift so, she and V11 (Agency CNA) were preparing to leave for the day. V12 said R3 reported V11 was very rude, so she notified V1 (Administrator). V12 said the agency staff rarely wear name badges. V12 said she's worked for an agency before and they provide you with a badge after you work a few shifts. V12 stated, There's no excuse for not having a name tag on. If you forget to wear yours, then we have sticker name tags at the front desk. V12 said V11 should have told R3 her name because the resident's have the right to know who is working. The surveyor asked V12 if a staff member should tell a resident they are a big girl during care. V12 replied, Absolutely not! That's rude and disrespectful. V12 said R3 is alert and oriented and able to make her needs known. V12 said the facility utilizes a lot of agency staff and it's hard to keep them straight. V12 said she isn't familiar with V11 and doesn't know how she interacts with residents. On 1/8/25 at 1:38 PM, V1 (Administrator) said on 12/29/24 was notified by V12 (LPN) that R3 complained that her CNA (V11) was rude during the night. V1 said R3 reported that V11 had been rude to her, wouldn't tell R3 her name, and commented that she was a big girl. V1 said all staff should be wearing name tags while working. V1 said there are disposable name tags available, so there is really no excuse. V1 said if a resident asks the staff's name, then they should provide it. The surveyor asked if V11 should have made the big girl comment to R3 during care. V1 replied, She absolutely shouldn't have made that comment. It's a dignity issue and no one wants to be treated that way. You should speak to others how you want to be spoke to. [V11] will not be returning to this facility. The facility's Abuse Investigation file include an email to All staff dated 1/2/25 that showed, Please remember to always wear your name tag. Remember that this is our resident's home, and we must treat them with dignity and respect. Wearing your name tag ensures that they know who is providing care for them and helps them feel safe. The facility's undated Uniforms and Name Tags policy showed, .Name tags should be worn at all times when working in the facility so that our residents and families can easily identify our staff. The facility's undated Resident Rights' Policy showed, Your rights to safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction with yourself, at their highest practical levels .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's was free of misappropriation for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. The findings include: On 1/7/25 at 10:13 AM, R2 was sitting up in bed with her cell phone resting on the overbed table, in front of her. R2 said on 12/28/24 she was taking a nap. R2 said she woke up and her cell phone was missing. R2 said she figured (V4 - Agency CNA (Certified Nursing Assistant) had it, but she wasn't sure. R2 stated, The first time she saw [V4] was 4 days before. She (V4) asked me if she could use my phone and I gave her permission that day, but she used it in front of me. Then she came back on 12/28/24 and asked me if she could use my phone. I told her no a few times. When I woke up from my nap, my cell phone was gone. I called the CNA to report my cell phone was gone and she looked all over the place. They looked and looked and couldn't find it. I told the CNA (I don't remember her name) that V4 had it. I knew she took it. The CNA told me they couldn't find [V4]. Then the nurse (V5 - RN) came in and asked me if I gave [V4-CNA] permission to take my phone and I told him I did not. At some point they called the police. I didn't want to get that girl (V4) in trouble. She seemed like she may of had something wrong with her, like bipolar or something and I didn't want her to get messed up with the law. Everyone deserves a second chance. Then [V4] came back in room and the nurse was telling her she had to leave. She was standing over here in this corner (pointed to the corner, near the window on the far side of the resident room and to the right of R2's bed). She was moving around like she was trapped or something. She insisted that she had to use my phone again to punch out. I guess she put some app (application) on there. The nurse told her she couldn't use my phone and she needed to leave, but she picked up my phone again and said she removed the app. It was a wild situation. Then the police came and checked my phone. They said it looked like she made several phone calls, but I didn't want to press charges. It wasn't right what she did, but I don't want anyone to get wrapped up with the law. The surveyor asked if R2 had any personal information on her cell phone. R2 replied, It's my daughter's old phone, so I'm not sure. I don't know what's on there. I know my daughter was worried about that. It was so wild, [V4] didn't even try to deny she took my phone without permission. It seemed like she didn't understand what she did was wrong. I feel sorry for people that have disability. I guess I'm just too trusting. I didn't know all that information can be stored in a phone. If she (V4) was such a crook, then why did they hire her? R2's Face Sheet dated 1/7/25 showed diagnoses to include, but not limited to congestive heart failure, generalized muscle weakness, major depressive disorder, chronic pain syndrome, lymphedema, COPD (Chronic Obstructive Respiratory Disease), and morbid obesity. R2's facility assessment dated [DATE] showed she was cognitively intact. R2's progress notes were reviewed and did not contain any notes regarding this incident. The facility's undated Investigation Summary showed, R2 was alert and oriented x4 (to person, place, time, and situation). This report showed that V5 (RN) reported that V4 (Agency CNA) took R2's phone (without permission) and used R2's cell phone in her car. This report showed V4 (Agency CNA) admitted she had taken the phone, but she had returned it. This report showed that V5 educated V4 (Agency CNA) that she was not allowed to take resident's belongings for any reason. This report showed V4 replied, everything is okay now. This report showed that the police were called and V4 (Agency CNA) was escorted out of the facility (and was not allowed to return to the facility). R2 reported that she awoke from a nap and noticed her cell phone was missing. R2 reported she knew V4 was working and thought V4 took her phone. The facility's Abuse Investigation file for R2 include an email to All Staff, dated 1/1/25 that stated, Under no circumstances is it allowable to use a resident's personal belongings: including but not limited to cellphones. Under no circumstances should a resident's cell phone be used by staff to make calls, access apps, or send texts for their own personal use. On 1/7/25 at 3:11 PM, V3 (DON) said she was not present the day V4 took R2's cell phone, but she received a phone call from V7 (ADON). V3 said V7 reported V4 went into R2's room, took her cell phone (without permission) and used R2's cell phone in the parking lot. V3 stated, I couldn't believe it? How did she (V4) think it was acceptable to do that? I was on the phone with [V7-ADON] and could hear the Agency CNA's (V4) crazy answers over the phone. Apparently [V4] downloaded her agency staffing app onto [R2's] phone and used the phone in her car. She (V4) didn't seem to see anything wrong with that. She (V4) only worked here one other day and that was it. I DNR'd (Do Not Return) her from the facility. The resident's cell phone is their personal property and the staff should never ask to use their phones for any reason. We have computers and phones at the facility. She shouldn't have done that. It's unacceptable. On 1/8/25 at 10:27 AM, V5 (RN) said he worked 12/28/24, when the Agency CNA (V4) took R2's cell phone. V5 stated, [R2] reported to me that she didn't give (V4) permission. When I left [R2's] room CNAs (unable to recall their names) approached me and told me the same thing. I had already been having issues with her (V4) staying in the building that shift. She kept going in and out of the facility or in the break room and I was having a hard time keeping track of her. I told her (V4) that she had to remain near her assigned unit. Then this happened. I found [V4] and asked her if she took [R2's phone] and she admitted she took the phone. I told her that she isn't allowed to do that and V4 stated, I gave the phone back, everything is okay now. I guess the resident had let (V4) use her phone once before. Then V18 (R2's family member) called the facility and she had been trying to call [R2]. V5 said V7 (ADON - Assistant Director of Nursing) was the Manager on call that weekend, so he notified her. V5 said V18 (R2's family member) was concerned that V4 accessed private information in R2's phone. V5 said at some point the police were called and V7 (ADON) told him to escort V4 out of the building. V5 said he told V4 she had to leave and she started acting squirrely, and said she had to take her work app off R2's phone. V5 said V4 went in R2's room and picked up R2's phone again. V5 said he repeatedly told V4 that she was not to touch R2's phone and the facility would take care of her punch out with the agency. V5 said R2 told him V4 did not have permission to download an app on her phone. V5 said he finally got V4 (Agency CNA) out of R2's room and walked her to the lobby, but V4 was refusing to leave and demanding to be paid on the spot. V5 said he tried to explain the process to V4, but she said he was stalking her. V5 said he explained that was not the case, but he had to ensure she left the facility. V5 said he got a phone call from at the front desk and at that point V4 (Agency CNA) took the opportunity to leave the building. V5 said V4 sat in her car, in the parking lot for a while, but left when the police came. V5 said the police met with R2 and looked at her phone. V5 stated, She (V4) really didn't think there was anything wrong with it. It was crazy. I've been a nurse for a long time and I've never seen anything like it. On 1/8/25 at 10:36 AM, V6 (Restorative Aide) said V5 (RN) asked her to go with him to escort an Agency CNA (V4) out of the building. V6 said V5 (RN) told V4 (Agency CNA) that you can't touch R2's cell phone, but she did it anyway. V6 said V4 just went by R2's bed and grabbed the cell phone. V6 said R2 didn't give V4 permission. V6 said V4 (Agency CNA) was concerned with clocking out, on the staffing app that she had downloaded on R2's phone. V6 said V5 was telling V4 that the facility would handle her clock out, but V4 wouldn't listen. V6 said V4 (Agency CNA) said to R2, You let me use it before, and R2 replied, I did then, but not today. I told you no. V6 said the facility staff should never use a resident's cell phone for personal use. V6 stated, It's a known rule that we don't use any of the resident's belongings. That belongs to the resident. I don't know how she (V4) thought it was okay. On 1/8/25 at 11:14 AM, V7 (ADON) said she was on call 12/28/24 and V5 notified her that V4 (Agency CNA) took R2's cell phone without permission. V7 said V5 told her that R2's family was upset and wanted to talk to management. V7 said V18 (R2's family member) had called R2's cell phone numerous times and R2 did not answer, but finally R2 answered her phone and told her that V4 (Agency CNA) took her phone. V7 said V18 (R2's family member) was concerned about the possibility of V4 (Agency CNA) tried to steal banking information or personal information from R2's phone. V7 said it's unacceptable for staff to take anything that belongs to the resident. V7 said V5 (RN) reported that V4 (Agency CNA) kept disappearing and was difficult to keep track of. V7 said V4 returned R2's phone and didn't seem to think she did anything wrong, then she went back and grabbed R2's phone again because she needed to clock out and delete the staffing app. V7 said V5 (RN) was able to get V4 (Agency CNA) out of R2's room, then V4 started calling the on-call phone. V7 said V4 called from a different number, so she obviously had access to a cell phone. V7 stated, [V4] kept stalling and it didn't seem right. The police told us to detain her, but we're not allowed to do that. She eventually went out to her car, but she sat out there. She didn't leave until the police came. The facility has phones and computers that she could have used. There is no reason for her to be asking a resident to use their phone. She (V4) only worked here 1 other day and didn't even make it through half of that shift. It's crazy that it happened, then she refused to leave and demanded to get paid. It's all just crazy. On 1/8/25 at 12:50 PM, V18 (R2's family member) said on 12/28/24 she attempted to call R2 10+ times. V18 said someone picked up, but would hang up the phone. V18 said she was getting concerned, then R2 finally picked up and was yelling, She stole my phone. V18 said R2 told her that V4 (Agency CNA) had asked to use R2's phone multiple times on 12/28/24, but R2 said No. V18 said R2 said she took a nap and when she woke up her phone was gone. V18 stated, That's when I called the facility. V18 said she works in the industry and knows what should be done in this time of situation. V18 said she told the facility to handle it or she would. V18 said the police checked R2's phone and told her that V4 made several phone calls and attempted to access a cash app on her phone. V18 said she has passwords protection in place, so V4 was not able to get any money. V18 said the police told her that they called the numbers V4 (Agency CNA) had called and she was asking them for money. V18 said R2 is too trusting and believes everyone deserves a second chance. V18 stated, I tried to explain to her what information is on cell phones and that she (V4) had attempted to access my money. [R2] doesn't like that V4 (Agency CNA) had to be involved with the police, but I explained that we were aware enough to stop it before she got anything, but she may get away with it for other unsuspecting, vulnerable people. On 1/8/25 at 1:38 PM, V1 (Administrator) said there was no doubt that V4 (Agency CNA) took R2's phone, used it in her care, and made personal phone calls. V1 said she had no idea why V4 downloaded her staffing app onto R2's phone. V1 stated, It's completely inappropriate. We have computers and phones at the facility. She could have borrowed a co-worker's phone. She shouldn't have used the phone PERIOD, EVER. V1 said she it's clear that R2 doesn't understand how much personal information is contained in cell phones now. V1 stated, That was the daughter's concern too. The surveyor asked if she knew V4 had attempted to access cash apps on R2's phone. V1 replied, I did not know that. In hindsight, I should have substantiated (misappropriation). The facility's Abuse, Prevention and Prohibition Policy revised 1/2024 showed, Statement of Intent: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse to anyone, including, but no limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, or legal guardians, friends, or other individuals. Policy: The facility prohibits mistreatment, neglect, or abuse of residents . The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect . Definitions: .Misappropriation of Resident Property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's urinary catheter was changed when is was dirty and clogged. The facility failed to keep the catheter drainage bag below the level of the bladder and off the bed for 2 of 3 residents (R1, R3) reviewed for catheters in the sample of 3. Findings include: 1. R1's Face Sheet dated 12/10/24 showed he was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, left hand contracture, pressure ulcer, type 2 diabetes mellitus, severe protein calorie malnutrition, hyperlipidemia, obstructive sleep apnea, spastic hemiplegia of the left side, hypertension, atrial fibrillation, aphasia, left sided hemiplegia, dysphagia, obstructive and reflux uropathy, and gastrostomy. The Physician Orders dated 12/10/24 showed, urinary catheter 16 French, 10 ml (milliliter). Change indwelling urinary catheter as needed for blockage or dislodgement. Change catheter drainage bag as needed for leaking. The Treatment Administration Records dated April 2024, May 2024, June 2024, July 2024, August 2024, September 2024, October 2024, November 2024, and December 2024 did not show that the indwelling urinary catheter was changed. The Progress Notes from 4/3/24 through 12/5/24 did not show that R1's indwelling urinary catheter was changed. R1's Care Plan dated 9/12/24 showed, R1 has a catheter: obstructive and reflux uropathy. R1 will show no signs/symptoms of urinary infection through review date. Catheter care every shift and as needed. Monitor/report to medical doctor for signs of UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urgency/frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. On 12/5/24 the Nurse's Notes for R1 showed, at the ambulance arrived at just before 1:00 AM to transport R1 to the hospital for shortness of breath and audible gurgling. At 3:23 AM, the nurse called the emergency room to check on R1's status, spoke with the ER (Emergency Room) doctor who stated R1 was being admitted for sepsis possible related to the indwelling urinary catheter. The hospital ER Nurse's Note dated 12/5/24 at 2:30 AM for R1 showed, patient came in with indwelling urinary catheter from the nursing home; tubing clogged with sediment and stained orange. The catheter tip was corroded in sediment. Indwelling urinary catheter replaced with a new catheter per ER doctor. The ER Physician's Note showed, ED (Emergency Department) Course as of 12/5/24 6:03 AM: 2:52 AM - Indwelling catheter tubing appears to have a lot of sediment and no active drainage upon arrival to the emergency room. After removal of the indwelling urinary catheter, patient had a large amount of bloody urine draining spontaneously, followed by several blood clots, new catheter was placed and patient continued to drain another 400 cc of cloudy fluid, followed by milky thick urine. Gross hematuria spontaneously improved. At 3:23 AM - I spoke with the nursing home nurse .who reports she noticed the patient having trouble breathing and gurgling respirations around midnight Unknown when last catheter was changed. On 12/10/24 at 1:00 PM, V2 DON (Director of Nursing) reviewed R1's ER Nurse's Note and stated she was not aware of any problem with R1's catheter. V2 stated if the catheter tubing was leaking or looked old, had built up secretions, or wasn't draining properly the catheter should have been changed. V2 stated staff should be monitoring the catheter and if it looks bad it should be changed. V2 stated it was not typical to not change a catheter in an 8-month time. V2 stated when a catheter is changed it should be documented on the TAR (Treatment Administration Record). On 12/10/24 at 1:46 PM, V7 RN (Registered Nurse) stated she charts by exception. V7 stated when assessing a catheter, she starts distally to see where the drainage bag is placed; it should be off the floor. V7 stated she looks at the out put of urine as well as the color and consistency of the urine. V7 stated she looks at the insertion site to see if there is any drainage or leaking. V7 stated she changes a catheter if she notices the urine is cloudy, if there is any blood present or if the resident has pain. V7 stated she documents any placement of a catheter or catheter change in the progress notes. V7 stated as far as she new a resident should have catheter changes every 4 or 6 weeks or a rationale as to why the catheter should not be changed. V7 stated not changing a catheter for a long period of time would not be best practice. V7 stated the facility has admission orders; at that time the parameters for catheters and when they are changed should be entered. On 12/10/24 at 5:18 PM, V6 RN stated R1 was her patient in the ER. V6 stated R1 had a catheter in place that looked horrible. The tubing was stained orange. V6 stated she had never seen anything like it. V6 stated the catheter was clogged and not draining so they removed the catheter. The catheter tip appeared corroded and there was blood present. V6 stated R1's urine had a foul odor. V6 stated when they placed the new catheter there wasn't any blood in the drainage bag but there was pus, and the urine was cloudy. V6 stated R1 had a urinary tract infection. V6 stated the ER physician called the nursing home, spoke with the nurse and she did not know when the last time R1's catheter had been changed. The facility's Infection Prevention and Control Manual Resident care - Prevention of Catheter-Associated Urinary Tract Infections policy (2019) showed changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. If an obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. 2. The Face Sheet dated 12/10/24 for R3 showed diagnoses including chronic obstructive pulmonary disease, retention of urine, chronic respiratory failure with hypoxia, obstructive and reflux uropathy, venous insufficiency, congestive heart failure, peripheral vascular disease, type 2 diabetes mellitua, asthma, obstructive sleep apnea, hypertension, hyperlipidemia, neuropathy, edema, and atrial fibrillation. The Care Plan dated 11/29/24 for R3 showed, R3 has a catheter due to obstructive uropathy. R3 will show no signs/symptoms of urinary infection through the next review date. Catheter care every shift and as needed. Position catheter bag and tubing below the level of the bladder and away from the entrance room door. Monitor/report to medical doctor for signs of UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urgency/frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. On 12/10/24 at 11:32 AM, V5 CNA (Certified Nursing Assistant) and V4 CNA were at R3's bedside to provide bowel incontinence care and catheter care. V4 and V5 had gowns and gloves on. R3 was laying in bed on her back with her catheter drainage bag in a bag holder on the lower side of the bed. R3's catheter tubing showed cloudy urine with sediment present. V4 used disposable wipes to clean the stool off from R3's groin and vagina. V4 changed her gloves, used a disposable wipe and cleaned the catheter tubing from the urinary meatus and away from the resident. V5 took the drainage bag and handed across the bed, holding it at her chest level and above the resident's bladder when giving the drainage bag to V4. R3 stated, keep the bag down otherwise the urine is going to go back down the tube, and I will get an infection. It also hurts when it (urine) goes backwards. V4 and V5 nodded yes and then stated R3 was a retired nurse. R3 was turned onto her side and V4 cleaned her buttocks with disposable wipes. V4 picked the drainage bag up and sat it on the end of the bed. V5 picked the drainage bag up from the bed and placed it on the lower side of the bed. V5 picked the drainage bag up and emptied 2300 ml of urine from the bag. V4 and V5 stated the drainage bag should not be above the resident's bladder because urine can flow back and cause an infection. V4 and V5 stated the drainage bag should not go on the bed for infection reasons. On 12/10/24 V2 DON (Director of Nursing) stated the drainage bag should always be kept below the level of the bladder. V2 stated the drainage bag should not be on the bed due to infection control. The facility's Infection Prevention and Control Manual Resident care - Prevention of Catheter-Associated Urinary Tract Infections policy (2019) showed, keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an alleged physical abuse was immediately reported to the administrator for 1 of 4 residents (R1) reviewed for allegations of abuse in the sample of 4. Findings include: R1's Face Sheet shows that he was admitted to the facility on [DATE]. On 7/18/24 at 1:03 PM, V13 (R1's Family Member) said that about a month ago, R1 called her and said that he fell out of his wheelchair and a (specific race) male Certified Nursing Assistant (CNA) came into his room and reprimanded him and picked him up and pushed him against the wall and he fell again. V13 said that she went to the facility and spoke with the head nurse about the situation. V13 said, I told her exactly what I just told you. V13 said that V2 (Director of Nursing) left the room and came back about 15 minutes later and said that it did not happen. On 7/18/24 at 11:30 AM, R3 (who resides in the room next to R1) said that he heard R1 complaining about V7 (CNA) on 7/4/24. R3 said that he heard R1 yelling don't hit me, don't push me when V7 was in his room. On 7/18/24 at 9:21 AM, V5 (CNA) said that V7 (CNA) came to her about a week ago (verified it was 7/10/24) and asked her to go into the room with him to provide care to R1. V5 said that when she was in the room, R1 stated to her that V7 was evil and had pushed him. On 7/18/24 at 11:13 AM, V7 (CNA) said that on 7/4/24 around 3-4:00 PM, he went into R1's room because he noticed that his legs were hanging off of the bed. V7 said that he fixed his legs and R1 said to him that he hit him. V7 said that he told R1 that he did not hit him and went and told the nurse what had happened. V7 said that the nurse told him to not listen to R1 and to just leave him alone. V7 said that after that incident, he made sure that there was another staff member in the room with him when he went to provide care to R1. On 7/18/24 at 1:35 PM, V14 (Assistant Administrator) said that around 7/4/24, he and V2 (Director of Nursing) went into R1's room and spoke with R1 and V13 (R1's Family Member) about a fall incident. V14 said that initially, R1 told them that he was pushed into the wall by the CNA and fell. V14 said that in the same conversation, V13 said that she doubted that that happened. On 7/18/24 at 2:18 PM, V1 (Administrator) said that she is the abuse coordinator. V1 said that all allegations of abuse should be reported to her immediately even if the staff feel that they are not true. V1 said that if a resident says that a staff member pushed them and they fell, that would be an allegation of physical abuse and should be reported to me immediately and investigated. V1 said that she did hear from V2 and V14 about the fall incident on 7/4/24 but they never told her that R1 was alleging that a staff member pushed him and he fell. The facility's Abuse Prevention and Prohibition Policy revised on 1/24 shows, Resident abuse must be reported immediately to the Administrator. The facility administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action.

