Based on record review and interview the facility failed to refund unused resident funds to a resident's representative within 30 days of the resident's death for one of three residents (R1) reviewed for resident funds in the sample of three.Findings include:The Illinois Department on Aging Centers for Medicare and Medicaid Understating Your Financial Rights Guidelines dated 7/12/21 document, Your financial rights: The nursing home must return funds with a final statement to the person or court handling your estate within 30 days after your death. R1's Hospital Record documents:R1 was transferred to the hospital from the facility on 6/21/25 and passed away while in the hospital on 6/23/25.R1's Resident Statement Landscape dated 11/5/24 through 6/12/25 documents R1 had 60.00 dollars each month deposited by SSA (Social Security Administration) into the facility's trust fund account for R1's personal use. R1's Resident Statement Landscape dated 8/1/25 documents R1 had 420.00 personal dollars left in the facility's trust fund account that R1 had not spent or used since 11/5/24.On 8/6/25 at 8:45 AM V7 (R1's Power of Attorney) stated, I have been asking since 7/8/25 for the facility to refund (R1's) remaining funds. The facility has yet to refund the funds, and I feel like I am getting the run around.On 8/8/25 at 11:30 AM V15 (Regional Director of Operations) stated, The facility does not have a policy on when remaining trust funds are distributed to the residents' representatives, however we (the facility) follow CMS (Centers for Medicare and Medicaid Services) guidelines. (V7/R1's Power of Attorney) should have received (R1's) remaining 420.00 dollars left in the facility's trust fund within 30 days after (R1's) death (6/23/25). The facility has not sent out the 420.00 dollars yet.

Based on record review and interview the facility failed to provide financial statements quarterly to residents and residents' representatives. This failure has the potential to affect all 44 residents residing within the facility. Findings include:The Resident Funds policy dated 3/2024 documents Guidelines: 5. The resident and/or resident representative is provided with a quarterly accounting report of his or her funds on deposit with the facility, and upon request.The Business Office Manager policy dated 7/2023 documents, Job duties: Prepare and mail statements.On 8/6/25 at 8:45 AM V7 (R1's Power of Attorney) stated, I have never received a copy of (R1's) financial statement from the facility.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, I worked for the facility from the day the company took over on 11/1/24 until I was terminated on 6/12/25. While I was there, I never provided the residents or residents' representatives with quarterly financial statements. I used to mail those for the prior company, but since I started with this company I did not have time to as I was doing three different jobs there.On 8/6/25 at 11:30 AM V3 (Business Office Manager) stated, I just started a little over a month ago. I have not had a chance to send out quarterly financial statements to the residents or residents' representatives.On 8/6/25 at 1:55 PM R2 stated, I don't think I have every received a financial statement.On 8/6/25 at 2:30 PM V1 (Administrator) stated, One of the reasons (V6) was terminated was due to (V6) not doing her job. (V6) knew she should have been sending out quarterly financial statements to the residents and families and was not.The facility's Daily Census Report dated 8/6/25 documents 44 residents currently reside within the facility.

Based on record review and interview the facility failed to promptly provide a copy of the updated admission agreement/contract to all residents and/or residents' representatives upon change of facility ownership. These failures have the potential to affect all 34 residents residing within the facility upon change of ownership on 11/1/24.Findings include:The facility's Daily Census Report dated 11/1/24 documents 34 residents residing within the facility on 11/1/24. The Business Office Manager policy dated 7/2023 documents Business Office Manager Job Description Summary: The primary purpose of the Business Office Manager is to assist in the day-to-day accounting functions of the facility in accordance with current acceptable accounting and cost reimbursement principles relating to nursing facility operations, and as may be directed by the Administrator, Director of Finance, or Accountant. Ensure that resident admission contracts are signed and appropriately filed.V5's (Prior Business Office Manager's) Performance Improvement Plan dated 4/28/25 documents V5 was responsible for doing admission contracts with the residents and residents' representatives and was not doing the admission contracts within 24-48 hours of the residents' admission. On 8/9/25 at 8:30 AM V1 (Administrator) provided a list of all residents residing within the facility upon change of ownership on 11/1/24 with the date of when the admission contract was provided to the residents or residents' representatives. According to this list, none of the 34 residents residing within the facility on 11/1/24 received the facility's admissions agreement within 30 days.On 8/6/25 at 1:38 PM V8 (R3's Guardian) stated, I did not sign (R3's) admission contract until months after (the facility) took ownership.On 8/7/25 at 11:30 AM V1 (Administrator) verified none of the residents' admission contracts were signed or given to the residents or residents' representatives immediately, or within 30 days, upon the facility taking over ownership on 11/1/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to follow Physician Orders to apply bilateral lower extremity compression stockings and provide basic activity of daily living nail care for one of five Residents (R2) reviewed for cares in a sample of 12. Findings include: The Facility Resident Rights for People in Long-Term Care Facilities, revised 11/2018, documents: must treat you with dignity and respect and care for Residents in a manner that promotes quality of life; provide equal access to quality of care regardless of diagnosis or condition; provide services to keep physical and mental health at highest practical levels; and receive services included in plan of care. The Facility's Certified Nursing Assistant/CNA Job Description, revised 7/2023, documents: to provide Resident of this Facility with nursing and personal care and to safeguard the health, safety and welfare of all Residents of the Facility in accordance with policies and procedures and applicable laws and regulations; carry out assignments for Resident care including bathing and grooming; and responsible for well-being and nursing care of all Residents assigned to unit; attend nursing department and care plan meetings; attend in-service educational classes and on-the-job training programs. R2's current Physician Order Sheet/POS, documents R2 admitted to the facility on [DATE] and R2's diagnoses included Chronic Kidney Disease Stage Two, Osteoarthritis, Aneurysm, Repeated Falls, Muscle Disorder, Abnormal Gait and Mobility, Lack of Coordination Anemia, Zoster, Major Depressive Disorder and Dementia. The POS documents an order dated 5/14/25, for compression stockings to be on in the morning and off at night for Edema (bilateral lower extremities). R2's Care Plan documents: an Activity of Daily Living self-care performance that requires staff assistance with personal hygiene and bathing; check nail length and trim and clean on bath day and as necessary; and to report any changes to the nurse. R2's Care Plan does not document a care area for R2's physician order for bilateral lower extremity compression stockings. R2's Medical Record documents R2's shower dates of 5/13/25, 5/19/25, 5/22/25 and 5/26/25. The Shower Sheets do not document that R2's fingernails were cleaned or trimmed. R2's Minimum Data Set/MDS, dated [DATE], documents that R2 requires substantial/maximal assistance with personal hygiene. On 5/27/25 (8:39 am, 9:47 am, and 1:40 pm) and 5/28/25 (8:43 am and 1:56 pm), R2's legs were swollen with moderate pitting Edema and R2 did not have compression stockings on bilateral lower extremities. R2's fingernail tips were long and had a moderate amount of black dry debris under each nail tip. On 5/27/25 at 8:39 am, R2 stated, They do not put on my stockings but they are suppose to, so my legs get swollen. No one has cleaned my nails, I like them long but they need cleaned. On 5/28/25 at 1:56 pm, V1 (Administrator) verified that R2's fingernail tips had a moderate amount of debris under each nail tip. V1 stated, I will make sure that (R2's) fingernails get cleaned up. Nails are supposed to be cleaned on shower days. (R2) just had a shower on Monday (5/26/25) and they should have been cleaned then.

Based on observation, interview and record review the Facility failed to maintain a sanitary and orderly environment for Residents by failing to stock disposable hand towels and/or cloth hand towels/wash clothes in Resident restrooms for nine of nine Residents (R2, R3, R4, R7, R8, R9, R10, R11 and R12) and maintain clean and orderly Resident restrooms for two Residents (R1 and R7) of nine reviewed for clean and homelike environment in a sample of 12. Findings include: The Facility Resident Rights for People in Long-Term Care Facilities, revised 11/2018, documents: the Facility must provide services to keep your physical and mental health at the highest practical levels; and must be safe, clean, comfortable, and homelike. The Facility Housekeeper Job Description, revised 7/2024, documents: the primary purpose is to perform day-to-day activities of the Housekeeping Department in accordance with federal, state and local standards, guidelines and regulations; to ensure the Facility is maintained in a clean, safe and comfortable manner; and to coordinate housekeeping services with nursing services when performing routine cleaning assignments in Resident living and/or residential areas. The Facility Assessment, dated 3/1/2025, documents the Facility must ensure that staff members are educated and trained on the rights of the Resident and the responsibilities of a Facility to properly care for its Residents; Infection Control competencies for hand-hygiene and standard universal precautions; and the physical environment needs include body cleansing products. The Facility Supply Purchase Orders, dated 5/1/25 through 5/27/25, were reviewed and document one entry on 5/27/25 for two cases of roll towels. a) On 5/27/25 at 9:00 am, R1's bathroom commode interior toilet bowl was moderately black tinged with black debris exposed through the porcelain bowl. On 5/27/25 at 9:01 am, R1 stated, My toilet bowl has been like that for quite a while. It's like all the paint at the bottom of the bowl is scraped off and the porcelain is off, but it looks dirty. I do not think they have ever tried to replace it or fix it. b) On 5/27/25 at 8:39 am and 5/28/25 at 1:56 pm, R2's and R9's shared adjoining restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. On 5/27/25 at 8:39 am, R2 stated, I have not had any paper towels to dry my hands off for quite a few days. On 5/28/25 at 1:57 pm, R9 stated, I have been here for six days, and I have not had any paper towels in the bathroom since I have been here. I do not even have any towels to dry my hands, so I just wipe my hands on my clothes. c) On 5/27/25 at 8:52 am and 5/28/25 at 2:07 pm, R3's (Resident Council President) restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. R3's restroom had a moderate area of yellow colored wet substance (urine) on the floor base of the commode and debris on the floor. On 5/27/25 at 8:52 am, R3 (Resident Council President) stated, I do not have any towels in by bathroom to clean my hands, they ran out. d) On 5/27/25 at 9:13 am, R8's restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. On 5/27/25 at 9:14 am, R8 stated, They run out of towels in the bathroom all the time. I just do not use anything to dry my hands, I just shake them. e) On 5/27/25 at 8:26 am, R4's restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. On 5/27/25 at 8:27 am, R4 stated, There are no hand towels in the bathroom. Sometimes I have to ask for them, now they have not filled them for a couple of days. f) On 5/27/25 at 9:08 am, R7's restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. R7's bathroom commode had an attached raised plastic seat riser. The bottom side rim of the seat riser (closest to the water in the commode bowl) was entirely black tinged on the rim and the seat riser, toilet tank and surrounding commode had a substantial amount of splattered brown/black debris. On 5/27/25 at 9:08 am, R7 stated, I ran out of bathroom towels, and they have not put any in for a couple days. I am not sure what that black stuff on that white toilet riser is, it looks like black mold, and it never cleans off. g) On 5/17/25 at 9:50 am, R10's restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash cloths/hand towels. R10 was not available for interview. h) On 5/28/25 at 8:40 am, R11 and R12's restroom paper towel dispenser was empty, did not have disposable paper towels or did not have clean wash clothes/hand towels. On 5/28/25 at 8:49 am, V8 (Housekeeping) was pushing a housekeeping supply cart down the hallway, and V8's cart did not have any disposable paper towels. V8 stated, I do not have any paper towels. On 5/27/28 at 10:30 am, the Facility main supply closet did not have disposable paper towels in stock. V7 (Housekeeping/Maintenance/Laundry Supervisor) stated, We do not currently have any paper towels, our shipment should be coming in within the next day or so. I do know that some of the rooms are out of paper towels, but they probably did not get changed since it was the Memorial Day holiday weekend. V7 verified that the Facility did not have paper towels in stock to re-stock the Resident restrooms. On 5/28/25 at 11:00 am, V1 (Administrator) stated, I just sent (V8) to buy more disposable towels at the local discount store until our shipment gets in. I was never made aware that we did not have any paper towels until now, and that so many Residents were without them. (V8) has only been here for about two months and has to oversee three departments, so (V8) is still learning how to order supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a PASARR (Pre-admission Screening and Resident Review) Level I screening and/or Level II referral were completed for one (R2) of two residents reviewed for PASARR Screenings in the sample of 22. Findings include: The facility's Preadmission Screening and Annual Resident Review (PASARR) Policy and Procedure dated 3/2024 documents, It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASARR) screening process (Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD (Serious Mental Illness/Serious Mental Disorder)), intellectual disability (ID) or related condition. Based upon the Level I screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been requested. The facility will coordinate with the State PASARR representative related to the individual needs of the resident as indicated. R2's current diagnoses include: Unspecified Psychosis; Chronic Obstructive Pulmonary Disease(COPD), Alcohol Dependence, Alcoholic Hepatitis, Esophageal varices, Anxiety, Epilepsy, Cirrhosis of Liver. Facility documentation indicated that R2 was admitted to the facility on [DATE]. R2's current Medical Record has no documentation to show that a PASARR screening was completed prior to R2's admit to the facility. On 3/20/25 at 11:40 AM, V5 Minimum Data Set/MDS/Care Plan Coordinator stated that the facility got new owners on 11/1/24 and she does not know where the resident charts from the previous owners of the facility were located; V5 stated that she was unable to locate a Level I screening that should have been done for R2 prior to his admit to the facility. At this same time, V5 stated: There should also have been a Level II screening referral for (R2) as well for his Psychosis diagnosis. I will try to follow up with the (agency) to see if they (Level I and Level II Screenings) were done and have copies.