Based on observation, interview and record review the facility failed to ensure the prescribed treatment was applied to a resident with Moisture Associated Skin Damage. This applies to 1 of 18 residents (R13) reviewed for quality of care in the sample of 18. Findings include: R13's Physician Order Summary (P.O.S.) dated June 2024 shows orders wound care: left and right gluteal: cleanse with wound cleanser, gently pat dry. Apply collagen to wound bed, cover with large calcium sheet to cover wound areas not covering anus. R13's Wound Evaluation Non-Pressure Evaluation Report dated 5/27/24 documents right buttock wound Moisture Associated Skin Damage (MASD), bloody drainage, measuring 6.3 cm (centimeters) x 7.6 cm x 01.cm. Description of peri wound bed: macerated, reddened and denuded. R13's Wound Evaluation Non-Pressure Evaluation Report dated 5/27/24 documents left buttock wound MASD, bloody drainage, measuring 5.9 cm x 6.2cm x 0.1 cm. Description of peri wound: macerated, reddened and denuded. On 6/3/24 at 10:41 AM, V5 and V6 (Both Certified Nursing Assistant's-CNA's) provided incontinence care to R13. R13's bottom was red and excoriated. The top of his buttock fold was red and bleeding. Two large dressings were in place to both buttocks. R13 said it hurts my bottom, V5 replied, sorry it's raw and bleeding. At 11:03 AM, V4 (Wound Nurse) came into the room to provide wound care. V4 removed the old dressings, his bottom was excoriated with bleeding, several clusters of open areas were reddened on both side of his buttocks. V4 applied cream and did not apply a dressing. V4 said he applied remedy cream to R13's wound and did not have the calcium alginate dressing.

Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with a history of pressure injuries for 1 of 4 residents (R75) reviewed for pressure in the sample of 18. Findings include: On 06/03/24 at 09:52 AM, R75 was in bed on his back with his heels flat on the bed. R75's feet were up against the foot board with a pillow in between his feet and the foot board. On 6/4/24 at 12:50 PM, R75 was in bed on his back with his heels flat on the mattress. There were no heel boots observed. On 06/04/24 at 12:52 PM, V4 Wound Licensed Practical Nurse said R75 was admitted with a pressure injury to the arch of his foot and one on his heel that have since been resolved. V4 said the interventions for R75 are to float heel/feet of the bed with off loading boots when in bed. V4 said R75 sometimes doesn't like the boots due to being too hot, so then pillows should be used to keep heels off the bed. The pillows should keep the heels off the bed, so the heels aren't touching the mattress. Heels should not be up against foot board even if pillow in between, because it still is creating pressure. R75's Care Plan dated 4/3/24 shows R75 has actual skin impairment to skin integrity. Float heels while in bed as tolerated. Heel protectors on when in bed. The facility's Pressure Ulcer/Pressure Injury Prevention Policy dated 3/2022 shows A pressure ulcer/injury can occur wherever pressure has impaired circulation to the tissue a facility must: implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess and implement interventions for a resident with contractures for 1 of 7 residents (R75) reviewed for range of motion in the sample of 18. Findings include: On 06/03/24 at 9:51 AM, R75 was in bed with his left arm and hand flat on the bed. R75's left arm/hand was slightly edematous. R75's fingers on his left hand were curled under towards the palms of his hand. R75 shook his head no when asked if he could move his left hand. On 6/4/24 at 10:29 AM, V12 Restorative Certified Nursing Assistant said she was not doing restorative therapy for R75's contracture. On 6/4/24 at 11:00 AM, V13 Regional Registered Nurse said there is no restorative program for R75. R75 has a contraction to his left fingers at the first joint. V13 said she just went and looked at R75's left hand and saw some swelling so she elevated the hand and put rag between his fingers and his palm. V13 said R75 had therapy when he first admitted , but is not on physical therapy now. V13 said she will look for the initial admission assessment of R75's left hand contracture. R75's most recent Care Plan shows R75 was admitted on [DATE] with diagnoses of spastic hemiplegia affecting left side and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. This same care plan does not show R75 has a contracture to the left hand or interventions for the contracture. On 6/04/24 at 1:00 PM, V13 said there was no assessment of R75's left hand contracture done on admission. V13 said Occupational Therapy didn't see R75 so there is no evaluation on his left hand contracture. There is no restorative recommendations due to not being seen by occupational therapy. V13 said there should be interventions in place in order to prevent the contracture from getting worse. The facility's undated Restorative Nursing Policy and Procedure shows It is the policy of this facility to provide restorative nursing, which promotes the resident's ability to adapt and adjust to living as independently and safely as possible. Restorative nursing focuses on achieving and/or maintaining optimal physical, mental, and psychological function of the resident.

Based on observation, interview, and record review the facility failed to ensure a urinary catheter urine collection bag was positioned off the floor to prevent cross-contamination for 1 of 10 residents (R24) reviewed for urinary catheters in the sample of 18. Findings include: On 6/3/24 at 9:25 AM, R24's urinary catheter bag was full with urine and was resting on the floor under R24's bed. On 6/3/24 at 12:28 PM, R24's urinary catheter bag (still full of urine) was resting on floor. R24 stated they just came in here and put the catheter bag in a privacy bag. On 6/4/24 9:35 AM, R24's urinary catheter bag was resting on floor. On 6/4/24 at 12:52 PM, V11 Licensed Practical Nurse said urinary catheter bags should be placed below the level of the bladder and not on floor. V11 said the urinary catheter bag should not be touching a contaminated surface (the floor) for infection control. R24's Physician Order shows (Urinary) catheter 18 french 30 ml (milliliter) balloon for obstructive and reflux uropathy. The facility's Catheter Care Policy dated January 2017 shows be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and record review the facility failed to ensure R75's enteral nutrition bag was labeled for 1 of 4 residents (R75) reviewed for enteral feedings in the sample of 18. Findings include: On 6/3/24 at 9:49 AM, R75's feeding pump was running at 70 ml (millilters)/hr (hour). The enteral feeding bag was labeled with R75's name and a date of 5/31/24. The enteral feeding bag did not contain the name of the contents of the bag or when the feeding was started. R75's Physician Orders dated June 2024 shows Administer Isosource 1.5 via G-tube at 70 cc (cubic centimeters)/hr. On at 1300 (1:00 PM) off at 0900 (9:00 AM). Total volume to be infused 1400 ml in 24 hours. May turn off for short periods of time for care and services. Verify total volume infused prior to turning off. On 6/4/24 at 1:05 PM, V15 Nursing Supervisor said R75 gets Iso-source 1.5 from 1:00 PM to 9:00 AM. V4 stated We pour Iso-source cans into feeding tube bag and then we label the bag with residents name, date of birth , order- Iso Source 1.5, total to infuse, and date and time hung. If the bag is not labeled, you wouldn't be able to know what it was and verify it with the order in computer. The facility's Enteral Tube Feeding via Gravity Bag dated 1/2022 shows Check the enteral nutrition label against the order before administration. Add the following information: resident name, type of formula, date and time formula was prepared, and rate of administration. On the formula label document initials, and date and time the formula was hung.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for three of 18 residents (R70, R28, R30) reviewed for medications in the sample of 18. Findings include: 1. R70's admission Record dated June 5, 2024 shows he was admitted to the facility on [DATE] with diagnoses including duodenal ulcer, congestive heart failure, chronic kidney disease, alcoholic cirrhosis of liver, nausea with vomiting, alcohol abuse, major depressive disorder, anxiety disorder, gastro-esophageal reflux disease, and acute respiratory failure with hypoxia. On June 4, 2024 at 10:15 AM, during resident council meeting, R70 said last Saturday (June 1, 2024) he did not receive his morning medications until about 1:00 PM. R70 said it was a nurse from an agency. R70 said he takes depression medications, anxiety medications, and medicine to keep his ammonia levels down. R70 said if he does not get the medication to keep his ammonia levels down, then he passes out. R70 said he was frustrated and worried about not getting his medications on time since he has passed out before. R70's Medication Administration Report shows that on June 1, 2024 R28 received his 8:00 AM and 9:00 AM medications at 1:11 PM and 1:12 PM. This same report shows that R70 should receive rifaximin (antibiotic) two times daily for metabolic encephalopathy at 9:00 AM and 5:00 PM, lactulose (osmotic laxative) two times a day related to alcoholic cirrhosis of liver-titrate for bowel movement 3-4 times per day at 9:00 AM and 5:00 PM, and coreg two times a day for high blood pressure at 9:00 AM and 5:00 PM. 2. R28's admission Record dated June 5, 2024 shows she was admitted to the facility on [DATE] with diagnoses including osteoarthritis, major depressive disorder, personal history of traumatic fracture, anxiety disorder, high blood pressure, convulsions, and cerebral infarction. On June 4, 2024 at 10:15 AM, during resident council meeting, R28 said she received her morning medications late last Saturday (June 1, 2024). R28's Medication Admin Audit Report dated June 4, 2024 shows she receives dilantin every morning and at bedtime for convulsions at 9:00 AM and 9:00 PM. R28 received her morning dose at 11:56 AM. R28 should receive keppra two times daily related to convulsions at 9:00 AM and 5:00 PM. R28 received her keppra at 11:56 AM. 3. R30's admission Record dated June 5, 2024 shows he was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, major depressive disorder, hearing loss, osteoarthritis, and psychotic disorder with hallucinations. On June 4, 2024 at 10:15 AM, during resident council meeting, R30 nodded his head yes when he was asked if he received his medications late on the past Saturday. R30 is non verbal. R30's Medication Administration Record dated June 1, 2024-June 30, 2024 shows R30 receives Rytary (Antiparkinson) extended release (carbidopa-levodopa extended release) three capsules at 7:00 AM, two capsules at 10:30 AM, 2:00 PM, and 5:30 PM, and one capsule at 9:00 PM. R30's Medication Admin Audit Report dated June 4, 2024 shows he received rytary two capsules at 12:30 PM (scheduled at 10:30 AM), 3:10 PM (scheduled at 2:00 PM), and 4:37 PM (scheduled at 5:30 PM). On June 5, 2024 at 11:18 AM, V1 Administrator said she wasn't aware that medications were given late on Saturday (June 1, 2024) until she came in on the following Monday and saw a grievance form in her box from a resident that said his medications were given late. V1 said the nurse that gave the medications late will no longer be returning to the facility. The facility's Administration of Medications policy revised on April 2021 shows, Immediately after a drug is ingested, it should be recorded on the MAR (Medication Administration Record). The facility shall check the Physician's Order sheet and MAR against the current physician's orders to assure proper administration of medications to each resident. On June 5, 2024 at 12:30 PM, V2 DON (Director of Nursing) said the facility does not have a policy in regards to significant medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure staff donned all applicable Personal Protective Equipment while providing direct care to a resident with Enhanced Barrier Precautions. This applies to 1 of 18 residents (R13) reviewed for infection control in the sample of 18. The findings include: R13's Physician Order sheets dated June 2024 shows R13's diagnoses including obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, peripheral vascular disease and complete traumatic amputation at level between knee and ankle left and right lower leg. R13's Physician's Order Sheet (POS) shows orders for enhanced barrier precautions related to urinary catheter and wound care every shift wear gloves and gown when providing high contact care. On 6/3/24 at 10:41 AM a sign was posted outside of R13's door. Enhanced Barrier Precautions. V5 and V6 (Both Certified Nursing Assistant's-CNA) donned gloves and did not wear a gown, they transferred R13 from his wheelchair to his bed, emptied R13's urinary catheter and provided incontinence care to R13. R13's bottom had several open wounds. On 6/4/24 at 10:24 AM, V7 (CNA) said staff should wear gown and gloves when providing direct care to residents who are on enhanced barrier precautions. The facility's Infection Prevention and Control [NAME] Enhanced Barrier Precautions undated Policy states, Enhanced Barrier Precautions are infection control intervention designed to reduce transmission of multidrug-resistant (MDROs) in nursing home .Enhanced Barrier Precautions are recommended for residents with any of the following .a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices include central venous catheters, urinary catheters, feeding tubes .high contact resident care activities where a gown and gloves should be used include: transferring residents from one position to another, changing briefs or assisting with toileting, caring for or using an indwelling medical device, performing wound care.