Based on observation, interview and record review the Facility failed to provide activity of daily living/ADL assistance for hygiene/scheduled baths for one dependent resident (R4) of 16 resident's reviewed for Activity of Daily Living assistance in a sample of 22. Findings include: The Facility Bathing, Shower and Tub Bath Policy, revised 10/2024, documents: To ensure the residents cleanliness to maintain proper hygiene and dignity; shower, tub bath or bed/sponge bath will be offered according to resident's preference, no less than once per week or according to the resident's preferred frequency and as needed or requested; and shower chair or bed, towels and wash cloths, body wash, shampoo, deodorant/antiperspirant, lotion and other toiletry items as requested by resident and residents clothing. R4's current Care Plan documents: (R4) requires staff assistant for Activities of Daily Living/ADL for bathing and grooming; assure resident that staff is plentiful and available for assist at any time;.maintain consistent routine to insure compliance and avoid confusion; monitor for changes in condition ADL assist level; has an ADL self-care performance deficit related to Hemiplegia/Hemiparesis following a stroke (Cerebral Vascular Accident) affecting right dominate side; requires the assist of two staff members with bathing/showering and dressing; and requires one assist with personal hygiene and oral care. The Facility Resident Shower Schedule, undated, does not document a scheduled shower day or time for R4's (Room number) shower. On 3/19/25 at 11:00 am, V4 (Corporate Regional Nurse Consultant) could not provide R4's Shower/Abnormal Skin Reports in the entirety for the period of 12/15/25 through 3/19/25. V4 did provide R4's Shower/Abnormal Skin Sheets that were dated 1/9/25, 1/13/25, 1/20/25, 1/23/25, 1/27/25, 1/30/25, 2/14/25, 2/18/25, 2/21/25 and 2/25/25. All Shower/Abnormal Skin Reports document that R4 received a bed bath, and no showers were documented. On 3/18/25 at 11:30 AM, R4 was lying in bed, hair unkempt and appeared to be oily/greasy. R4 stated, I never get a shower, all they do is just wash me up while I am in bed. They wash my hair with a sponge that they just swipe it about three or four times across my crown. I know that I am a big lady, but I would like to actually get up out of bed and into the shower. I have not gotten a real shower since before Christmas. On 3/19/25 at 1:02 PM, R4 was lying in bed talking to V4 (Corporate Regional Nurse Consultant) and stated to V4 I have not had a shower since before Christmas. They just give me bed baths and I want to get in a shower. On 3/19/25 at 11:01 AM, V4 (Corporate Regional Nurse Consultant) stated, I cannot find all of (R4's) Shower records. I am not going to lie to you, but when I looked up (R4's) bathing ADL (Activity of Daily Living) in our computer program it looks like (R4's) showers were scheduled for midnight so they documented that she was always refusing them, so (R4) never got any showers.

Based on observation, interview, and record review, the facility failed to have orders for a BiPAP/Bilevel Positive Airway Pressure machine and failed to label and change oxygen and nebulizers per their policy and orders for three (R30, R191, and R192) of five residents reviewed for oxygen in a sample of 22. Findings include: Facility Oxygen and Respiratory Equipment- Change/Cleaning, copyright 2025, documents The hand held nebulizer should be changed weekly and PRN (as needed). A clean plastic bag with a zip loc or draw string will be provided with each new set up and will be marked with the date the set up was changed. Nasal cannulas are to be changed once a week and PRN. A clean plastic bag with a zip loc or draw string will be provided to store the cannula when it is not in use. It will be dated with the date the tubing was changed. On 3/21/25 at 11:11 AM, V19 RN/Registered Nurse stated Night shift nurses are responsible for changing oxygen tubing and humidifiers out. We assist residents with cleaning their CPAP (Continuous Positive Airway Pressure)/BIPAP or make sure they are on at night and off in the morning, and document that on the MAR/Medication Administration Record or TAR/Treatment Administration Record, or the CNAs/Certified Nurse Aides document in their tasks. The oxygen and nebulizer tubings are changed weekly on night shift and should be labeled with the date they were changed. 1. R30's current orders for March 2025 document Oxygen at 3L (liters) via nasal cannula continuous with an order date of 1/29/2025. Change Oxygen tubing cloth/plastic holding bag every night shift every Wednesday with an order date of 1/29/2025. Change 02 (oxygen) and Nebulizer Tubing weekly every night shift every Wednesday. On 3/18/25 at 11:30 AM, R30 was in her room with oxygen on via nasal cannula at three liters. R30 also had a nebulizer machine with tubing not in a bag that she stated she uses four times a day. Oxygen tubing was dated February 2025 and nebulizer tubing had no date. 2. On 3/20/25 at 1:50 PM, R191 had a BiPAP machine and distilled water in his room. At that same time, R191 stated he uses his BiPAP every night. R191's medical record has no orders for his BiPAP machine. 3. On 3/19/25 at 11:34 AM, R192 had distilled water and a CPAP at the bedside, nebulizer machine and tubing not in a bag, and oxygen was on at 4L via nasal cannula. The nebulizer and oxygen tubing had no dates. At that same time, R192 stated she uses her oxygen and nebulizer daily, and her CPAP at night. R192's current orders for March 2025 document O2/Oxygen via nasal prongs at 4L with an order date of 1/9/25. Change oxygen tubing and humidifier bottle weekly and PRN at bedtime every Sunday with an order date of 1/9/25. R192's orders for March 2025 had orders for her CPAP and nebulizer treatments.

Based on observation, interview and record review, the facility failed to provide specialized rehab services after an order for one (R191) of one resident reviewed for Rehab Services in a sample of 22. Findings include: R191's hospital Physical Therapy notes, dated 3/4/25, documents Decline in functional mobility, poor functional mobility, and deconditioning. Discharge disposition: Nursing home for continued therapy. Frequency: 1-2 times/day on Monday through Friday. Duration: 2 weeks. Treatment plan to include the following: Gait training; mobility/transfers/strength/ROM (Range of Motion); education; family training; and balance activities. R191's medical record documents an admission date of 3/5/2025 (Wednesday), and a medical diagnosis of Polymyalgia Rheumatica and Congestive Heart Failure/CHF. R191's current care plan for March 2025 documents The resident is at risk for falls related to impaired mobility. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Pt evaluate and treat as ordered or PRN/as needed. R191's progress note, dated 3/5/2025 2:56 PM, documents Resident arrived in a wheelchair from the hospital with admitting diagnosis of Muscle Weakness (Generalized). R191's nursing note, dated 3/6/25 at 12:50 PM, documents Needs assist with transfers and ADL's/Activities of Daily Living. R191's physician orders, dated 3/6/25, documents the following: OT (Occupation Therapy)/PT (Physical Therapy)/ST (Speech Therapy) may evaluate and treat as indicated. R191 Physical Therapy evaluation and plan of treatment notes, document a start of care date 3/14/25. On 3/21/25 at 10:00 AM, R191 was in the hallway with physical therapy and a gaitbelt with a wheeled walker. At that same time R191 was alert and oriented and stated the following: I am getting therapy for my legs; I didn't get it for two weeks and I was about to leave; I started therapy this week; I was really disappointed I didn't start right away and I was going to go home and walk down the road with my wife if they didn't get therapy started; and I am not sure why it didn't start right away because that is why I am here to get therapy and go home with my wife. On 3/21/25 at 11:05 AM, V20 PTA/Physical Therapy Aid stated (R191) got therapy 3/17, 3/18, 3/20, and 3/21/25 for 55 minutes. He was evaluated last Friday on 3/14/25. We have a COTA/Certified Occupational Therapy Aid here 2-3 days a week and PTA here five days a week. I have six residents I give PT to for about 3.5 hours a day here.

Based on interview and record review, the facility failed to have a Registered Nurse/RN for eight hours a day seven days a week. This has the potential to affect all 46 residents in the facility. Findings include: Facility Assessment, updated 3/1/25, documents Average daily census of 40. Facility resources needed to provide competent support and care for our resident population every day and during emergencies. Staff type; Nursing Services RN-1 on day shift. State PBJ/Payroll Based Journal Staffing Data Report, Quarter (October 1 - December 31, 2024) documents no RN hours on the following dates: 11/01 (FR/Friday); 11/02 (SA/Saturday); 11/03 (SU/Sunday); 11/09 (SA); 11/10 (SU); 11/16 (SA); 11/17 (SU); 11/23 (SA); 11/24 (SU); 11/30 (SA); 12/01 (SU); 12/07 (SA); 12/08 (SU); 12/14 (SA); 12/15 (SU); 12/21 (SA); 12/22 (SU); 12/25 (WE/Wednesday); 12/28 (SA); and 12/29 (SU). Facility daily staffing sheets for January thru March 2025 reviewed with no RN coverage for 1/11, 1/12, 1/25, 1/26, 2/8, 2/9, 2/22, 2/23, 3/8 and 3/9/25. V2 DON confirmed no RN coverage on those dates. Facility CNA/Nurse listing, undated, documents ten nurses are employed by the facility where two (V2 DON and V19 RN) are RN's and the rest are LPN's/Licensed Practical Nurses. On 3/18/25 at 10:45 AM, V1 Administrator stated the current facility took over the Nursing Home November 1, 2024. On 3/21/25 at 11:00 AM, V2 DON/Director of Nursing stated the following: We have three opening for nurses; no RN's thru agency available; LPN's cover the weekend shifts that V19 RN doesn't work; and we only have one RN on staff and she works every other weekend. At that same time, V2 verified she does not come in on the weekends to cover the RN coverage openings. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 3/18/2025, documents 46 residents reside in the facility.