Based on observation, interview, and record review the facility failed to ensure residents oxygen equipment was changed and labeled for 4 of 9 residents (R4, R14, R24, R34) reviewed for oxygen use in the sample of 18. Findings include: 1. On 6/3/24 at 9:59 AM, R4's oxygen tubing and humidification water bottle, connected to the oxygen concentrater were not dated. On 6/3/24 at 10:16 AM, R4 was up in her wheelchair with a portable oxygen tank. R14 was wearing a nasal canula tubing which was undated. R4's June Physician orders shows Oxygen Tubing - Change Weekly every night shift every Sunday for infection control and Oxygen at 2 L/min via nasal canula, PRN. Maintain saturation >90% as needed for Anxiety and congestive heart failure. On 6/4/24 at 12:52 PM, V11 Licensed Practical Nurse said oxygen tubing is changed every Sunday on night shift, both the tubing and the bubbler, for infection control. V11 said the tubing and bubbler should be labeled and dated to show when they were changed. 2. On 6/3/24 at 9:19 AM, R14 was in bed with a nasal canula on. R14's oxygen tubing was not dated and R14's humidification water bottle was dated 5/17/24. R14's June Physician Orders does not contain any orders to change oxygen tubing/water bottle. 3. On 6/3/24 at 9:28 AM, R24 was in bed, with oxygen on via nasal canula. R24's tubing was not dated. R24's Physician Orders dated 5/4/24 shows Oxygen Tubing - Change Weekly every night shift every Sun. 4. On 6/3/24 at 10:20 AM, R34 was in bed with oxygen on via nasal canula. R34's oxygen tubing was not dated. R34's Physician Orders dated 5/19/24 shows Oxygen Tubing - Change Weekly every night shift every Sun. The facility's Oxygen Administration Policy dated January 2017 does not address oxygen tubing or humidification water bottle changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility to administer medications at the prescribed time. This applies to 4 of 18 residents (R47, R70, R28, R30) in sample of 18 reviewed for medication administration. The findings include: 1. On 6/3/2024 at 10:52AM, R47 said there was a nurse call in on Saturday (6/1/2024) and her medications were given late. R47 said her morning medications are normally given around 9:00AM, but on Saturday were given between 2:00PM - 2:30PM. R47 is alert and oriented. On 6/5/2024 at 9:52AM, V9 Staffing Coordinator said there was a nurse call in on Saturday 6/1/2024 for the morning shift. On 6/4/2024 at 1:20PM, V2 Director of Nursing (DON) said medications should be given one hour before or after the scheduled time. R47's Medication Administration (Admin) Audit Report dated 6/1/2024 shows an order for Metoprolol Tartrate Oral Tablet (Antihypertensive) 25 milligrams (mg) give 1 tablet by mouth two times a day. Scheduled date/time was 6/1/2024 at 9:00AM, administered date/time was 6/1/2024 at 2:31PM. R47's Medication Admin Audit Report dated 6/1/2024 shows an order for Gabapentin (Anticonvulsant) Oral Capsule 100mg give 2 capsules by mouth three times a day. Scheduled date/time was 6/1/2024 at 9:00AM, administered date/time was 6/1/2/2024 at 2:31PM. R47's Medication Admin Audit Report dated 6/1/2024 shows an order for DULoxetine HCL (Hydrochloride) (Antidepressant) Oral Capsule Delayed Release Particles 20mg give 1 capsule by mouth two times a day. Scheduled date/time was 6/1/2024 at 9:00AM, administered date/time was 6/1/2024 at 2:31PM. R47's Medication Admin Audit Report dated 6/1/2024 shows an order for Bumetanide (Diuretic) Tablet 1mg give 1 tablet by mouth two times a day. Scheduled date/time was 6/1/2024 at 9:00AM, administered date/time was 6/1/2024 at 2:31PM. The facilities Medication Pass Tips policy dated May 2019, states . Administer each medication as instructed on the eMAR and within the time-frame established by the facility. The medication pass should be completed within the 2 hour time frame: 1 hour before or 1 hour after the ordered time. 2. R70's admission Record dated June 5, 2024 shows he was admitted to the facility on [DATE] with diagnoses including duodenal ulcer, congestive heart failure, chronic kidney disease, alcoholic cirrhosis of liver, nausea with vomiting, alcohol abuse, major depressive disorder, anxiety disorder, gastro-esophageal reflux disease, and acute respiratory failure with hypoxia. On June 4, 2024 at 10:15 AM, during resident council meeting, R70 said last Saturday (June 1, 2024) he did not receive his morning medications until about 1:00 PM. R70 said it was a nurse from an agency. R70 said he takes depression medications, anxiety medications, and medicine to keep his ammonia levels down. R70 said if he does not get the medication to keep his ammonia levels down, then he passes out. R70 said he was frustrated and worried about not getting his medications on time since he has passed out before. R70's Medication Administration Report shows that on June 1, 2024 R28 received his 8:00 AM and 9:00 AM medications at 1:11 PM and 1:12 PM. This same report shows that R70 should receive pantoprazole (Anti-reflux daily related to gastro-esophageal reflux disease at 8:00 AM, rifaximin (Antibiotic) two times daily for metabolic encephalopathy at 9:00 AM and 5:00 PM, lactulose (osmotic laxative) two times a day related to alcoholic cirrhosis of liver-titrate for bowel movement 3-4 times per day at 9:00 AM and 5:00 PM, and coreg (beta-blocker heart medication) two times a day for high blood pressure at 9:00 AM and 5:00 PM. On June 5, 2024 at 11:18 AM, V1 Administrator said she wasn't aware that medications were given late on Saturday (June 1, 2024) until she came in on the following Monday and saw a grievance form in her box from a resident that said his medications were given late. V1 said the nurse that gave the medications late will no longer be returning to the facility. 3. R28's admission Record dated June 5, 2024 shows she was admitted to the facility on [DATE] with diagnoses including osteoarthritis, major depressive disorder, personal history of traumatic fracture, anxiety disorder, high blood pressure, convulsions, and cerebral infarction. On June 4, 2024 at 10:15 AM, during resident council meeting, R28 said she received her morning medications late last Saturday (June 1, 2024). R28's Medication Admin Audit Report dated June 4, 2024 shows she receives tizanidine three times per day for muscle relaxer at 9:00 AM, 1:00 PM, and 8:00 PM. On June 1, 2024, R28 received this medication at 11:56 AM, 2:52 PM, and 8:37 PM. R28 should receive dilantin every morning and at bedtime for convulsions at 9:00 AM and 9:00 PM. R28 received her morning dose at 11:56 AM. R28 should receive keppra two times daily related to convulsions at 9:00 AM and 5:00 PM. R28 received her keppra at 11:56 AM. 4. R30's admission Record dated June 5, 2024 shows he was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, major depressive disorder, hearing loss, osteoarthritis, and psychotic disorder with hallucinations. On June 4, 2024 at 10:15 AM, during resident council meeting, R30 nodded his head yes when he was asked if he received his medications late on the past Saturday. R30 is non verbal. R30's Medication Administration Record dated June 1, 2024-June 30, 2024 shows R30 receives Rytary (Antiparkinsons) extended release (carbidopa-levodopa extended release) three capsules at 7:00 AM, two capsules at 10:30 AM, 2:00 PM, and 5:30 PM, and one capsule at 9:00 PM. R30's Medication Admin Audit Report dated June 4, 2024 shows he received rytary two capsules at 12:30 PM (scheduled at 10:30 AM), 3:10 PM (scheduled at 2:00 PM), and 4:37 PM (scheduled at 5:30 PM). The facility's Administration of Medications policy revised on April 2021 shows, Immediately after a drug is ingested, it should be recorded on the MAR (Medication Administration Record). The facility shall check the Physician's Order sheet and MAR against the current physician's orders to assure proper administration of medications to each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare and serve food to meet residents' needs for four of 18 residents (R28, R29, R3, R8) reviewed for food in the sample of 18. 1. R28's admission Record dated June 5, 2024 shows she was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to embolism of unspecified cerebral artery. R28's Order Summary Report dated June 5, 2024 shows an order for regular texture diet, no cranberry juice, and no green leafy vegetables. R28's order summary report shows that R28 is on coumadin (blood thinner). On June 4, 2024 at 10:15 AM, during resident council meeting, R28 said that she is not supposed to eat green leafy vegetables because she is on coumadin. R28 said the green leafy vegetables thickens her blood. R28 said she gets green leafy vegetables frequently. R28 said she got spinach on her lunch tray on June 3, 2024. R28 said she did not receive any other vegetable as an alternative to the spinach. The facilities Diet Guide sheet shows that sauteed spinach with garlic was served for the lunch meal. On June 3, 2024 the facility served spinach and broccoli as vegetable options for the lunch meal. There were no other vegetable options served off of the steam table. On June 5, 2024 at 11:37 AM, V21 District Manager/Certified Dietary Manager said residents on coumadin should receive carrots as an alternate for the vegetable option. V21 said he did know why R28 received spinach. R28's Activity Log Report dated May 22, 2024 shows, NO SPINACH, NO LEAFY GREENS, NO GRAVY. 2. The facility's Diet Type Report dated June 5, 2024 shows that R29, R3, and R8 receive puree diets. On June 4, 2024 at 12:45 PM, a test tray was sampled. The barbeque hamburger was not a smooth consistency, free of small chunks, and required some chewing. At 1:00 PM, V21 sampled the same pureed barbeque hamburger and said the puree had little bumps and was a little gritty. V21 said the meat should be a smooth consistency. The facility's Menus policy revised September 2017 shows, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guideline. The facility's Food: Quality and Palatability policy revised February 2023 shows, Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. The facility's Pureed Diet and Nutrition Care Manual dated 2021 shows, All foods must be the consistency of moist mashed potatoes or pudding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident rooms were maintained in a homelike environment for 2 of 17 residents (R28 and R48) reviewed for homelike environment in the sample of 17. The findings include: On 07/17/23 at 11:12AM, R28's and R48's rooms had loose wallpaper on the wall. The baseboard was loose. The back of the wallpaper had a black substance. The wall under the wallpaper was broken and uneven. There was a dark brown stain at the base of wall and on the floor. On 07/17/23 at 11:12AM, R28 said, look behind the door. They have a shower on the other side of the wall next to my room. I hear things about black mold. I think they could do something about the condition of the wall. It looks bad to me, there is obviously a water leak. Do you see the baseboard, it is swelling up under my closet. Is that from black mold? On 07/17/23 at 1:39PM, R48 said, the wall in my room has been that way since August of 2022 when I was admitted to the facility. On 07/19/23 at 11:52AM, V1 (Administrator) said, I do not have a written maintenance policy related to this issue. R28's Minimum Data Set, dated [DATE] shows, Brief Interview for Mental Status 15 Mentally Intact. R48's Minimum Data Set, dated [DATE] shows, Brief Interview for Mental Status 15 Mentally Intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On [DATE] at 9:17 AM, and again on [DATE] at 8:40 AM, the following medications were sitting on R7's bedside table and nightstand: artificial tear eye drops, redness relief eye drops, a nasal spray, and throat spray. On [DATE] at 8:03 AM, V18 (Licensed Practical Nurse) said she was not aware of residents on the hallway where R7's room is that are allowed to self-administer medications. V18 said all residents' medications should be given or supervised by nursing and not left in a resident room. R7's Physicians Order Report shows she has orders for artificial tears to be given daily as needed and for fluticasone nasal spray also to be given every 12 hours as needed. That same order summary does not show an order for R7 to be able to self-administer her medications. On [DATE] at 8:05 AM, V2 (DON) said the medications left in R7's should not have been left, they should be kept in the medication cart, and she should be observed while using those. She also said R7 did not pass the medication self-administration assessment that was performed on her on [DATE]. V2 said R7 was not able to put in the eye drops and did not know her medications. Based on observation interview and record review the facility failed to administer prescribed medications and failed to ensure medications were not left at bedside to 2 of 5 residents (R7, R116) in the sample of 17. 1. R116's Physician Order Sheet dated 7/2023 show R116 has an order of Sodium Bicarbonate Oral Tablet 650 mg (milligrams) BID (two times per day) for gastroesophageal reflux disease. On [DATE] at 8:30 AM, R116 was sitting in his room, R116 said he does not get all his medications and his daughter was handling this. On [DATE] at 1:17 PM, V7 (R116's daughter) said R116 was admitted to the facility with orders of Sodium Bicarbonate. V7 said R116 has been on this medication for a long time. V7 said R116 did not get this medication for at least two days. R116's progress notes dated [DATE] timed at 11:26 PM show, Sodium Bicarbonate is not available in the facility. Spoke with NP (Nursed Practitioner) . if there is an alternative medication that we can give, she said to call pharmacy. Pharmacy is closed and available for urgent matters. Will endorse to the next shift. R116's progress notes dated [DATE] timed at 1837 (6:37 PM) Sodium Bicarbonate Oral Tablet 650 mg. Give 650 mg by mouth two times a day for antacid not available. This nurse notified our in-house supplier to order more of this supplement ASAP. On [DATE] at 10:45 AM, V2 (Director of Nursing/DON) said the facility supply of Sodium Bicarbonate was expired. All prescribed medications should be administered. R116's care plan dated [DATE] show R116 has GERD due to hyperacidity with intervention to give medications as ordered.