Based on observation, interview and record review, the facility failed to have a Certified Dietary Manager/CDM and failed to have certified staff. This has the potential to affect all 46 residents in the facility. Findings include: Facility Dietary Aid job description, copyright 2025, documents The dietary aid is responsible for aiding all food functions as directed/instructed and in accordance with established food policies and procedures. Essential Duties and Responsibilities: Ensure food is prepared in accordance with sanitary regulations. Facility Dietary Manager/DM job description, copyright 2025, documents The Dietary Manager is responsible for partnering with the Dietician to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, to assure that quality nutritional services are provided on a daily basis and that the Dietary Department is maintained in a clean, safe, and sanitary manner. Must possess Food Service Sanitation Manager Certification. Facility Cook job description, copyright 2025, documents The [NAME] is responsible for food preparation in accordance with current applicable federal, state, and local standards, guidelines and regulations, with our established policies and procedures, to assure that quality food services is provided at all times. Must have Illinois Food Service Sanitation certification. Dining Menu Week at a Glance, copyright 2025, documents for week four 3/18/25 (Tuesday) lunch of the following: Ground Beef Stroganoff Over Noodles, Soft Chopped Sauteed Fresh Zucchini, Bread/Margarine, Soft Chopped Canned Chilled Fruit, and Beverage. Facility Dietary Schedule, March 2025, documents the following: V6 DM worked 3/2-3/4; 3/8, 3/12, 3/14, 3/17 and 3/20/25 as a cook, afternoon or morning aid, and DM; V10 [NAME] worked 3/1, 3/2, 3/4-3/7, 3/10-3/13, 3/15, 3/16, 3/18-3/20/25 as the morning cook; V11 [NAME] 3/9/25 as the afternoon aid; V12 [NAME] worked 3/3-3/5; 3/8-3/11; 3/13, 3/14, 3/17-3/19/25 as the morning cook, and morning aid; V13 [NAME] worked 3/1-3/4, 3/7, 3/10, 3/11, 3/13, 3/15, 3/16, 3/18/25 as the afternoon cook, and afternoon aid; V14 DA worked 3/1-3/3, 3/6-3/8, 3/15, 3/16/25 as the morning aid; V15 DA 3/3/25 as the afternoon aid; and V16 DA worked 3/3/1, 3/2, 3/5-3/7, 3/9, 3/10, 3/12, 3/14-3/17, and 3/19/25 as the afternoon aid. During this survey from 3/18/25-3/21/25, the facility was unable to provide a CDM certificate and staff food handler certificates. On 3/18/25 at 11:00 AM, V6 DM/Dietary Manager stated I don't have my CDM certificate; I have been here since November 2024 working as the DM; my food handler certificate expired the beginning of this month (March 2025); and I cannot find any of my staff food handler certificates and my staff does not have a copy or able to obtain their food handler certificates. At that same time, V10 [NAME] and V12 Dietary Aid were observed during a meal delivery service where V10 scooped the food onto plates for the residents, and V12 put the drinks and supplements on the trays and handed to the staff outside of the kitchen. V6 DM Serv Safe Certification documents Date of Expiration 3/2/25. Facility Food Protection Manager (Sanitation 8 hour course for cooks), undated, documents the following: V6 [NAME] expiration date 3/2/25; and V10-V13 all Cooks had no certification. Facility Food Handlers Certificate (dietary aides), undated, documents the following: V14-V16 all dietary aides had no certification. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 3/18/2025, documents 46 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to have sufficient staff during the meal service. This has the potential to affect all 46 residents in the facility. Findings include: Facility Assessment, updated 3/1/25, documents Average daily census of 40. Facility resources needed to provide competent support and care for our resident population every day and during emergencies. Staff type: Food and Nutrition Services (Director, support staff, Registered Dietician). Facility Dietary Aid job description, copyright 2025, documents The dietary aid is responsible for aiding all food functions. Facility Dietary Manager job description, copyright 2025, documents The Dietary Manager is responsible to assure that quality nutritional services are provided on a daily basis. Facility Cook job description, copyright 2025, documents The [NAME] is responsible to assure that quality food services is provided at all times. Facility Meal times and locations, undated, documents 7:30 AM small and main dining room; 11:30 AM small and main dining room; and 5:30 PM small and mail dining room. On 3/18/25 at 11:00 AM during a meal service, staff filled meal carts for residents that eat their meals in their room and left the dining room to serve residents down the hallways which left no staff to serve the residents who were seated in the dining room. On 3/18/25 at 11:00 AM, V6 Dietary Manager/DM stated We serve room trays first and there is quite a lot of them. The staff delivers the food down the hallways and the residents in the dining room have to wait for their food because there is not enough staff to serve the residents in the dining room. I have one person help deliver trays from the dietary department. During the resident council meeting on 03/19/25 at 10:00 AM, all five residents (R13, R3, R36, R31, and R33) in attendance stated We have to wait for our meals in the dining room because their is not enough staff; they serve the room trays first and the staff is busy doing that; they tried serving the dining room first but that didn't work either; they don't have enough staff for meals; and they need to find a solution. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 3/18/2025, documents 46 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to have a delivery, use-by date, or expiration date for Zucchini and loaves of bread. This has the potential to affect all 46 residents in the facility. Findings include: Facility Food and Supplies: Storage, copyright 2025, documents All foods will be covered, labeled, and dated. If there is no expiration date on the package or container, a use-by date must be written on the product. On 3/18/25 at 11:00 AM during the kitchen tour with V6 DM/Dietary Manager a bag of frozen zucchini had no date on it when received, use-by date, or expiration date; and multiple loaves of bread did not have a received, use-by date, or expiration date on them. At that same time V6 DM stated I thought the bread had a date on them, but I don't see one, and that bag of zucchini was taken out of the box today. I am on staff all the time to make sure they are dating when we get our deliveries and when they are opened. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 3/18/2025, documents 46 residents reside in the facility.

Based on observation, interview and record review the Facility failed to ensure that ongoing resident centered activity programs were being offered. This failure has the potential to affect all 40 Residents residing in the Facility. Findings include: Facility Resident Census Roster, dated 12/9/24, documents 40 Residents residing in the Facility. Facility Resident Rights Policy, revised 11/2018, documents: the Facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; must provide equal access to quality care; must provide services to keep your physical and mental health, at their highest practical levels; and you have the right to participate in social and community activities. The Facility Activity Director Essential Duties and Responsibilities/Job Description, revised 5/2023, documents: to provide ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial wellbeing of each Resident; and to develop and plan activities. On 12/10/24 at 9:30 am, 9:55 am, 10:02 am, 10:30 am, 11:40 am, 12:42 pm, 1:10 pm and 1:30 pm, the Facility did not have any scheduled Activities being conducted. On 12/10/24 at 10::00 am, R5 (Resident Council President) stated, We lost our Activity girl and we have not had anything going on in activities for over a week. I would definitely go, if they had them, because I like to stay busy. I have had other Residents complain about this too. On 12/10/224 at 10:40 am, R7 stated, I go to the activities when they have them, but they are not having any right now. On 12/10/24 at 10:45 am, R6 stated, There are no activities here. I like music and Bingo. I am legally blind, so I would need someone to help me play Bingo. I get a lot of anxiety from just sitting in my room. On 12/10/24 at 1:33 pm, R2 stated, There are no activities to go to, they are not having them right now. I would like to go to Bingo and I also like to color and stuff. On 12/10/14 at 1:40 pm, R3 stated, I am here getting therapy and I have not been to any activities in over a week. I have not heard or seen anything going on. On 12/9/24 at 10:02 am, V3 (Social Service Director) stated, I just started working here on 11/18/24, and we have not had an Activity Director for at least over a week. The last I knew, was that she just up and quit. I have not seen hardly any activities going on in here for the Residents. I just found out that they are assigning me to the Activity Director position as well, so I guess I will be doing both jobs. On 12/12/24 at 11:10 am, V1 (Administrator in Training/AIT) verified that the Facility did not have an Activity Director or full time Activity Assistant, and stated, (V10/Former Activity Director) had just started recently, then just up and quit over a week ago, and we have not had anyone in that position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to cover a urinary catheter bag with a privacy bag and failed to provide a washcloth instead of a paper towel to use to wash the resident's face for two residents (R15, R23) of 16 residents reviewed for dignity in the sample of 29. Findings include: The Resident Rights Booklet dated 11/18, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must be safe, clean, comfortable, and homelike. 1. R15's current electronic medical record, documents R15 was admitted to the facility on [DATE] with diagnosis which included Neoplasm of Uncertain Behavior of Right Kidney, Alzheimer's Disease, Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Schizophrenia, and Altered Mental Status. R15's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 3/15, indicating severe cognitive impairment. R15's Physicians Order dated 1/5/24 documents R15 has a (indwelling) catheter for diagnosis of Urinary Retention. On 6/02/24 at 7:35 AM, R15 was sitting in the dining room. R15's urinary drainage bag was not covered with a privacy bag. The urinary drainage bag was hooked under R15's chair and the bag with urine was visible. On 6/5/24 at 1:10 PM, V17/Certified Nursing Assistant/CNA stated that there were no privacy bags to use to cover R15's urinary drainage bag until Monday (6/3/24). V17 also stated I know it is a dignity thing. On 6/5/24 at 1:13 PM, V22/CNA stated that R15's urinary drainage bags are provided by hospice, but it might have been misplaced and that is why it was not on the urinary drainage bag on 6/2/24. 2. R23's current electronic medical record, documents R23 was admitted to the facility on [DATE] with diagnosis which included Repeated Falls, Urinary Tract Infection, Benign Proximal Vertigo/Right Ear, Malignant Neoplasm of Bladder, Anxiety Disorder, and Major Depressive Disorder. R23's MDS (Minimum Data Set) dated 5/9/24 documents a BIMS (Brief Interview for Mental Status) Score of 15/15, indicating cognitively intact. On 6/4/24 at 7:50 AM V17 (CNA) opened the linen storage room. The linen storage room had no wash cloths or towels. V17 stated there is only one linen storage room and there is never wash cloths or towel available. On 6/02/24 at 7:38 AM R23 stated Staff act like I don't exist. It is hard for me to get anyone to help me. The staff don't show any dignity or respect to any of us. On 6/4/24 at 9:00 AM V18 (CNA) stated, We never have wash clothes or towels in the building. There are maybe two of each. We use bath blankets or pillowcases to wash the residents up. The shower curtain has had mold on the bottom of it for two years. On 6/4/24 at 10:35 AM R23 stated, It is not right we do not have wash clothes. My dog is treated better. I wash my face with a paper towel.

Based on record review and interview the facility failed to prevent resident (R35) to resident (R19) verbal abuse for one of two residents (R19) reviewed for abuse in the sample of 29. Findings include: The facility's Abuse Prevention Program dated 11-28-16 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies. Verbal abuse in the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. R35's Progress Notes dated 4-1-24 at 1:23 PM documents, V5 (Social Service Director) Note Text: Writer overheard resident (R35) at bingo yelling at another resident (R19), Get out of here. No n*****s allowed. I'm getting out of here too many n****rs in here. Writer spoke to resident that it is politically incorrect to use that term, and this is the other residents home as well as his. On 6/03/24 at 09:29 AM R19 stated R35 has called me a n****r twice and the last time I was playing bingo R35 stated a n****r should be hung from a tree. I do not want R35 to call me a n****r. It is abusive to call me a n****r. On 6/03/24 at 02:18 PM V5 (Social Service Director) stated, I heard (R35) call (R19) a n****r during bingo. I consider that verbal abuse and reported this to (V2/Administrator-In-Training) immediately.

Based on record review and interview the facility failed to report an allegation of resident (R35) to resident (R19) verbal abuse to the state agency for two of two residents (R19 and R35) reviewed for abuse in the sample of 29. Findings: The facility's Abuse Prevention Program dated 11-28-16 documents, Verbal abuse in the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility must ensure that all alleged violations involving abuse are reported to the (State agency) immediately after forming suspicion but no later than two hour after forming suspicion. R35's Progress Notes dated 4-1-24 at 1:23 PM documents, V5 (Social Service Director) Note Text: Writer overheard resident (R35) at bingo yelling at another resident (R19), Get out of here. No n*****s allowed. I'm getting out of here too many n****rs in here. Writer spoke to resident that it is politically incorrect to use that term, and this is the other residents home as well as his. On 06/03/24 at 2:18 PM V5 (Social Service Director) stated, I heard (R35) call (R19) a n****r during bingo. I consider that verbal abuse and reported this to (V2/Administrator-In-Training) immediately. On 06/03/24 at 11:00 AM V2 (Administrator-In-Training) stated, I did not do an abuse investigation regarding (R19) and (R35), therefor the allegation was not reported to (the State Agency).