Based on observation, interview, and record review the facility failed to use the correct serving utensils for mechanical soft and puree residents. This applies to 14 of 14 residents (R2, R8, R10, R11, R15, R22, R23, R25, R29, R32, R41, R47, R51, and R55) reviewed for mechanically altered diets in the sample of 17. The findings include: Facility provided menu printed on 7/17/23 at 2:32 PM, shows lunch for Monday, 7/17/23, included a turkey and cheese hoagie sandwich, a lettuce and tomato plate, a marinated cucumber and tomato salad, macaroni salad, and a summer fresh fruit cup. Facility provided Order Search reports dated 7/15/23, show R2, R8, R10, R11, R15, R22, R23, R25, R29, R32, R41, R47, R51, and R55 have current orders for mechanically altered diets. Facility provided puree meal ticket dated 7/17/23, shows a #8 scoop (4 ounces) is needed for the pureed turkey, a #16 (2 ounces) scoop is needed for the pureed bread/hot dog bun, a #8 (4 ounces) scoop is needed for the pureed macaroni salad, and a #10 (3 ounces) scoop is needed for the pureed marinated mixed vegetable salad. Facility provided mechanical soft meal ticket dated 7/17/23, shows a #10 (3 ounces) scoop is needed for the ground turkey, a 1/2 cup portion is needed for the macaroni salad, and a 1/2 cup portion is needed for the marinated mixed vegetable salad. On 7/17/23 at 12:45 PM, V12 (Cook) used a #30 (1 ounce) scoop for the pureed bread, a #16 (2 ounces) scoop for the pureed turkey, a #16 (2 ounces) scoop for the ground turkey, a #8 scoop (4 ounces / 1/2 cup) for the macaroni, and a 4-ounce scoop for the pureed vegetable salad. The marinated mixed vegetable salad for mechanical soft was already pre-portioned into cups for service. On 7/18/23 at 9:14 AM, V10 (Food Service Director) said the cook should double check scoop sizes prior to service by referencing the menu and production sheet. V10 said if a #16 scoop was used instead of a #10 scoop, residents are not receiving the correct amount of nutrients. If done throughout the day, the resident will not be receiving their total needed nutrients. Facility Food: Quality and Palatability policy, revised on 9/17 states, . Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs.

Based on observation, interview, and record review the facility failed to employ a qualified Food Service Director. This applies to all 67 residents in the facility. The findings include: The Centers for Medicaid and Medicare Services Conditions and Census report (CMS-672) dated 7/17/23 showed a census of 67 residents. On 7/19/23 at 8:19 AM, V10 (Food Service Director) said he has not completed the Certified Dietary Manager course and he is not currently enrolled to his knowledge. Facility provided employee file shows V10 was hired on 3/6/23. Facility Dining Services Director job description (no date) states, . Must hold state and/or federal required credential within no more than three months of placement in Dining Services Director/Account Manager position.

Based on observation, interview, and record review the facility failed to serve the menu as written. This applies to all 67 residents in the facility. The findings include: The Centers for Medicaid and Medicare Services Conditions and Census report (CMS-672) dated 7/17/23 showed a census of 67 residents. Facility provided menu printed on 7/17/23 at 2:32 PM, shows lunch for Monday, 7/17/23 included a turkey and cheese hoagie sandwich, a lettuce and tomato plate, a marinated cucumber and tomato salad, macaroni salad, and a summer fresh fruit cup. On 7/17/23 at 12:45 PM, V12 (Cook) served plain pasta with a turkey and cheese hoagie. On 7/17/23 at 1:58 PM, V11 (District Manager for Healthcare Services Group) said that over halfway through meal service, V11 put Italian dressing onto remaining noodles. On 7/18/23 at 8:29 AM, R45 said the menus don't usually match what we get. On 7/18/23 at 9:14 AM, V10 (Food Service Director) said that the cooks should follow the menu and recipes unless authorized by the Food Service Director. V10 also said the macaroni salad recipe does not use Italian dressing. Facility Food: Quality and Palatability policy, revised on 9/17 states, . 4. The Cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate.

Based on observation, interview, and record review the facility failed to wash, handle, and store food service utensils in a sanitary manner. This applies to all 67 residents in the facility. The findings include: The Centers for Medicaid and Medicare Services Conditions and Census report (CMS-672) dated 7/17/23 showed a census of 67 residents. 1. On 7/17/23 at 9:18 AM, V12 (Cook) was at the three-compartment sink washing dirty dishes. V12 then went to the dish machine and removed a clean and sanitized sheet pan to place in the drying area. V12 did not wash hands prior to handling the clean and sanitized sheet pan. On 7/17/23 at 9:20 AM, V12 placed a 4-inch hotel pan into the dish machine. At 9:22 AM, V12 removed the 4-inch hotel pan from the dish machine and placed it in the drying area. V12 did not wash hands prior to handling the clean and sanitized 4-inch hotel pan. On 7/17/23 at 9:27 AM, V12 said hands should be washed between handling dirty and clean dishes. On 7/18/23 at 9:14 AM, V10 (Food Service Director) said employees should definitely wash hands between clean and dirty. If not, it could lead to cross contamination. 2. On 7/17/23 at 9:39 AM, a soiled ice cream scoop was sitting on top of fortified pudding container. On 7/17/23 at 9:41 AM, the connection nozzle for the bag in box juice machine was lying on the ground. On 7/18/23 at 8:53 AM, the connection nozzle was now connected to a box of juice. On 7/18/23 at 9:14 AM, V10 said that the juice bag in box connector should never be on the ground. V10 also said spoiled utensils should ever be placed inside of a cooler and should be cleaned after every use. 3. On 7/17/23 at 11:09 AM, V12 finished pureeing the turkey for lunch. When finished, V12 went to the three-compartment sink to start washing the dishes. V12 washed and rinsed the food processor components and spatula. V12 then ran all components and the spatula under running water from the automatic sanitizer dispenser. V12 then placed the items on the drying area until finished with all items. V12 did not allow the items to be fully submerged. V12 removed the items from the drying area while visibly wet and returned to continue and puree the bread and vegetables for lunch. On 7/17/23 at 9:27 AM, V12 said dishes should be put away once dried. On 7/17/23 at 11:32 AM, V11 (District Manager Healthcare Services Group) said dishes should be submerged at least 20 seconds when using the three-compartment sink. V11 also said sanitized dishes should be allowed to air dry before being used again. Facility Ware washing policy, revised on 9/2017 states, All dishware, service ware, and utensils will be cleaned and sanitized after each use. Procedures: 1. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware . 4. All dishware will be air dried and properly stored.