Based on record review and interview the facility failed to investigate an allegation of resident (R35) to resident (R19) verbal abuse for two of two residents (R19 and R35) reviewed for abuse in the sample of 29. Findings: The facility's Abuse Prevention Program dated 11-28-16 documents, Internal Investigation of Allegations and Response: 1. Once the administrator or designee receives and allegation of abuse the administrator will appoint a person to take charge of the investigation. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. R35's Progress Notes dated 4-1-24 at 1:23 PM documents, V5 (Social Service Director) Note Text: Writer overheard resident (R35) at bingo yelling at another resident (R19), Get out of here. No n****rs allowed. I'm getting out of here too many n****rs in here. The facility's Abuse Investigations dated 3-1-24 through 6-2-24 do not include an abuse investigation regarding the alleged verbal abuse between R35 to R19 that occurred on 4-1-24. On 6/03/24 at 2:18 PM V5 (Social Service Director) stated, I heard (R35) call (R19) a n****r during bingo. I consider that verbal abuse and reported this to (V2/Administrator-In-Training) immediately. On 6/03/24 at 11:00 AM V2 (Administrator-In-Training) stated, I did not do an abuse investigation regarding (R19) and (R35). I guess I did not think of (R35) calling (R19) a n****r as abuse. I just filled out a grievance form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a PASRR (Pre-admission Screening and Resident Review) Recommendations Care Plan for one resident (R15) out of 16 reviewed for Care Plans in a sample of 29. Findings Include: The Comprehensive Care Plan dated 11/1/17, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. The following procedures shall be utilized in the development and maintenance of care plans 3. Components of the CPC (Comprehensive Care Plan) may include: a. Care Plans Summary/Participation Record-Contains pertinent information about the Resident including a summary listing of healthcare information such as physician orders, dietary orders, therapy services, social services, PASARR (Preadmission Screening and Resident Review) recommendations and discharge plans as appropriate for the Resident at the time a conference is held and documents involvement of the resident/resident representative in the development, review and revision of the care plan. e. Care Plan-Plan of care describing a need/problem and indicating approaches/interventions to be instituted to assist the Resident in maintaining/ receiving care in relation to the need/problem. 1. R15's current computerized medical record, documents R15 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Schizophrenia, and Altered Mental Status. R15's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 3/15, indicating (severe cognitive impairment) R15's PASRR (Preadmission Screening and Resident Review) Level I Screen Outcome dated 10-13-17 documents, Based on the initial OBRA-I review, the individual has been referred to one (1) of the following authorized pre-admission screening entities. Indicate the date of the referral. Indicate also the type and name of the organization to which the individual is being referred. R15's current Care Plan does not include a plan of a care to address R15's PASRR recommendations. On 6/6/24 at 2:40 PM, V4/Resident Care Coordinator verified there is no Care Plan for R15's PASRR Level I recommendation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R15's current electronic medical record, documents R15 was admitted to the facility on [DATE] with diagnosis which included Neoplasm of Uncertain Behavior of Right Kidney, Alzheimer's Disease, Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Schizophrenia, and Altered Mental Status. R15's MDS (Minimum Data Set) dated 4/5/24 documents a BIMS (Brief Interview for Mental Status) Score of 3/15, indicating (severe cognitive impairment). R15's PASRR Level I Screen Outcome dated 10-13-17 documents, Based on the initial OBRA-I (Omnibus Budget Reconciliation Act) review, the individual has been referred to one (1) of the following authorized pre-admission screening entities. Indicate the date of the referral. Indicate also the type and name of the organization to which the individual is being referred. R15 is being referred to (Hospital Behavioral Health). R15's Medical Record does not include evidence of the facility obtaining R15's PASRR Level II. On 6/4/24 at 1:32 PM, V5/Business Office Manager/Social Services stated that R15 has a level I Preadmission Screening and Resident Review/PASRR done and was referred to the (hospital) Behavioral Health. R15 did not have a PASRR level two completed. 3. R21's current computerized medical record, documents R21 was admitted to the facility on [DATE] with diagnosis which include Bipolar Disorder, Current Episode Mixed, Severe, with Psychotic Features, Vascular Dementia, Moderate, with Mood Disturbance, Depression, and Schizoaffective Disorder. R21's MDS (Minimum Data Set) dated 4/12/24 documents R21 is rarely understood with moderate impairment. R21's Medical Record does not include evidence of the facility obtaining R21's PASRR Level I prior to admission to the facility. On 6/03/24 at 12:45 PM, V5/Business Office Manager/Social Services stated A pre-admission screen was requested by the facility. The facility did not get it back. I don't know why it was not done earlier. I checked with Adult Senior Services, and they verified that they did not do a screening on (R21). Based on record review and interview the facility failed to obtain a level one PASRR (Pre-admission Screening and Resident Review) for one resident (R21) and failed to obtain a level II PASRR for two residents (R3 and R15). These failures have the potential to affect three of 16 residents (R3, R15, and R21) reviewed for pre-admission screenings in the sample of 29. Findings include: The admission Policy (undated) documents Prior to admission, a thorough pre-screening of potential residents shall be done with the resident or guardian or responsible party determining appropriate placement. 1. R3's Plan of Care documents R3 was admitted to the facility on [DATE]. R3's PASRR Level I Screen Outcome dated 12-14-23 documents, Level I Outcome: Refer for Level II Onsite. Rationale: A PASRR Level II evaluation must be conducted. That evaluation will occur as an onsite face-to-face evaluation. R3's Medical Record does not include evidence of the facility obtaining R3's PASRR Level II. On 6-4-24 at 12:30 PM V2 (Administrator-In-Training) stated, We (the facility) have not got a PASRR Level II done for (R3).

Based on interview and record review the facility failed to develop a Wound Care Plan for one resident (R24) out of 16 reviewed for Care Plans in a sample of 29. Findings Include: The Comprehensive Care Plan dated 11/1/17, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. The following procedures shall be utilized in the development and maintenance of care plans. 3. Components of the CPC (Comprehensive Care Plan) may include: a. Care Plans Summary/Participation Record-Contains pertinent information about the Resident including a summary listing of healthcare information such as physician orders, dietary orders, therapy services, social services, PASARR (Preadmission Screening and Resident Review) recommendations and discharge plans as appropriate for the Resident at the time a conference is held and documents involvement of the resident/resident representative in the development, review and revision of the care plan. e. Care Plan-Plan of care describing a need/problem and indicating approaches/interventions to be instituted to assist the Resident in maintaining/ receiving care in relation to the need/problem. R24's MDS (Minimum Data Set) dated 3/9/24 documents BIMS (Brief Interview for Mental Status) Score of 15/15, indicating R24 is cognitively intact. R24's Skin/Wound Note dated 5/22/2024 at 12:59 PM, documents the Wound Nurse Practitioner is here to see R24, due to new areas on right and left buttock and right lower leg. R24's current Care Plan does not document a Care Plan for any of R24's wounds. On 6/02/24 at 7:20 AM, R24 stated she has a wound on her buttock that she got after coming to the facility. On 6/6/24 at 2:45 PM, V4/Resident Care Coordinator verified there is no Care Plan for R24's wounds.

Based on observation, interview, and record review the facility failed to document justifiable behaviors or diagnosis to warrant the use of an anti-psychotic medication for one of one resident (R27) reviewed for anti-psychotic medication use with the diagnosis of Alzheimer's Disease in the sample of 29. Findings include: The Psychotropic Medication Policy dated 11/28/17, documents Policy: It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: 4. Without adequate indication for its use. Definition of a Psychotropic Medication: Medication that is used for or listed as used for antipsychotic, antidepressant, antimonic, antianxiety, behavior modification, or behavior management purposes. Definition of Antipsychotic Drug: A neuroleptic drug that is helpful in the treatment of psychosis and has a capacity to ameliorate thought disorders.7. Any resident receiving such medications shall have a psychiatric diagnosis or documented evidence of maladaptive behavior, which can be considered harmful to themselves or others, destructive to property, or if emotional problems exist which caused the resident frightful distress. R27's BIMS (Brief Interview of Mental Status) dated 3-11-24 documents R27 is severely cognitively impaired. R27's MDS (Minimum Data Set) Assessments dated 3-11-24 and 12-10-23 document R27 has no physical, verbal, or other behaviors that affect herself or others. R27's Order Summary Report dated 6-2-24 documents R27 has the diagnoses of Alzheimer's Disease and Delusional Disorders and has the following order: Order date: 2-29-24 Quetiapine (Seroquel) 50 mg (milligrams) one tablet two times daily. R27's Psychotropic Medication Quarterly Evaluation dated 3-12-24 documents R27 receives Seroquel for the diagnosis of Agitation and for the targeted behaviors of verbal aggression and refusal of cares. R27's current Care plan documents R27 is receiving an anti-psychotic medication for the targeted behaviors of pacing, wandering, disrobing, inappropriate response to verbal communication, and violence/aggression towards staff. R27's Behavior Monitoring and Interventions Reports dated 2-1-24 through 6-5-24 document R27 has had no behaviors except for on 2-19-24, 3-20-24, and 5-21-24 when R27 experienced self-isolation, anxiety, was making disrupting sounds, and was experiencing frustrations. On 6-5-24 at 11:00 AM V17 (CNA/Certified Nursing Assistant) used a gait belt and stand-by-assistance and walked R27 from her room to the dining room. R27 had no behaviors during this time. On 6-5-24 from 11:00 AM through 12:15 PM R27 was sitting in a dining room chair with her head lying on the dining room table. R27 was sleeping during this time. On 6-2-24 at 7:30 AM V6 (LPN/Licensed Practical Nurse) stated, (R27) only hits and yells at staff during cares. (R27) does not have behaviors any other time. On 6-4-24 at 2:15 PM V18 (CNA/Certified Nursing Assistant) stated, (R27) really does not have any behaviors except for yelling during cares. On 6-5-24 at 11:30 AM V16 (CNA) and V17 (CNA) stated R27 only has behaviors of yelling at staff during cares only and swatting at staff during cares only. V16 and V17 stated R27 does not have behaviors any other time and sleeps a lot. On 6-5-24 at 11:15 AM V4 (Resident Care Coordinator) stated, (R27) has been on Seroquel since 9-29-21. I cannot find in (R27's) the medical justification or behaviors (R27) was having to start (R27) on Seroquel. (R27) only has behaviors during cares of yelling at staff and sometimes hitting at staff. (R27) does not have behaviors any other time. (R27) having behaviors with cares and the diagnosis of Alzheimer's Disease only does not justify the use of (R27) receiving an anti-psychotic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R16's current electronic medical record, documents R16 was admitted to the facility on [DATE] with diagnosis which included Chronic Pulmonary Edema, Essential Primary Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Acute Kidney Failure, and Chronic Systolic (Congestive) Heart Failure. R16's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 13/15, indicating (cognition intact). R16's Care Plan dated 5/14/24, documents Will actively participate in moving/exercising joints with verbal cues twice daily thru next 90 days. Interventions Encourage (R16) to Perform ROM (Range of Motion) exercises to joints bid (twice a day), using 5-10 reps to each joint. On 6/2/24 at 7:03 AM, R16 was sitting in his recliner in his room. R16 stated that he stays in his room most of the time and does not do exercises. 4. R24's current electronic medical record, documents R24 was admitted to the facility on [DATE] with diagnosis which included Polyneuropathy, Atherosclerosis of Native Arteries of Extremities with Intermittent Claudication, Unspecified Extremity, Bilateral Primary Osteoarthritis of Knee, and Thrombocytosis. R24's MDS assessment dated [DATE] documents a BIMS Score of 15/15, indicating (cognition intact) and documents R24 requires substantial assistance for activities of daily living and bed mobility. R24's Care Plan documents Goal- R24 will allow CNA/Certified Nursing Assistant to perform Passive Range of Motion with no resistance or evidence of pain thru next 90 days. R24 will actively participate in moving/exercising joints with verbal cues twice daily thru next 90 days. Interventions Advance number of repetitions to joints indicated by 3-4 repetitions per month when joints move freely and easily with no pain. Assess and document Restorative participation and response to program quarterly and as needed for change in abilities. Note barriers to participation and endurance. Review goals and approaches with Intradisciplinary Team/IDT quarterly and as needed with changes in Resident condition. Revise goal and approaches as needed to maximize participation and independence levels. Note and share successful strategies for participation and goal achievement. Encourage Resident to Perform ROM/Range of Motion exercises to joints twice a day, using 5-10 reps to each joint. Remind Resident never to move joint further in range if pain occurs. On 6/02/24 at 7:20 AM, R24 stated I can't do as much for myself as I used to. They are not good at repositioning me. They don't come around every two hours to reposition me. I can't reposition myself. Nobody does exercises with me. On 6-5-24 at 10:40 AM V16 (CNA) and V17 (CNA) both stated they do not have time to perform R16, R24, or R35's range of motion exercises. On 6/7/24 at 11:50 AM, V1/Administrator stated, The staff don't do range of motion with the residents, they are too busy sitting behind the nurse's desk on their phones. Based on observation, interview, and record review the facility failed to implement services to maintain and/or improve range of motion limitations for four of four residents (R6, R16, R24, R35) reviewed for limitations in range of motion in the sample of 29. Findings include: The Range of Motion Protocol policy dated 9/08 documents Policy: It is the policy of the facility to provide range of motion exercises for residents who through assessment demonstrate the need for exercise to prevent functional decline in range of motion. Responsibility: Nursing Assistance and Therapy Aids monitored by Licensed Nurses and Therapists. Procedure: 2) Parts of the body on which range of motion exercises can be performed include all body joints or only those affected by disease process and may include the fingers, wrist, forearm, elbow, shoulder, toes, foot, ankle, knee, hip and trunk. 3) Range of motion exercises will be conducted as scheduled by nursing staff based on need determined by assessment of risks. 6) Perform the exercises or assist the resident to perform the exercises as identified on the care plan. 7) Range of motion exercises should be repeated approximately 5-10 times as per resident's tolerance. Proceed slowly and carefully. Caution should be taken to not overtire the resident. Exercise or movement of any joint should never be proceeded beyond the point pain is noted. 1. R35's current Care Plan documents, Focus: Restorative Nursing Program-Range of Motion. Goal: Will actively participate in moving/exercising joints with verbal cues twice daily. Interventions: Advance number of repetitions to joints indicated by three to four repetitions per month when joints move freely and easily with no pain. On 6-2-24 at 8:58 AM R35 stated, There is no therapy here and what little they do have they can take and shove it up their a**. I was supposed to be getting muscle strengthening exercises to go home. I do not get s**t! 2. R6's Order Summary Report dated 6-2-24 documents R6 has the diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction Affecting the right dominant side, Chronic Pain, and Morbid Obesity. R6's MDS (Minimum Data Set) assessment dated [DATE] documents R6 has functional limitations in range of motion affecting one side of the lower and upper extremity. R6's Care Plan dated 5-28-24 documents, Focus-Restorative Nursing Program-Range of Motion. Goal: Will actively participate in moving-exercising joints with verbal cues twice daily. Interventions: Advance number of repetitions to joints indicated by three to four repetitions per month when joints move freely and easily with no pain. Encourage (R6) to perform range of motion exercises to joints twice daily using five to 10 repetitions to each joint. On 6-5-24 at 10:36 AM R6's right hand was closed in a fist position. R6 stated, I cannot open my right hand or move my right foot. I do not get exercises from the staff. On 6-5-24 at 10:40 AM both V16 (CNA/Certified Nursing Assistant) and V17 (CNA) were providing cares to R6. Both V16 and V17 stated they do not have time to perform range of motion exercises with R6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide fresh water for four residents (R6, R7, R23, and R138) of 16 residents reviewed in a sample of 29. Findings include: The Hydration policy dated 6/06 documents It is the policy of (the facility) that the facility will provide each resident with sufficient fluids to maintain proper hydration. Procedure: 2. Provide fresh water and ice at the bedside except where contraindicated, example residents with fluid restrictions. The Hydration Policy dated 2/08, documents It is the policy of (the facility) to assess individual residents who are at risk for dehydration and to provide adequate fluids to all residents to maintain proper fluid balance, prevent skin breakdown, reduce infections and to maintain residents current level of function. 1. R6's current electronic medical record, documents R6 was admitted to the facility on [DATE] with diagnosis which included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified Disorder of Kidney and Ureter, and Edema. R6's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 13/15, indicating R6 is cognitively intact. On 6/5/24 at 1:45 PM R6 was lying in bed. R6's water pitcher was sitting on the bed side table and was empty. R6 stated, I do not get fresh water every shift. I would like to have fresh water every shift. 2. R7's current electronic medical record, documents R7 was admitted to the facility on [DATE] with diagnosis which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Personal History of Urinary (Tract) Infections, Chronic Obstructive Pulmonary Disease, and Heart Failure. R7's MDS assessment dated [DATE] documents a BIMS Score of 15/15, indicating R7 is cognitively intact. On 6/5/24 at 1:55 PM, R7 was lying in bed. R7's water pitcher was almost empty. R7 stated, I have not had fresh water since yesterday evening. It is a rarity to get fresh ice water around here. I would like to get fresh water every shift. 3. R23's current electronic medical record, documents R23 was admitted to the facility on [DATE] with diagnosis which included Repeated Falls, Urinary Tract Infection, Benign Proximal Vertigo/Right Ear, Malignant Neoplasm of Bladder, Anxiety Disorder, and Major Depressive Disorder. R23's MDS assessment dated [DATE] documents a BIMS Score of 15/15, indicating R23 is cognitively intact. On 6/02/24 at 7:38 AM R23 was sitting in the dining room. R23 stated Staff do not bring me water or offer me water. Sometimes I go all day without water and staff say I have to ask for it. They say I am independent and can get it myself. On 6/5/24 at 2:10 PM R23 was lying in bed. R23's water pitcher and two empty glasses were sitting on her bedside table. R23's water pitcher was empty, R23 also stated, They do nothing for me around here. I do not get fresh ice water. 4. R138's current electronic medical record, documents R138 was admitted to the facility on [DATE] with diagnosis which included Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Chronic Kidney Disease (stage 3), Chronic Systolic Congestive Heart Failure, and Chronic Gout due To Renal Impairment. R138's MDS assessment dated [DATE] documents a BIMS Score of 15/15, indicating R138 is cognitively intact. On 6/5/24 at 2:15 PM R138 was sitting in a recliner. R138's water pitcher was half full of warm water. R138 stated, The staff could improve on making sure I get fresh ice water. I do not always get fresh ice water.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling urinary catheters for 11 of 12 residents (R3, R6, R7, R8, R15, R18, R24, R32, R33, R36, and R138) reviewed for EBP in the sample of 29. Findings include: The Enhanced Barrier Precautions dated 7/13/23 documents Purpose: To reduce transmission of multi-drug-resistant organisms/MDRO (Multi-Drug Resistant Organisms). Enhanced Barrier Precautions should be used when contact precautions do not apply, for residents with any of the following: Open wounds that require a dressing change, Indwelling Medical Devices, Infection or colonized with a MDRO. Enhance Barrier Precautions require use of a gown and gloves during high contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP is primarily intended to use for care that occurs within a residence room when high contact resident care activities are bundled together. Outside of a resident's room, EBP should be followed when performing transfers in the shower/assisting with shower and when assisting a resident with toileting and common restrooms. High-contact care activities include Dressing, Bathing/Showering, Transfers (when bundled with other high- contact resident care activities), Hygiene, Changing linens, Changing briefs or Toileting, Caring for medical devices (central lines, urinary catheters, feeding tubes, tracheostomies, drainage tubes, end ports), Wound care (pressure ulcers, diabetic ulcers, unhealed surgical wounds, chronic venous stasis wounds), and Skilled Therapies. Procedure 1. Educate staff on EBP. 2. Identify residents with an infection or colonized with a MDRO, residents with medical devices or chronic wounds that do not require contact precautions. 3. Review Contact precautions to ensure that Enhanced Barrier Precautions are appropriate. Post approved EBP signage that indicates high-contact activities. 4. Ensure that disposable or washable isolation gowns and gloves are available to HCP (Health Care Providers), where high- contact resident care activities may be required. 5. Keep a container or hamper inside resident's room for HCP to dispose of PPE (Personal Protective Equipment). On 6-2-24 at 2:00 PM V4 (Infection Preventionist) provided a list of residents who should have been placed in enhanced barrier precautions but were not. The list included the following residents: R3, R15, and R32 due to having indwelling urinary catheters and R6, R7, R8, R18, R24, R33, R36, and R138 due to having wounds. On 6-2-24 from 7:00 AM to 9:00 AM a tour of the building was done. During this tour R3, R6, R7, R8, R15, R18, R24, R32, R33, R36, and R138's doors did not have signs indicating they were in enhanced barrier precautions and V6 (LPN/Licensed Practical Nurse), V7 (CNA/Certified Nursing Assistant), and V11 (CNA) were not wearing gowns while providing personal cares to R3, R6, R7, R8, R15, R18, R24, R32, R33, R36, and R138. On 6-4-24 at 10:20 AM V20 (Agency RN/Registered Nurse) provided pressure ulcer treatments to R6's wounds to the left and right buttock. During these treatments V20 did not wear a gown. On 6-4-24 at 10:45 AM V20 provided pressure ulcer treatments to R36's right heel. During this treatment R36 did not wear a gown. On 6-4-24 at 2:00 PM V4 stated, I am the Infection Preventionist and did not know anything about Enhanced Barrier Precautions. I just requested the policy from corporate today and the facility should have been using that policy. No residents were ever placed in Enhanced Barrier Precautions prior to today.

Based on interview and record review, the facility failed to have Resident Council Meetings for five of twelve meetings in the past year, this has the potential to affect all 36 residents who live in the facility. Findings: The document, Resident Council, no date, states, It is the policy of this facility to establish a Resident Council for the purpose of residents sharing in the planning and controlling of their lives. The Resident Council shall provide a setting where personal choices, opinions, concerns, interests and complaints can be openly discussed All decisions made by this council shall be made democratically and all residents shall be encouraged to participate in the council. The council shall meet at least once per month or more often of desired. The Resident Council shall communicate to the Administrator the opinions and concerns of the residents. The council shall review procedures for implementing resident rights and facility responsibilities and make recommendations for changes or additions. On 6/03/24 at 10:00 AM, a group meeting was held with R3,R14,R20 and R36. Several topics were addressed. Attendees denied being invited to Care Plan Meetings; complained that there are not enough towels, wash cloths, linens; stated that they feel like no one listens to them when they tell them issues; did not know what a formal Grievance was, how to fill one out or where they could get a Grievance Form; had no knowledge of a Survey Book, where it was or what is kept in the Survey Book or it's importance. R14 stated, We don't have an Activity Director and she was the one who used to set up the meetings and made sure we got to them. That means we don't have a Resident Council President that we can tell things to like we used to. Residents come to me with problems that they have as I sit in the hall all the time and see what's going on. But I don't really know what to do as I don't know who to tell that it will do any good. The thing is, I used to tell staff stuff, but nothing happened, so I stopped. I feel that when we had the meetings we were able to get more things done. Or at least get things out in the open and hear what (other residents) thought. R36 stated, We don't have activities to go to and it's boring. Nothing since February. That's when the meetings stopped, too. We've asked for different things in our meetings, like a church service or some kind of entertainment. Nothing happened. No one tells us why we can't have or do things. It's like the questions go into outer space. Not that it was much better when we had the meetings, but at least (the activity director) would listen to us and it did help for some things. I'd like to have meetings so we could talk to each other about problems we have or things that would make it better to live here. I don't feel comfortable talking about my problems when I'm around staff. I don't want to make anyone mad. When you're in a group, you don't get singled out so much. R3 stated, I need to use a (two person) Mechanical Lift to get in and out of my wheelchair. Now they have a stupid rule that they need two people to transfer me. It's so stupid because the girls (Certified Nursing Assistants, CNA's) can't find someone to help her so now I have to wait a long time to get and out of this (wheelchair). Or even to take a shower. It was better when just one CNA could (transfer) me. I don't have much to do other than watch a little television or listen to music. I think we could get more done if we had the meetings again. I've never talked to the Administrator. I don't get to talk to many (staff) as they are running here and there. They're too busy to talk to me. I'm bored. I'm just waiting to die. The past twelve Resident Council Minutes were reviewed. Grievances/Complaints that were recorded include: Short staffing; Long time wait for call lights to be answered; No BINGO; not getting clothing back; no ice water; request a notary in the facility; noise and clutter in the hallways; not getting a daily menu to mark; menus not being updated (nothing new); cold meals; going on outings; bathroom cleaning; communication issues; lighting; courtesy knocking when entering resident rooms There were no documents showing that these issues were addressed or resolved. Many items were repeated at each meeting. When asked, all of the attendees thought that the Resident Council would be beneficial in making the facility more of a home for them. The facility's Activity Director's Job Summary, undated, documents, The Activity Director represents the facility and acts as advisor to the Resident Council/Prepares the minutes of the meetings and follow up on council suggestions, complaints, questions, and requests. On 6/06/24 at 12:40 PM, V2, Administrator in Training, stated, No, we haven't had Resident Council Meetings, we didn't have anyone to run them. I wasn't aware of complaints that have been made during the meetings that were held. The facility's Daily Census dated 6/2/24 documents 36 residents currently reside within the facility.