Based on observation, interview and record review the facility failed to ensure Enhanced Barrier Precautions were implemented and failed to develop Enhanced Barrier Precautions Policy and Procedures. The findings include: The facility's Resident Census and Conditions Report (CMS) dated 7/17/23 show there were 67 residents residing at the facility. This report also shows that there are 9 residents with indwelling catheters, 8 residents with pressure ulcers, 2 residents receiving tube feedings and one resident receiving Intravenous Therapy. None of these residents were placed on Enhance Barrier Precautions. On 7/18/23 at 10:00 AM, both V2 (Director of Nursing-DON) and V3 (ADON-Infection Control) said they have not implemented the Enhance Barrier Precautions (EBP) at the facility. V2 stated, I heard about that- Enhanced Barrier Precautions, it is a precaution more that the standard precaution, like wearing PPE of gown and gloves for residents with catheters or with wounds. V2 (DON) said they have not updated their Infection Control Policy to include the EBP. The CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organism (MDROs) dated July 12, 2022, shows: Enhanced Barrier Precaution (EBP) are an infection control intervention designed to reduce transmission of resistant organism that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precaution do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and or Infection or colonization with an MDRO.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a resident's physician and representative of a change in condition for 1 of 3 residents (R1) reviewed for notification of changes in the sample of 8. The findings include: R1's admission Record, printed by the facility on 3/28/23, showed she had diagnoses including complex regional pain syndrome, muscle weakness, malignant neoplasm of cervix uteri, and multiple sclerosis. R1's facility assessment dated [DATE] showed she required extensive assist of one staff member for bed mobility, dressing and personal hygiene. The assessment showed R1 was dependent on staff for transfers, toileting, and bathing. The assessment showed R1 was always incontinent of bowel and bladder. On 3/28/23 at 8:50 AM, V20 (R1's daughter) said R1 developed a pressure injury while residing in the facility and no one called her to inform her of the pressure injury. V20 said she did not find out about the pressure injury until R1 was admitted to a local hospital. On 3/29/23 at 1:50 PM, V3 (Licensed Practical Nurse-LPN/Wound Nurse) said she does not recall if she notified R1's daughter (V20) about the pressure injury to R1's sacrum. V3 said she did not document that she notified her (V20). On 3/28/23 at 5:06 PM, V2 (Director of Nursing-DON) said the resident's doctor and the family/POA (power of attorney) should be notified right away when a pressure injury is identified. V2 said the family should be notified so they are aware of the injury and what is being done to treat it. R1's electronic census tab showed she was readmitted to the facility on [DATE]. R1's admission paperwork from a local hospital, printed on 12/23/22, that was provided to the facility on readmission showed she had a pressure injury to her sacrum. R1's Skin and Wound Evaluation dated 12/28/22 showed R1 had a deep tissue pressure injury to her sacrum measuring 5.0 cm (centimeters) x 7.3 cm. R1's Skin/Wound Note (in the progress notes) showed Unstageable pressure to the sacrum 5 cm x 7.3 cm. slough and eschar present. Tenderness noted to palpation. Scant serosanguinous drainage to peri-wound. The Skin/Wound note identified what treatment was provided. The note did not show that R1's Physician, Nurse Practitioner or V20 were notified. R1's Health Status note dated 1/3/23, documented by V16 (LPN) showed Resident sacrum pressure wound getting worse. It smell(s) really bad and dressing was super nasty. Cleaned with wound cleanser, pat dry and applied a new calcium alginate and two medium silicone dressing because couldn't find the bigger one. Wrote a note for wound care nurse and put it in her mailbox. Endorsed to the morning nurse. Will continue to monitor. On 3/29/23 at 1:39 PM, V16 (LPN) said they (the nurses) must let the wound nurse know when a pressure injury is getting worse. V16 said she wrote a note to the wound nurse and put it in her mailbox. V16 said she endorsed the information to the oncoming nurse. V16 said she did not notify R1's Physician or the Nurse Practitioner. V16 said when a wound is getting worse and smelling bad it could be a sign of infection and it is important to let the resident's doctor, or the Nurse Practitioner know. R1's Progress notes from 1/3/23-1/4/23, do not show any other assessments or that R1's Physician or the Nurse Practitioner were notified of the worsening pressure injury. The notes do not show that V20 was notified of R1's worsening pressure injury. On 3/29/23 at 3:29 PM, V2 (Director of Nursing-DON) said if a nurse finds something wrong, documenting is not an intervention. V2 said the nurse should have notified R1's doctor to get new orders and then notified the daughter of the changes. V2 said the nurse should have notified the doctor or the Nurse Practitioner right away. The facility's policy and procedure titled Significant Condition Change and Notification, with a review date of 11/2019, showed the purpose was to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below .A significant change in the resident's physical, mental or psychosocial status. The policy lists new wounds, bruises, or skin tears as one of the listed situations in which the licensed nurse will contact the resident's representative and their medical practitioner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to do a skin assessment on a resident with an existing pressure injury upon readmission to the facility. Failed to identify the existing pressure injury during cares and obtain orders for a treatment to the existing pressure injury. The facility failed to provide treatments as ordered once the pressure injury was identified. The facility also failed to develop care plans for residents at risk for the development of a pressure injury for 2 of 3 residents (R1 and R2) reviewed for pressure in the sample of 8. 1. R1's admission Record, printed by the facility on 3/28/23, showed she had diagnoses including complex regional pain syndrome, muscle weakness, malignant neoplasm of cervix uteri, and multiple sclerosis. R1's facility assessment dated [DATE] showed she required extensive assist of one staff member for bed mobility, dressing and personal hygiene. The assessment showed R1 was dependent on staff for transfers, toileting, and bathing. The assessment showed R1 was always incontinent of bowel and bladder. The assessment also showed R1 had an unstageable pressure injury that was present on her readmission to the facility. On 3/28/23 at 8:50 AM, V20 (R1's daughter) said the facility was not providing wound care or putting any interventions in place for R1's pressure injury. R1's readmission paperwork from a local hospital, with a printed date of 12/23/22 (R1's readmission date to the facility), showed she had an unstageable pressure injury to her sacrum, with slough (non-viable dead tissue, usually cream or yellow in color) and eschar (dry, black, hard non-viable tissue). The hospital paperwork showed on 12/22/22 the wound measured 15 cm (centimeters) x 10 cm x 0.1 cm. R1's electronic census tab showed she was readmitted to the facility on [DATE]. No Progress note was in R1's electronic medical record showing she was readmitted to the facility on [DATE], or that any skin assessment was completed for R1. On 3/28/23 at 4:35 PM, V3 (Licensed Practical Nurse-LPN/Wound Nurse) said she did not see any assessment for the pressure injury to R1's sacral area prior to the one she completed on 12/28/22. V3 said there was no treatment order in place prior to 12/28/22 for R1's pressure injury. V3 said she was not aware of any pressure injury to R1 until she did the assessment on 12/28/22. V3 said no staff reported any skin concern to her prior to her doing the assessment on 12/28/22. V3 said a skin assessment was not completed for R1 upon readmission to the facility on [DATE] and the first skin assessment for R1 was the one she (V3) did on 12/28/23. V3 said she saw on the paperwork that this surveyor was provided on 3/28/23, that the hospital records from R1's readmission did show that she had an unstageable pressure injury. On 3/29/23 at 1:50 PM, V3 said no additional assessments of R1's sacral pressure wound were completed after the assessment she did on 12/28/22. R1's electronic Progress notes do not have any mention of a pressure injury for R1 until V3's Skin/Wound note dated 12/28/22. R1's Braden Scale for Predicting Pressure Sore Risk dated 11/15/22 (from her original admission date) showed she had a high risk for the development of pressure injuries. R1's Braden Scale for Predicting Pressure Sore Risk dated 12/23/22 (from her most recent admission to the facility) showed she had a high risk of developing pressure injuries. R1's care plans were reviewed. No care plan for R1's risk of developing a pressure injury or identifying her existing pressure injury were in her care plans. R1's December 2022 Treatment Administration Record (TAR) showed no treatment in place for the pressure injury on R1's sacrum until 12/29/22. R1's December 2022 TAR showed an order, started on 12/29/22, for sacrum unstageable pressure: Cleanse with wound cleanser, pat dry. Apply skin-prep to peri-wound. Apply calcium alginate with silver to wound bed. Apply large silicone dressing over wound. Notify wound team if worsening condition. The order showed this treatment should be done every day and night shift for wound management/comfort. The TAR showed this treatment was not completed on 12/31/22 on the night shift. R1's January 2023 TAR showed the same treatment order for R1's sacrum. The TAR showed the treatment was not completed on 1/1/23 on the night shift. R1's Skin and Wound Evaluation dated 12/28/22 showed a deep tissue injury pressure wound to her sacrum that was present on admission. The assessment showed the wound measured 5.0 cm x 7.3 cm with slough and eschar tissue. The assessment showed redness/inflammation with light serosanguinous (pale red or clear liquid mixed with the blood) drainage. The assessment also showed that there was no dressing present at the time of the evaluation. R1's Progress note dated 12/29/22, documented by V3, showed Noted strong odor to unstageable sacral wound with dressing change. Treatment frequency increased to BID (twice daily). R1's Health Status note dated 1/3/23, documented by V16 (LPN) showed Resident sacrum pressure wound getting worse. It smells(s) really bad and dressing was super nasty. Cleaned with wound cleanser, pat dry and applied a new calcium alginate and two medium silicone dressing because couldn't find the bigger one. Wrote a note for wound care nurse and put it in her mailbox. Endorsed to the morning nurse. Will continue to monitor. On 3/29/23 at 1:50 PM, V3 (LPN/Wound Nurse) said she did not have any idea if V16 left a note in her mailbox on 1/3/23 regarding R1's wound getting worse. V3 said typically if she gets a note about a resident's wound, she will go and check the wound. V3 said she did not have any progress notes showing she checked R1's pressure wound on 1/3/23 or on 1/4/23. V3 said it does not appear that she (V3) looked at R1's wound on those dates. R1's Progress note dated 1/5/23 at 12:16 AM showed R1 went to her scheduled radiation therapy appointment at 2:45 PM. The note showed the writer of the progress note call the local hospital (where R1 was receiving radiation therapy) at 7:30 PM because she had not returned to the facility yet. The progress note showed R1 was admitted to the local hospital with diagnoses of pancreatitis and UTI (urinary tract infection). R1's Order Summary Report from 12/23/22 through 1/5/23 showed no order for the pressure injury to her sacrum was obtained until 12/28/22. On 3/28/23 at 5:06 PM, V2 (Director of Nursing-DON) said the hospital documentation was given to the readmitting nurse on 12/23/22. V2 said the admitting nurse should be reviewing the hospital documentation and doing a skin assessment on admission or readmission to the facility. V2 said it is important to do an assessment of the resident's body and to review the hospital documentation carefully to identify the resident's needs and any concerns so the facility can get orders and treatments in place to prevent any skin concerns from getting worse. On 3/29/23 at 3:29 PM, V2 (DON) said the CNAs (Certified Nursing Assistants) should have identified the pressure injury to R1's sacrum during cares and talked to the nurse on duty. V2 said the nurses document that a treatment was completed by checking it off on the resident's Treatment Administration Record (TAR). V2 said if it is not documented, then it is not done. V2 said if the treatment is done, it should be marked as done on the TAR. On 3/29/23 at 2:26 PM, V15 (Wound Doctor) said he would expect the facility to do a skin assessment in a timely manner to check for any residents with skin concerns on admission or readmission to the facility. V15 said most of the people in nursing homes are at a higher risk for skin breakdown. V15 said you would want to identify any skin concerns and put interventions and treatments in place to promote healing and prevent deterioration. 2. R2's admission Record, printed by the facility on 3/28/23, showed he had diagnoses including cerebral infarction (stroke), anemia, type II diabetes mellitus, moderate protein-calorie malnutrition, adult failure to thrive and chronic kidney disease stage 3. On 3/28/23 at 2:25 PM, V4 (Registered Nurse-RN) provided wound care for the pressure injuries on R2's bilateral heels. The wound on R2's left heel was the size of a fifty-cent piece with about 70-80% of the wound bed covered in slough tissue, with the remainder of the wound bed being red granulation tissue. The wound to R2's right heel was purple in color and the wound was not open. V4 said she believes R2's wounds were due to him getting up early every morning and sitting in his wheelchair all day. V4 said she believes the wounds were caused by R2's shoes and the way he was sitting with his legs straight out all day. On 3/29/23 at 2:00 PM, V3 (Wound Nurse/LPN) said the deep tissue injury to R2's left heel was identified on 1/13/23 and the deep tissue injury to R2's right heel was identified on 3/17/23. V3 said it is her understanding that the pressure injuries were likely because he didn't want to get into bed, and he would extend his legs out. V3 said R2 would not put his legs up on the leg rests and he was refusing the pressure offloading boots. V3 said they were looking for something that R2 would be agreeable to when the pressure injuries occurred. This surveyor asked for documentation of interventions tried prior to the pressure injuries occurring on R2's bilateral heels and any refusals that were documented prior to 1/13/23. The only refusals documented in R2's progress notes from 1/13/23 through the present was R2 refusing a low air-loss mattress. R2's Braden Scale for Predicting Pressure Sore Risk dated 11/22/22 showed he had a moderate risk of developing pressure injuries (score of 14). R2's Braden Scale for Predicting Pressure Sore Risk dated 11/29/22 showed the same moderate risk (score of 14). R2's Braden Scale for Predicting Pressure Sore Risk dated 1/13/23 (the day the pressure injury was identified on his left heel) showed he was not at risk for the development of a pressure injury (score of 19). R2's Braden Scale for Predicting Pressure Sore Risk dated 2/19/23 showed he was at risk of developing pressure injuries (score of 17). R2's Skin/Wound note dated 1/13/23 showed left heel suspected DTI (deep tissue injury) measures 4 cm x 3.5 cm. Peri-wound is red and purple. Wound bed is maroon with epidermal separation, macerated. Scant amount of serosanguinous drainage. The note showed a treatment was performed and R2's foot was elevated while in wheelchair and put on a pillow. R2's Skin and Wound Evaluation dated 1/13/23 showed a deep tissue pressure injury to his left heel measuring 4.0 cm x 3.5 cm with light serosanguinous drainage and redness/inflammation. R2's most recent Skin and Wound Evaluation dated 3/23/23 showed a stage 3 full-thickness pressure injury to his left heel measuring 2.5 cm x 2.5 cm with slough covering 40% of the wound bed and a faint odor. R2's Skin/Wound note dated 3/17/23 showed During noc (night) noted right lateral heel with intact purple blister measuring approximately 4 cm x 4 cm. Skin prep applied for protection and protective boot applied. Ensured heel floated completely off bed. The note showed the writer sent a fax to the resident's physician medical group to notify and request treatment orders. R2's care plans showed his pressure care plan was not initiated until 1/13/23, the same day the left heel pressure injury was identified, even though he was at risk of developing a pressure injury since his admission on [DATE]. The care plan was last revised on 2/21/23. The care plan does not show any documentation identifying R2's pressure injury to his right heel or any interventions implemented after 1/13/23. The facility's policy and procedure titled Wound Assessment, with a revision date of 3/2/22, showed It is the policy of the facility to assess each wound initially either at the time of admission or at the time the wound is identified. Each wound will be assessed weekly thereafter or with any significant noted change in the wound .2. A thorough assessment includes the following: Location, size (cm), depth (cm), stage (appropriate for pressure ulcer/pressure injury only), exudate (amount, type, color), tissue (epithelium, granulation, necrotic, slough or eschar), signs of infection (fever, erythema, edema, purulent drainage), peri-wound skin condition, pain. The facility's policy and procedure titled Pressure Ulcer/Pressure Injury Prevention (PUP/PIP), with a revision date of 3/2022, showed A pressure ulcer/injury can occur wherever pressure has impaired circulation to the tissue. A facility must: Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter. Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI. Implement, monitor, and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; and If a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/PI's.