Based on observation, interview, and record review the facility failed to ensure the facility had an adequate amount of wash clothes and towels and maintained a clean shower curtain. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The Laundry policy and procedures (undated) documents, It is the policy of (the facility) that clean linens and clothing are available at all times to provide a clean sanitary environment for residents. Clean linens will be stored in clean linen rooms, and available for nursing use. The Housekeeper Job Summary (undated) documents Housekeepers are responsible for maintaining the facility in a clean, orderly and sanitary manner. Responsibilities: 1 Duties b) Deep clean assigned bath/shower rooms, each resident room and all other rooms or areas at least once each month or per the cleaning schedule or as directed. d) Bath/shower rooms are monitored for cleanliness and sanitation and the need for soap and paper products at least four times each shift. On 6-4-24 at 7:40 AM V17 (CNA/Certified Nursing Assistant) was providing a bed bath to R6. V17 was using a pillowcase to wash R6. V17 stated, We never have washcloths or towels to use. We have not had enough washcloths or towels for months. A lot of days there is only one or two washcloths in the building to use for all of the residents. R6 stated, There is never towels or washcloths to use. On 6-4-24 at 7:50 AM V17 opened the linen storage room. The linen storage room had no washcloths or towels. V17 stated there is only one linen storage room and there is never wash cloths or towels available. On 6-4-24 at 8:10 AM the main shower room shower curtain had a thick black musty smelling substance that was spread across 12 inches of the entire bottom of the curtain. On 6-4-24 at 10:30 AM R36 was sitting in a wheelchair in her room. R36 stated, It is ridiculous here. We do not even have washcloths to wash our faces. I used a paper towel to wash my face. The staff have to use sheets to wash me up in the shower. On 6-4-24 at 9:00 AM V18 (CNA) stated, We never have washcloths or towels in the building. There are maybe two of each. We use bath blankets or pillowcases to wash the residents up. The shower curtain has had mold on the bottom of it for two years. On 6-4-24 at 10:35 AM R23 stated, It is not right we do not have washcloths. My dog is treated better. I wash my face with a paper towel. The shower room curtain has always been moldy. On 6-4-24 at 10:53 AM R19 stated, We do not have enough linens. There are times I do not have washcloths. On 6-24-24 at 10:53 AM R19 stated, The shower curtain has had mold at the bottom since I have been her for two years. It is disgusting. On 6-4-24 at 2:30 PM V2 (Administrator-In-Training) stated, I tried to order washcloths and towels from a vendor and was not allowed to order from that vendor. I am now using a new vendor but have not placed an order for wash clothes or towels yet. I have known for at least a month that the shower curtain has mold on the bottom. I have not ordered a new one yet. I am working on it.