Based on observation, interview, and record review that facility failed to ensure a dressing was in place for a resident with a stage 3 pressure injury and failed to ensure an ordered dressing was applied to the pressure injury for 1 of 3 residents (R3) reviewed for pressure injuries in the sample of 3. The findings include: R3's Treatment Administration Record shows an order for, Stg3 (Stage 3) pressure to sacrum: Cleanse w/wound cleanser, pat dry. Apply skin prep to peri-wound. Hydrogel Ag (Alginate-has antibacterial properties and absorbs wound drainage) to wound bed. Cover with silicone dressing. Every day shift for wound management. R3's Wound Care Report dated 2/9/23 shows that R3 has a stage 3 pressure injury on his sacrum measuring 0.8 centimeters (cm) x 0.3 cm x 0.3 cm and has a treatment order of hydrogel and AG (Alginate) circled. On 2/15/23 at 12:15 PM, V4 and V5 (Certified Nursing Assistants/CNAs) provided incontinence care to R3. R3 was turned to his right side. There was no dressing on R3's sacrum. There was no dressing located in R3's incontinence brief. R3 had a small amount of stool present. At 12:40 PM, V6 (Licensed Practical Nurse) cleaned the wound, applied a hydrogel dressing (package was reviewed and no AG was in the dressing) and covered the wound with a silicone dressing. The sacral wound measured 1 cm x 0.5 cm. On 2/15/23 at 12:30 PM, V6 said that R3 should have a dressing on his sacrum. V6 said that she has not heard from the staff that it was not in place. V6 said that if the CNAs noticed that a dressing was not in place, they should notify the nurse right away so they can go in and clean the wound and apply a new dressing. On 2/15/23 at 12:40 PM, V7 (CNA) said that she checked R3's incontinence brief in the morning and there was no dressing present at that time. V7 said, He did have a dressing last week, but I am not sure why he does not now. R3's Task List Report printed on 2/15/23 shows, BARRIER CREAM-** DO NOT** apply barrier cream to buttocks. Requires treatment to st.3 (Stage 3) pressure sore on the buttock. Notify nurse if dressing is missing or becomes soiled that [sic] nurse can apply new treatment. R3's Skin Integrity Care Plan shows, [R3] will have wound dressing treatment changes completed per order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was treated in a dignified manner by all staff. This applies to 1 of 18 residents (R7) reviewed for dignity in a sample of 18. The findings include: On 8/22/22 at 10:15 AM R7 stated, I had an issue with one CNA (V12), and I reported it to the nurse and told him I didn't want her to work with me ever again. R7 stated, I told her that I am paying privately to be cared for at the facility and (V12) told me that I should be thankful that she is taking care of me, then she walked out and slammed the door. R7 stated that she also came in here to answer my call light and said, 'What you want, Boo?' I don't know if that was some kind of slang against me because I am white or what that was, but I told her she should not be talking to me like that. On 8/24/22 at 11:30 AM R7 stated, I don't want to get anyone in trouble, but I reported it to the nurse that was on that night (about 3 weeks ago). I told him I didn't want her working with me again. She has a bad attitude. I have had her again one other time at night because she was the only one on, but I just tried not to call her. I just laid in my pee until the morning came and someone else could come in and help me. R7's EMR (Electronic Medical Record) shows that she was admitted to the facility on [DATE] and has no cognitive impairment. On 8/24/22 at 10:30 AM V2 (Director of Nursing) stated, Sometimes we don't fill out a grievance because the resident says they don't want to. Then we just follow up with the issue. (V12) is a really good CNA, she is just a little rough around the edges. On 8/24/22 at 10:41 AM V18 (Social Service Director) stated, I always file a grievance and then forward them on to V1 (Administrator) and V2 (Director of Nursing). Often times I do not get them back. I know R7's sister filed a grievance on her behalf because she was pretty upset about a few things. Some of their expectations were a little unrealistic. I never talked to R7 about a problem with (V12). On 8/24/22 at 11:00 AM V1 stated, Well I'm sure what we did was just move (V12) off of that assignment, there should be some notes in her chart. At 1:30 PM V2 stated, I didn't know anything about it, it might just be that (V12) just didn't work with (R7), she doesn't really work that often. No one ever talked to me about any of this. A Grievance dated 7/19/22 also shows another (discharged ) resident's family complained about V12 stating, (V12) needs to be a lot nicer to the residents and find out what is needed. Then listen to whoever is involved. (discharged Resident) waited way too long once the light was pressed. The resolution written at the bottom of this form states, Aid will be counseled on proper customer service. Spoke with (resident's) daughter-in-law- Resolved 7/25/22. On 8/24/22 V12's employee file was reviewed and showed no mention of V12's poor customer service and no disciplinary action for V12. The facility provided an undated document entitled Section 1: Right and Protections for Everyone with Medicare (facility stated this document is part of their admission packet provided to residents on admission to the facility). This document states, You have these rights: Be treated with dignity and respect at all times.

Based on observation, interview, and record review the facility failed to ensure a suprapubic catheter was changed for a resident with a history of a urinary tract infection for 1 of 7 residents (R42) reviewed for catheter care in the sample of 18. The findings include: On 8/22/22 at 9:05 AM, R42 was sitting in a wheelchair. R42's suprapubic catheter tubing was visible under R42's wheelchair. R42's care plan showed R42 had a history of a urinary tract infection and R42's suprapubic catheter was to be changed every four weeks starting on 8/15/22. R42's Order Summary Report printed on 8/22/22 showed, Per hospital: change suprapubic catheter every 4 weeks at facility beginning on 8/15/22 . for prevention of [urinary tract infections]. On 08/22/22 at 01:16 PM, V2 (Director of Nursing) said if R42's catheter was changed it would have been documented on the Medication Administration Record (MAR). R42's MAR was blank for changing the suprapubic catheter on 8/15/22. On 08/22/22 at 02:11 PM, V2 confirmed R42's suprapubic catheter was not changed on 8/15/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R51's Weight and Vitals Summary showed a significant weight loss of 6.5% in one month from 7/14/22 (148.6 pounds) to 8/11/22 (138.9 pounds). R51's Dietician Nutrition assessment dated [DATE] showed R51 had a significant weight loss that was not intended. The same document showed under Nutrition Plan for R51's protein supplement to be increased from 30 milliliters (ml) twice a day to 60 ml twice a day. R51's Order Summary Report printed on 8/22/22 showed R51's protein supplement order as 30 ml twice a day. It had not been increased as the Dietician Nutrition Assessment recommended. On 08/23/22 at 10:00 AM, V16 (Dietician) said when he makes recommendations on the Dietician Nutrition Assessment, they go to V2 (Director of Nursing). According to V16, V2 then gives the recommendations to the doctor for review. On 08/23/22 at 11:23 AM, V2 said she receives the Dietician Nutrition Assessment recommendations and order sheets with the recommendations on it. V2 said she gives the order sheets to the doctors for their review. V2 said she did not get the order sheet from V16 regarding the recommendation made for R51. The facility Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol with a review date of 2/21 showed, The Physician will authorize, and the staff will implement appropriate general or cause- specific interventions, as indicated Based on observation, interview and record review the facility failed to ensure a dietitian's recommendations were reviewed with a physician for residents with significant weight loss, failed to notify a dietitian of significant weight loss and failed to implement the dietitian's recommendations for a resident with significant weight loss. This applies to 2 of 6 residents (R39 and R51) reviewed for weight loss in the sample of 18. The findings include: 1. R39's electronic medical records (EMRs) lists her diagnoses to include: dysphagia, diabetes mellitus, dementia, hemiplegia, chronic atrial fibrillation, seizures, history of transient ischemic attack and cerebral infarction without residual deficits and gastro-esophageal reflux disease. R39's EMRs show, her weight on July 1, 2022, as 180.0 lbs (pounds) and her weight on August 1, 2022 as 166.0 lbs. That is a 14 lbs difference and 7.78% weight loss in one month. R39's EMRs does not show that her physician or dietitian was notified of the significant weight loss on August 1, 2022. R39's dietitian note dated August 18, 2022 (17 days later) shows, UBW (Usual body weight): 180 #(lbs) 7/22/22, 181 # 5/22/22. 8.4% weight loss within 1m (1 month), 9% weight loss within 3m (3 months). Significant weight loss not wanted . Recommend magic cup BID for weight stability . On August 22, 2022, at 9:35 AM, R39 was eating breakfast in bed. She did not have a magic cup on her tray. At 2:32 PM, R39 was eating lunch in bed. She did not have a magic cup on her tray. On August 23, 2022, at 9:40 AM, R39 was eating breakfast in bed. She did not have a magic cup on her tray. On August 23, 2022, at 1:03 PM, V2 Director of Nursing (DON) stated, once the dietitian sees a patient, he prints her off a list of recommendations. She has the physician review those recommendations. If they agree then she puts the orders in the computer. She stated the physician's review the orders usually within 24 hours. V2 DON verified, R39 did not have any orders for a magic cup at that time. R39's order summary report provided on August 24, 2022, shows, an order for magic cup two times a day for nutritional supplement. Ordered on August 23, 2022. R39's Minimum Data Set, dated [DATE], shows, she requires extensive assist of one-two person for most ADL's (activities of daily living). The same assessment shows, she requires supervision of one person assist for eating. R39's care plan dated initiated April 30, 2022, shows, Focus: The resident has nutritional problem or potential nutritional problem. The care plan has not been updated with her significant weight loss. The facility's nutrition (impaired)/Unplanned weight loss clinical protocol policy last reviewed February 2021 shows, Assessment and Recognition, 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time . 3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss = (usual body weight-actual weight)/ (usual weight X 100): a. 1 month- 5% weight loss is significant; greater than 5% is severe, b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe, c. 6 months- 10% weight loss is significant; greater than 10% is severe. 4. The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition .

Based on observation, interview and record review the facility failed to administer medications as ordered. There were 26 opportunities with 3 errors resulting in an 11.54 % error rate. This applies to 2 of 3 residents (R24 and R116) observed during medication pass. The findings include: 1. On August 22, 2022 at 9:10 AM, V3 Assistant Director of Nursing (ADON) was passing R24's morning medication. V3 gave R24 1 tablet of R24's Zoloft (anti-depressant) medication with her other morning medications. V3 verified that there were 7 pills in the medication cup. (Should have been 8 pills in total). R24's medication administration record (MAR) for the month of August 2022 shows, Zoloft tablet 50 mg (milligram), give 1.5 tablet by mouth in the morning for depression, Dose = 75 mg. On August 22, 2022 at 1:42 PM, V22 Registered Nurse (RN) verified that R24 has 2 cards for her Zoloft medication. One card is a whole tablet and the other is a ½ tablet. R24 is supposed to get 1 full tablet and one ½ tablet with her morning medications. V3 only gave 1 tablet. 2. On 8/23/22 at 8:21 AM V17 (LPN- Licensed Practical Nurse) prepared and passed medications for R116. V17 dispensed 9 medications into the medication cup and then prepared two inhalers for administration. There were 8 medications dispensed from medication cards and 1 from a house stock bottle. R116's Medication Administration Record (MAR) dated August 2022 shows that R116 should have received 11 medications and 2 inhalers. R116's MAR shows an order for Magnesium Oxide 400mg by mouth in the morning as a supplement and an order for Tamsulosin 0.4mg capsule by mouth daily for urinary retention. Both of these medications are initialed as given on 8/23/22 however V17 did not dispense either of these medications into the medication cup for R116. On 8/23/22 at 11:25 AM R116's medication card of Tamsulosin was reviewed and showed only 4 capsules had been administered since the order was started on 8/18/22. (Should be 6 capsules administered). V17 stated, I could have sworn I gave it- I would be the first to admit if I didn't. The Magnesium Oxide was then pulled out of the back of the top drawer of the medication cart. V17 stated, I noticed when I gave this that it did not have an opened date on it- and I always read the expiration date out loud before I give it. (V17 did not do this during the medication pass) The facility policy entitled Administration of Medications dated 4/2021 states, The nurse's station shall have necessary items and equipment available for proper administration of medications and current standards of practice should be followed.

Based on observation, interview and record review the facility failed to ensure food was prepared in a sanitary manner to prevent cross contamination for 1 of 18 residents (R8) reviewed for food preparation in the sample of 18. The findings include: On 8/22/22 at 12:52 PM, V20 (Cook/Aide) picked up a metal spatula that had food debris on it and used it to scrape dried food off of the flat top grill. Without washing the spatula off, he then used that spatula to make a grilled cheese sandwich. V20 had touched items in the kitchen such as the spatula handle, and without changing gloves or using a utensil he then picked up bacon he was cooking on the flat top grill and placed it on the grilled cheese sandwich that was served to (R8). On 8/23/22 at 10:10 AM, V9 (Dietary Manager) said V20 should have used the metal scraper provided to them to clean off the stove not the spatula, and he should have either changed his gloves first or used a utensil to pick up the bacon. The facility provided policy titles Food: Preparation states, All staff will practice proper handwashing techniques and glove use. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful, physical, biological, and chemical contamination. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use.

Based on observation, interview and record review the facility failed to ensure meals were served according to normal mealtimes in the community. This applies to 4 of 18 residents (R7, R11, R54, R60) reviewed for mealtimes in the sample of 18. The findings include: On August 22, 2022, at 9:30 AM, residents on the 100 hall were being served the morning meal. At 2:14 PM, residents on the 100 hall were being served the noon meal. On August 23, 2022, at 9:20 AM, residents on the 100 hall were being served the morning meal. On August 22, 2022, during the survey R7, R11, R54, & R60 all stated, the meal trays are late every day. On August 22, 2022, at 2:13 PM (prior to meal trays coming) V4 Certified Nursing Assistant (CNA) stated, the meal trays are always late. To be honest, they are this late every day. The facility's grievance report from R26 dated July 19, 2022, shows, Food always late. The facility's grievance report from R60 dated July 25, 2022, shows, No food provided for R60 at 6:30 PM . We did not get dinner until 7:15 PM . The facility's mealtimes list provided shows, Breakfast 7:30AM, Lunch 11:45 AM, Dinner 5:15 PM.

Based on observation, interview and record review the facility failed to ensure there was adequate staffing in the kitchen. This failure has the potential to effect all 68 residents receiving food from the kitchen. The findings include: The CMS 672- Resident Census and Condition of Residents form completed during the survey shows the census on 8/22/22 was 70 residents and 2 residents are being feed by tube feeding. On 8/22/22 the kitchen was observed continuously from 11:20 AM until 1:45 PM. There were a total of 4 dietary personnel in the kitchen. 3 staff (V9 Dietary Manager, V10 [NAME] and V20 Cook/Aide) who were working the serving prep and service line and 1 staff (V19 PM shift Dishwasher) who came in at 10:00 AM was doing dishes. At 11:30 AM, V9 began making pureed lunch trays. She then continued taking food out of the ovens and placing them on the serving line. V10 and V20 were doing other prep work and getting the serving line ready for the noon meal. Residents began arriving in the dining area at approximately 12:15 PM. At 12:25 PM, V9 began to plate food for residents in the dining room. V10 and V20 were bringing out cold food items prepping hallway carts with water and juices and items needed for room trays. The had to deliver out those carts to the units first. V9 had to stop serving because the resident meal tickets had not been cut yet. She went and cut those tickets washed her hands and began serving again. V10 was assisting with adding items that were needed to the trays such as ice creams, supplements special requests. etc. When residents had requested items other then what was on the scheduled menu for that meal, either V9 or V10 would have to stop what they were doing and go cook and prepare the items. During the service they ran out of clean silverware and V9 had to leave the prep line to go wrap more silverware. V10 then took over prepping and plating for the resident room trays. V20 who was assisting V10, would have to stop and take carts to the unit and wait for a cart to be emptied and bring it back to put the next hall of resident trays into. During the lunch observation V9 was also making more food items to add to the serving line in an attempt to keep foods from getting cold as they waited for carts to come back to resume prepping meal trays. At 1:45 PM, the meal service was not yet completed and there was still another hallway of resident trays to prep and send out. Those resident trays did not arrive until 2:13 PM. On 8/22/22 at 1:35 PM, V10 said they do have resident complaints about getting their food so late but with only 3 staff and how the process is set up it delays the mealtime. She said a staff person has to deliver an insulin cart out for residents on insulin to get their meals first, then deliver 4 hallway carts. V10 said due to cold food complaints they also have to wait for a staff person (CNA) on the unit to come and hand the cart off to them before they can return to the kitchen. V10 said the goal is for all the trays to be out by 1:45 PM. On 8/23/22 at 10:10 AM, V9 said the kitchen does not have enough staff. She said they currently have no dietary aides, and they really need about 4 aides. V9 said she is the dietary manager and has been working as a staff person in the kitchen because they need more staff. V9 said there are resident complaints about cold food and late food but the way the process is set up they have to have one of the cooks stop what they are doing and deliver carts to the hallways, come back wash their hands then resume what they were doing. They then go back to get a cart once it is emptied out, because they only have 3 carts. V9 said this delays meal service. She also said she has informed V1 (Administrator) that they need more carts and the company the dietary staff work for (a contracted food service company) that they need more staff. On 8/23/22 at 2:35 PM, V1 (Administrator) said he was aware of the issues going on in the kitchen and he had called the contracted company and told them they need more staff. V1 said they are currently working on resolving the food complaints from the residents which include late and cold food. V1 also said he is looking into ordering more food carts. A test tray was received along with other resident trays on 8/23/22 at 9:35 AM. The biscuits and gravy were lukewarm with a temperature of 128.5 degrees Fahrenheit. A facility Grievance Report Form dated 7/19/22 shows R26 filed a grievance stating, Everything I get that's supposed to be warm is always cold, coffee is always cold not even lukewarm . A facility Grievance Report Form from R60 dated 7/25/22 shows, No food provided for R60 at 6:30 PM . We did not get dinner until 7:15 PM . The facility's mealtimes list provided shows, Breakfast 7:30 AM, Lunch 11:45 AM, Dinner 5:15 PM. Resident Council Meeting minutes dated 5/27/22 show there are cold food complaints of the food being served to residents in the rooms. The facility provided Dietary Department Services Agreement dated 9/12/12 between the contracted company and the facility states, {The contracted company} will provide all management, supervision, labor, food and supplies necessary to perform the dietary services on the premises of the facility . Provide a full-time dietary manager (With support from a registered dietician) and an adequate staffing plan to meet the requirements of the dietary department .

Based on observation, interview and record review the facility failed to ensure food was served at a palatable temperature. This failure has the potential to affect all 68 residents receiving food from the kitchen. The findings include: The CMS 672- Resident Census and Condition of Residents form completed during the survey shows the census on 8/22/22 was 70 residents and 2 residents are being feed by tube feeding. On 8/22/22 at 9:09 AM, R54 said the food at the facility is terrible, it is always served late and cold. At 2:15 PM, R54 said his lunch was delivered to him and it was lukewarm. On 8/22/22 at 9:30 AM, R11 said the food is always cold and late. On 8/22/22 at 10:15 AM, R60 said the food is always served to her cold and she had to wait this morning to get brown sugar to put in her oatmeal. On 8/22/22 at 2:16 PM, R7 said staff do not cover hot foods when they bring them to her, and her soup and coffee are always brought in cold. On 8/23/22 a test tray was requested from the kitchen to be sent on the food cart with resident trays. The test tray came at 9:30 AM. The biscuits and gravy on the tray were lukewarm and were 128 degrees Fahrenheit. On 8/24/22 at 10:10 AM, V9 (Dietary Manager) said the facility does have a lot of cold food complaints. V9 said they plate the carts and take them to the units where the CNA's (Certified Nursing Assistants) pass them out to the residents. A Facility Grievance Report Form dated 7/19/22 shows that R26 filed a grievance stating, Everything I get that's supposed to be warm is always cold, coffee is always cold not even lukewarm . Resident Council Meeting minutes dated 5/27/22 show there are cold food complaints of the food being served to residents in the rooms. The undated, facility document from the food services group the facility contracts with states, hot food must be kept hotter than 140 degrees.