Based on observation, interview, and record review the facility failed to ensure residents were aware of the process to submit grievances, and aware of who the facility grievance official is, and failed to develop and implement a resolution to monthly resident council complaints. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The Resident Grievance/Complaints policy dated 11/1/17, documents Policy: It is the policy of (the facility) to actively encourage residents and their representatives to voice grievances and complaints on behalf of themselves or others without discrimination or reprisal. Grievances and/or complaints may be reported to the Administrator, any staff member, Resident Council and to State Agencies. All staff are required to report any and all grievances and complaints received from residents to the Social Service Director (SSD), who will serve as the grievance official. The grievance official will bring all grievance/complaints to the daily Quality Assurance meeting. The IDT (Interdisciplinary Team) will determine the best resolution. The Administrator is then responsible to ensure that resolution is carried out and the issue is resolved. Procedure: 1 The facility shall provide contact information including: grievance official name, business address, business phone; a reasonable expected timeframe for completing the review of the grievance and the right to contact outside agencies through required postings. 2 Resident Council meetings are to allow time for residents to address complaints, grievances and other concerns which shall be reflected in minutes of the meeting. The facility liaison to the Resident Council shall direct complaints and grievances to the grievance official who will take to the following morning Quality Assurance meeting. 6 Once a concern or grievance has been reported and is not easily resolved, a Grievance/Complaint Report form will be initiated. 7 The grievance official shall then investigate and take their findings to the morning Quality Assurance meeting on the next business day. The administrator will ensure the timely resolution. 8. Grievance and complaint investigations shall be completed within five working days by the SSD who should distribute copies of the report to the Administrator. The SSD shall keep complete forms on file. 9 The SSD and the Administrator shall discuss the grievance or complaint with all persons involved. The Administrator/SSD shall notify the resident/resident's representative of the circumstances and interventions for the situation and document the results of the investigation and notification of the resident/resident's representative on the Grievance/Complaint Report form. The facility's Resident Council Meeting Minutes dated 6-2023 document, Old Business: Church. The residents are still asking about church services, The facility's Resident Council Meeting Minutes dated 7-2023 document, Old Business: Church is still in question. The residents still would like to have church services on Sunday Afternoon. The facility's Resident Council Meeting Minutes dated 8-2023 document, Old Business: Church is still pending. Residents would like some kind of outing to a park or picnic at the river. The facility's Resident Council Meeting Minutes dated 9-2023 document, Residents would still like to do some kind of outing or picnic in the park. The facility's Resident Council Meeting Minutes dated 10-2023 document, The resident would still like some kind of outing, and they are still hoping to have church services again on Sunday afternoons. The facility's Resident Council Meeting Minutes dated 11-2023 document, The residents would like a group shopping trip to the store. They would still like to have church on Sunday afternoons. The facility's Resident Council Meeting Minutes dated 3-5-24 document, Activities-Would like more bingo and bags. On 6-2-24 (Sunday) from 7:00 AM through 2:15 PM no residents attended a church service outside of the building, and no church service was provided within the building. On 6-3-24 at 11:10 AM during the resident council meeting R3, R14, R20, and R36 all stated that they did not know what a grievance was, where grievance forms are to fill out if needed, or who the facility's grievance official is. R3, R14, R20, and R36 also stated that complaints voiced during resident council are never resolved. R3, R14, R20, and R36 stated they have wanted church services for over a year, and no one has tried to get them to church or have a church come in to do services. On 6-6-24 at 1:40 V2 (Administrator-In-Training) stated, I was not aware that residents could fill out and submit their own grievances. We (facility staff) have not offered to take the residents to church and have had no luck getting someone to come out to the facility to perform church services. We have not developed a plan to get the residents church services. Usually, the activity director is responsible for submitting resident council concerns, but the facility does not have an activity director currently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. R15's Activity Tracking Logs dated 4-1-24 through 5-31-24 document R15 only attended activities six times within this timeframe. R15's Activity Tracking Logs dated 1-1-24 through 1-31-24 document R15 only attended one activity during this timeframe. R15's Activity Preferences dated 10/107/23 documents that the following activities are very important: having books, newspapers, and magazines to read, listening to music, doing things with groups of people, doing his favorite activities (participate in bingo, arts/crafts, social gatherings, and parties), getting fresh air when the weather is good, and participating in religious services. On 6-2-24 at 9:42 AM V9 (R15's Power of Attorney) stated R15 would like to listen to music and stated R15 was receiving no activities. 10. R16's Activity Tracking Logs dated 4-1-24 through 5-31-24 document R16 only attended activities six times within this timeframe. R16's Activity Tracking Logs dated 1-1-24 through 1-31-24 document R16 only attended one activity during this timeframe. R16's Activity Preferences dated 10/19/23 documents that the following activities are very important: listening to music, being around animals such as pets, keeping up with the news, doing his favorite activities (going on outings with family), getting fresh air when the weather is good, and participating in religious services are very important to R16. R16's Care Plan dated 2/13/24 documents that R16 will participate in activities of choice three times per week thru the next 90 days. Interventions include R16 needs a variety of activity types and locations to maintain interest. On 6-2-24 at 7:03 AM R16 stated he would enjoy going to church services or listening to music but there have not been any activities. 11. R21's Care Plan dated 4-12-24 does not include a plan of care to address R21's activity goals or interests. R21's Activity Preferences dated 1/18/24 documents that the following activities are very important: having books, newspapers, and magazines to read, listening to music, being around animals such as pets, keeping up with the news, doing things with groups of people, doing his favorite activities (play card game or go outside), getting fresh air when the weather is good. R21's Activity Tracking Logs dated 4-1-24 through 5-31-24 document R21 only attended activities six times within this timeframe. R21's Activity Tracking Logs dated 1-1-24 through 1-31-24 document R21 only attended one activity during this timeframe. 12. R23's MDS dated [DATE] documents R23 is cognitively intact. R23's Care Plan dated 5-9-24 does not include a plan of care to address R23's activity goals or interests. R23's Activity Tracking Logs dated 4-1-24 through 5-31-24 document R23 only attended activities six times within this timeframe. R23's Activity Preferences dated 5/8/24 documents that the following activities are very important: having books, newspapers, and magazines to read, keeping up with the news, doing her favorite activities (using her computer), going outside to get fresh air when the weather is good, and participating in religious services. R23's Activities Participation Review dated 5/8/24 documents Goals were not met. On 6-2-24 at 7:38 AM R23 stated that there are no activities provided and she would like to have church services and music. 13. R24's MDS dated [DATE] documents R24 is cognitively intact. R24's Activity Tracking Logs dated 4-1-24 through 5-31-24 document R24 only attended activities six times within this timeframe. R24's Activity Tracking Logs dated 1-1-24 through 1-31-24 document R24 only attended one activity during this timeframe. R24's Activity Preferences dated 9/7/23 documents that the following activities are very important: having books, newspapers, and magazines to read, listening to music, being around animals such as pets, keeping up with the news, doing things with groups of people, doing his favorite activities (participate in bingo and trivia games), getting fresh air when the weather is good, and participating in religious services. R24's current Care Plan documents, Goal: R24 will express satisfaction with current level of activity for 90 days. Interventions: Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and Age appropriate. Provide with activities calendar. Notify resident of any changes to the calendar of activities. Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, and meals. On 6-2-24 at 7:20 AM R24 stated There are no activities. All day long there is nothing to do. On 6-2-24 at 8:09 AM V6 (LPN/Licensed Practical Nurse) stated, I work full-time. We (the facility) have not had church services since before the COVID-19 (Coronavirus Disease 2019) outbreak except for one Sunday and that is it. The residents would like to have church services. We have had no activities and had no staff in the activity department for over two months. The residents have not had activities on day shift or second shift for the last two months. On 6-3-24 at 10:40 AM both V16 (CNA/Certified Nursing Assistant) and V17 (CNA) stated the facility does not offer the residents daily activities on first or second shift. On 6-2-24 at 10:00 AM V7 (Certified Nursing Assistant/CNA stated, There are no activities offered daily. There is not enough staff to do activities. On 06-3-24 at 11:10 AM during the resident council meeting R3, R14, R20, and R36 all stated they have wanted church services for over a year, and no one has tried to get them to church or have a church come in to do services. R36 stated, They don't have any activities and nothing since February or March. My roommate sleeps all of the time and doesn't want the television on so I just sit in my room. I'm not much of a reader. My family member brings me puzzles/word finds and I do those but that's about all I do. The days are long I'm bored. R14 stated, I wish we could play Bingo. We haven't had a game for months. Just today four other residents asked me if we were going to play. They said the state is in the home and wanted to know if we can make them (staff) play Bingo with us. We don't have anything to do. I like to make bracelets and necklaces with beads. One of the CNA's bought some beads for me but they are all gone. I watch television some but that gets old. A lot of the residents sleep a lot. It's because there's nothing to do, I sit in the hall and wait for someone to come out of their room so I can talk to them. I don't think the facility cares what we want or what we tell them about. It doesn't matter to them. I wish we could play Bingo! R3 stated, I don't have much to do other than watch a little television or listen to music. I've never talked to the Administrator. They're too busy to talk to me. I'm bored. I'm just waiting to die. On 6-3-24 at 11:15 AM V14 (Ombudsman) stated, Every time I visit there is never any activities being offered. Residents are bored in their rooms or sleeping. On 6-3-24 at 3:00 PM V2 (Administrator-In-Training) stated, There was no activity calendar developed or given to the residents for the months of May 2024, April 2024, January 2024, or December 2023. No activities were offered on 6-2-24 or 6-4-2 to the residents and only bingo was offered to the residents on 6-3-24. We have not had anyone in the activity department for two months. We do not offer activities on second shift or the weekends. On 6-4-24 at 8:00 AM V5 (Social Service Director) stated R6, R21, R23, and R36 do not have activity plan of cares. The facility has not had scheduled activities for a couple months and does not offer any activities on second shift or on the weekends. No activities were provided on Sunday 6-2-24. Once or twice a week one of us (staff members) try to offer one activity. It is really hard since we (the facility) do not have activity staff or an activity director. No one has completed (R6, R19 R27's) quarterly activity assessments. On 6-4-24 at 2:30 PM V18 (CNA) stated, I work full-time second shift. There are never any activities offered to the residents on second shift or on the weekends. Based on observation, interview, and record review the facility failed to provide an ongoing program of activities daily on the day and evening shifts designated to meet the resident's physical, mental, and psychosocial well-being of each resident, failed to develop comprehensive activity care plans, and failed to assess resident activity interests and goals quarterly. These failures have the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The facility's Activity Policy dated 7-11-06, documents It is the policy of the facility to provide a program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The program is under the direction of an Activity Director, who shall have a specific planned program of group and individual activities based upon the resident's needs and interests. Residents shall have the opportunity to contribute to planning, preparation, conducting, clean up, and critiquing of programs. The Assessment Procedures: Assessments shall be updated at least quarterly, and upon a significant change in the resident's condition. 3. A record of the resident's daily attendance add activities shall be kept. 4. A monthly note will be completed as to the participation levels and the resident's response to activities. 5. Each resident shall be offered the opportunity to evaluate in written form the activities offered and to make suggestions for improvement on a yearly basis. This may also be done, at any time, on a verbal basis. CARE PLANNING 1. The facility will identify each residence interests, preferences, and abilities; and any issues, concerns, problems, or needs affecting the resident's involvement/engagement in activities. 2. The facility will establish individual activity goals and interventions related to the comprehensive care plan, based on measurable objectives, and focused on desired outcomes, not merely on attendance at a certain number of activities per week. 3. The care plan will identify what discipline(s) will carry out the approaches. 4. The care plan will be reviewed and updated, at least quarterly, and upon a significant change in the resident's condition. ACTIVITY PROGRAM (Facility) will provide a program of activities which includes a combination of large and small group, one-to-one and self-directed activities; and a system that supports the development, implementation, and evaluation of the activities provided to the residents in the facility. Activities shall be planned on a monthly basis for the following month. An activity calendar shall we post it at the beginning of each month for formal activities. The calendar will be printed in large print and displayed in the following area(s). (No information on areas provided) All residents shall be offered the opportunity, and encouraged to participate in activities, but shall not be required to participate. For residents with no discernible response, the facility will provide one- to-one activities. Activities can occur at any time and are not limited to formal activities being provided only by the activity staff, and can include activities provided by other facility staff, volunteers, visitors, residents, and family members. The activity program shall include, but is not limited to, the following: 1. Recreational: fun activities to stimulate and encourage socialization, such as bingo, birthday parties, seasonal parties group exercise, picnics/cookouts, popcorn socials, movies, and cooking club. 2. Crafts and Gardening: The emphasis in this area is to provide the opportunity for the residents to receive pleasure from self-accomplishments. Crafts/gardening may be done as a group or individual activity. Special crafts and gardening are used to enhance fine motor coordination and hand eye coordination. Perfection is not a goal; a sense of accomplishment and pride is. 3. Religion: Religious activities are offered frequently. A religious service is offered on Sunday. Denomination is rotated, as available, to satisfy all residents. 4. Intellectual: these activities are designed to stimulate and challenge the mind. Word games are group activities. Individual activities may include word searches and crossword puzzles. Resident Council meetings are a source of intellectual stimulation, and an extension of the Democratic process through election of officers. These meetings are usually conducted by the activity department. 5. Service Activities: These activities are oriented to residents who receive a sense of accomplishment through involvement in service. Group activities in this area might include pairing laundered socks, folding towels, or wash cloths, setting table for meals or activities. Individual activities may include management of daily calendar, welcoming new residents, or weeding flowerbeds. Participation in service activities is purely volunteer. 6. Community Involvement: Residents are encouraged to go on outings with family and friends. When weather permits, activity outings such as car rides, shopping trips, and lunch at a restaurant are offered. Resident may attend workshop if applicable. In addition, outside groups are invited into the facility to allow resident contact for those limited by physical conditions to remain within the facility. In addition, the facility will provide the following activities to be provided under certain circumstances that are identified through the resident's assessment. 1. One-to-one activities: Residents with no discernible response will be provided 1:1 activity such as sensory stimulation (e.g. (example), visual/auditory/touch stimulation) cognitive therapy, conversation, coffee visit, daily devotions, Bible reading, prayer, music, and talking books. 2. End of Life Activities: Residents who are terminally ill will be provided quality time with chosen relatives, friends, staff and/or other residents; spiritual support, touch, massage, music and/or reading to the resident. 3. Room Activities: Residents who prefer to stay in her/his room or are unable to leave his/her room will be provided with in-room visits by others with similar interests, touch, and sensory activities such as massage or aromatherapy, access to art/craft supplies, cards, games, reading materials, and access to technology of interest. 4. Young Age Group Activities: Younger residents will be offered individual and group music offerings, magazines, books, and movies that fit the resident's taste and era; contemporary group activities, such as video games; and the opportunity to play musical instruments, cards, board games and sports. 5. Diverse Ethnic or Cultural Background Activities: The facility will recognize special events that may include meals, decorations, celebrations, music, visits from spiritual leaders and other individuals of the same ethnic background. Printed materials about the resident's culture will be made available, if desired. If the resident has a language barrier, translation tools, publications and/or audio/video materials will be provided in the resident's language. ACTIVITIES FOR RESIDENTS WITH BEHAVIORS/COGNITIVE DEFICIT The facility will provide activities for the resident who displays behaviors such as combativeness or disruptive during activities. Activities should be provided in a calm, non-rushed environment with structure. 1. For the resident who engages in name-calling, hitting, kicking, yelling, biting, sexual behavior, or compulsive behavior the facility may want to provide such activities as: Folding, sorting and matching. One-to-One activities or small group activities that comfort the resident such as music, walking quietly with staff/family member/friend, or eating a favorite snack. Engage resident in exercise or movement activities. Exchange cell activity for a more socially appropriate activity that uses hands, in a public space. 2. For the resident who is disruptive during activities the facility may want to consider offering activities that may require task segmentation in order for the resident to succeed. This may involve small groups or one-to one activities such as: Delivering mail. Sorting supplies. Passing juice and snack. Working outside the facility. Walking. Exercise or dancing. Using stretch bands. Kneading clay. Slow tapping, clapping, or drumming. Providing a rocking chair. 3. For the resident who rummages, the facility may want to consider providing normalized activities such as: Stacking canned food onto shelves. Folding laundry. Sorting. Putting away supplies. Provide rummage areas in plain sight. Using non-entry cues such as Do not disturb, removable sashes for other resident's doors. It is the philosophy of (facility) to meet each individuals needs and to evaluate, acknowledge, develop, implement and assess each resident's outcome in order to provide or maintain the resident's highest practicable level of well-being. The facility's Facility Assessment Tool dated 3-1-24 documents, Resident support/care needs and types of care that your resident population requires and that you provide for your resident population. Psychosocial/Social/Spiritual Support: Find out what resident's preferences and routines are. What makes a good day for the resident. What upsets him/her and incorporate this information into the care planning process. Makes sure staff caring for the resident have this information. Record and discuss treatment and care preferences, Support emotional and mental well-being. Support helpful coping mechanisms. Support culturally competent care: learn about president preferences and practices with regard to culture and religion; stay open to requests and preferences and work to support those as appropriate. Provide or support access to religious preferences, use or encourage prayer as appropriate/desired by the resident. Provide opportunities for social activities/life enrichment (individual, small group, community). Support community integration if resident desires. The facility's Resident Council Meeting Minutes dated 6-2023 document, Old Business: Church. The residents are still asking about church services, The facility's Resident Council Meeting Minutes dated 7-2023 document, Old Business: Church is still in question. The residents still would like to have church services on Sunday Afternoon. The facility's Resident Council Meeting Minutes dated 8-2023 document, Old Business: Church is still pending. Residents would like some kind of outing to a park or picnic at the river. The facility's Resident Council Meeting Minutes dated 9-2023 document, Residents would still like to do some kind of outing or picnic in the park. The facility's Resident Council Meeting Minutes dated 10-2023 document, The residents would still like some kind of outing, and they are still hoping to have church services again on Sunday afternoons. The facility's Resident Council Meeting Minutes dated 11-2023 document, The residents would like a group shopping trip to the store. They would still like to have church on Sunday afternoons. The facility's Resident Council Meeting Minutes dated 3-5-24 document, Activities-Would like more bingo and bags. On 6-2-24 from 7:00 AM through 2:15 PM no activities were observed being offered to the residents throughout the facility during this timeframe. On 6-2-24 at 9:12 AM a tour of the facility was done. No activity calendars or activity postings with listed activities were posted throughout the facility. On 6-3-24 from 7:45 AM through 3:20 PM the only activity offered to residents during this timeframe was bingo from 2:00 PM through 2:40 PM. On 6-4-24 from 7:45 AM through 3:20 PM no activities were observed being offered to the residents throughout the facility during this timeframe. 1. R3's MDS (Minimum Data Set) Section C Cognitive Patterns documents R3 is cognitively intact. R3's Activity Interview for Daily and Activity Preferences dated 9-8-23 documents doing favorite activities is very important to R3. R3's current Care Plan documents, Goal: The resident will express satisfaction with type of activities and level of activity involvement when asked thru the next 90 days. Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Explain to the resident the importance of social interaction, leisure activity time, and encourage the resident's participation, invite/encourage the resident's family members to attend activities with residents in order to support participation. R3's Activity Tracking Logs dated 4-1-24 through 5-31-24 document R3 only attended activities six times within this timeframe. R3's Activity Tracking Logs dated 1-1-24 through 1-31-24 document R3 only attended one activity during this timeframe. On 6-2-24 at 8:10 AM R3 stated, There is not much to do. I would like to be offered something for activities. 2. R6's Order Summary Sheet dated 6-2-24 documents R6 has the diagnoses of Generalized Anxiety and Paranoid Personality Disorder and has orders to participate in social and indoor/outdoor activity programs. R6's BIMS (Brief Interview of Mental Status) dated 3-9-24 documents R6 is cognitively intact. R6's Activity Interview for Daily and Activity Preferences dated 9-8-23 documents having books, newspapers, and magazines to read, listening to music, being around animals, keeping up with the news, doing things with groups of people, doing favorite activities, going outside for fresh air, and participating in religious services are very important to R6. R6's Medical Record does not include an Activity Preferences Assessment or Quarterly Review of Activity Participation Assessment since 9-8-23. R6's Care Plan dated 5-14-24 does not include a plan of care to address R6's activity goals or interests. R6's Activity Tracking Logs dated 4-1-24 through 5-31-24 document R6 only attended six times within this timeframe. R6's Activity Tracking Logs dated 1 1-24 through 1-31-24 documents R6 only attended one activity during this timeframe. On 6-2-24 at 1:20 PM R6 stated, They do not offer any activities here anymore. They used to offer bingo and popcorn and I liked that. I do not get anything now and it is depressing. 3. R19's MDS Section C Cognitive Patterns dated 5-17-24 documents R19 is cognitively intact. R19's Order Summary Report dated 6-3-24 documents R19 has the diagnoses of Anxiety Disorder and Major Depressive Disorder and has orders to participate in social and indoor/outdoor activity programs. R19's BIMS dated 5-17-24 documents R19 is cognitively intact. R19's Activity Interview for Daily and Activity Preferences dated 9-6-23 documents having books, newspapers, and magazines to read, listening to music, keeping up with the news, doing things with groups of people, and participating in religious services are very important to R19. R19's Medical Record does not include an Activity Preferences Assessment or Quarterly Review of Activity Participation Assessment since 9-6-23. R19's current Care Plan documents, Goal: (R19) will continue to pursue independent leisure activities thru next review. Interventions: Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Explain to the resident the importance of social interaction, leisure activity time, and encourage the resident's participation, Invite/encourage the resident's family members to attend activities with residents in order to support participation. The resident needs a variety of activity types and locations to maintain interests. R19's Activity Tracking Logs dated 4-1-24 through 5-31-24 document R19 only attended activities six times within this timeframe. R19's Activity Tracking Logs dated 1-1-24 through 1-31-24 document R19 only attended one activity during this timeframe. On 6-3-24 at 9:26 AM R19 stated, The facility does not offer activities. I would like to go outside and go to the park. I would like church services on Sundays I would like to play bingo or anything. I was told there is not enough staff to do activities. I have not got an activity calendar with the activities provided since last year. Every day is depressing for me. 4. R25's MDS Section C Cognitive Patterns dated 3-20-24 documents R25 is cognitively intact. R25's Activity Interview for Daily and Activity Preferences dated 4-17-24 documents R25 likes doing favorite activities and going outside for fresh air are very important to R25. R25's current Care Plan documents, Goal: The resident will express satisfaction with type of activities and level of activity involvement when asked thru the next 90 days. Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Explain to the resident the importance of social interaction, leisure activity time, and encourage the resident's participation, Invite/encourage the resident's family members to attend activities with residents in order to support participation. R25's Activity Tracking Logs dated 4-1-24 through 5-31-24 document R25 only attended activities six times within this timeframe. R25's Activity Tracking Logs dated 1-1-24 through 1-31-24 document R25 only attended one activity during this timeframe. On 6-2-24 at 8:09 AM R25 stated, All I do is lay in my room. I do not get activities. It would be nice to go to the park or out somewhere. 5. R27's BIMS dated 3-11-24 documents R27 is severely cognitively impaired. R27's Activity Interview for Daily and Activity Preferences dated 9-11-23 documents having books, newspapers, and magazines to read, listening to music, being around animals, keeping up with the news, doing things with groups of people, doing favorite activities, going outside for fresh air, and participating in religious services are very important to R27. R27's Medical Record does not include an Activity Preferences Assessment or Quarterly Review of Activity Participation Assessment since 9-11-23. R27's current Care Plan documents, Goal: Resident will continue to attend activities as tolerated thru next review. Interventions: All staff to converse with resident while providing care. Assist with arranging community activities. Arrange transportation, encourage ongoing family involvement. Invite the resident's family to attend special events, activities, and meals. Ensure the activities the resident is attending are compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needs; compatible with individual needs and abilities; and age appropriate. Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Explain to the resident the importance of social interaction, leisure activity time, and encourage the resident's participation, Invite/encourage the resident's family members to attend activities with residents in order to support participation. Provide with activities calendar. On 6-2-24 at 9:53 AM V10 (R27's Family Member) stated, (R27) likes to play bingo. I do not think the facility offers bingo much. 6. R35's MDS Section C Cognitive Patterns documents R35 is severely cognitively impaired. R35's Activity Interview for Daily and Activity Preferences dated 4-17-24 documents doing favorite activities is very important to R35. R35's Medical Record does not include an Activity Preferences Assessment or Quarterly Review of Activity Participation Assessment since 9-8-23. R35's Care Plan dated 5-27-24 does not include a plan of care to address R35's activity goals or interests. R35's Activity Tracking Logs dated 4-1-24 through 5-31-24 document R35 only attended activities six times within this timeframe. R35's Activity Tracking Logs dated 1-1-24 through 1-31-24 document R36 only attended one activity during this timeframe. On 6-2-24 at 8:55 AM R35 stated, They have never offered activities. I would go on outings or play euchre (card game) if they offered it. 7. R36's MDS Section C Cognitive Patterns dated 3-26-24 documents R36 is cognitively intact. R36's Order Summary Report dated 6-2-24 documents R36 may participate in social indoor-outdoor activity programs. R36's Activity Interview for Daily and Activity Preferences dated 4-17-24 documents doing things with groups of people, doing favorite activities, going outside for fresh air, and participating in religious services are very important to R36. R36's Care Plan dated 5-14-24 does not include a plan of care to address R36's activity goals or interests. R36's Activity Tracking Logs dated 4-1-24 through 5-31-24 document R36 only attended activities six times within this timeframe. R36's Activity Tracking Logs dated 1-1-24 through 1-31-24 document R36 only attended one activity during this timeframe. On 6-2-24 at 7:48 AM R36 stated, I wish someone would get me out of my room for something to do. I would like to go outside and play bingo. It makes me get bored. My roommate doesn't talk much. 8. R138's MDS Section C Cognitive Patterns dated 5-23-24 documents R138 is cognitively intact. R138's Order Summary Report dated 6-3-24 documents R128 has the diagnosis of Severe Depressive Disorder and may participate in social indoor-outdoor activity programs. R138's Activity Tracking Logs dated 5-10-24 (Admission) to 5-31-24 document R138 only attended two activities during this timeframe. R138's Activity Interview for Daily and Activity Preferences dated 5-23-24 documents doing favorite activities are very important to R138. R138's current Care Plan documents, Goal: (R138) will express satisfaction with type of activities and level of activity involvement thru the next 90 days. Interventions: Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Explain to the resident the importance of social interaction, leisure activity time, and encourage the resident's participation, Invite/encourage the resident's family members to attend activities with residents in order to support participation. The resident needs a variety of activity types and locations to maintain interests. On 6-2-24 at 07:54 AM R138 stated, There is nothing to do outside of my room. I would like to go to bingo.

Based on observation, record review, and interview the facility failed to employ a full-time Activity Director to plan, schedule, and implement an ongoing program of activities. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The Activity Director policy (undated), Job Summary The Activity Director plans, schedules, and implements an ongoing program of activities designed to meet the physical, mental, and psychosocial needs of each resident. Residents are engaged in a meaningful, varied program of activities that meets the individual residents. The activities are conducted with individuals or in groups, according to the residents Plan of Care. The Activity Director completes the activity assessment for each resident and participates in developing the Interdisciplinary Care Plan. Responsibilities 1. Plan, organize and coordinate an activity program according to established policies. 2. Plan group and individual activities designed to restore self-care and well-being and geared to the individuals needs and interests. 3. Develop an appropriate plan of activities for and visit residents who are bedfast, unwilling, or unable to participate in group activities. 4. Group and individual activities will be based upon Interdisciplinary Care Plans and assessments. 5. Within 48 hours of admittance of a new resident, he/she will complete the new resident interim assessment. 6. Within 14 days of admittance, and quarterly thereafter, the Activity Director will assess the resident and attend the Care Plan Conference to develop/review an Interdisciplinary Plan of Care. 7. Charts monthly activity progress notes for each resident. Includes the resident's response to the individualized program. 9. Organizes, conducts, and assists a Family Council/Support Group and acts as the facility coordinator to the group. 11. Prepares and posts a monthly Activities Calendar including scheduled activities and their times for the coming month. 14. Plans and conducts facility sponsored community events. Becomes involved with community organizations in order to promote public relations. 17. Works shifts for staff in order to fill vacancies due to call-offs or to decrease excessive overtime within the department. On 06/03/24 at 11:10 AM during the resident council meeting R3, R14, R20, and R36 all stated the facility does not have an activity director within the building and therefore they do not get activity calendars, monthly resident council meetings, or daily activities offered. On 6-2-24 from 7:00 AM through 2:15 PM no activities were observed being offered to the residents throughout the facility during this timeframe and there was no activity calendar posted within the facility. On 6-3-24 from 7:45 AM through 3:20 PM the only activity offered to residents during this timeframe was bingo from 2:00 PM through 2:40 PM and there was no activity calendar posted within the facility. On 6-4-24 from 7:45 AM through 3:20 PM no activities were observed being offered to the residents throughout the facility during this timeframe. On 6-4-24 at 11:30 AM V5 (Social Service Director) stated, The facility has not had scheduled activities for a couple months and does not offer any activities on second shift or on the weekends. It is really hard since we (the facility) do not have activity staff or an activity director. On 6-4-24 at 9:44 AM V2 (Administrator-In-Training) stated, The last activity director (V19) the facility had was hired 2-5-24 and quit on 3-12-24. We have not had an activity director here since 3-12-24.

Based on observation, interview, and record review the facility failed to ensure there was enough nursing staff to provide nursing services. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The Facility Assessment Tool dated 8/18/2017, documents Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. The facility's Nursing Services policy (undated) documents, It is the policy of (the facility) to assure sufficient qualified nursing staff is available and on duty on a daily basis to provide nursing and related services to attain or maintain each resident's highest practical physical, mental, and psychosocial wellbeing as determined by resident assessment and plans of care. The facility's Nurse Master Schedule dated 5-1-24 through 6-3-24 documents, Needs: 5-11-24 6am to 6pm, 5-12-24 6am to 6pm, 5-25-24 6am to 6pm, 5-26-24 6am to 6pm, 5-31-24 6am to 6pm, 6-1-24 6am to 6pm, and 6-2-24 6am to 6pm. The facility's undated Medication Pass times list documents the morning medication pass time is 8:00 AM. On 6-2-24 from 7:10 AM through 10:45 AM V6 was administering medications for the morning medication pass scheduled at 8:00 AM. On 6-2-24 at 8:09 AM V6 (LPN/Licensed Practical Nurse) stated, We (the facility) have to have two full-time nurses on day shift and evening shift to get everything done. When I am the only nurse, I do not get all the wound treatments done and medications are administered really late. I just have to prioritize. On 06/03/24 at 11:10 AM during the resident council meeting R3, R14, R20, and R36 all stated the facility needs more nursing staff in the morning. R3, R14, R20, and R36 stated when there is only one nurse medications are late. On 6-5-24 at 1:00 PM V4 (Resident Care Coordinator) stated, I am responsible for scheduling the nurses. According to (V2/ Administrator-In-Training) we (the facility) are supposed to have two full-time nurses on day shift, two full-time nurses on second shift, and one full-time nurse on night shift. We did not have enough nurses on 5-11-24 6am to 6pm, 5-12-24 6am to 6pm, 5-25-24 6am to 6pm, 5-26-24 6am to 6pm, 5-31-24 6am to 6pm, 6-1-24 6am to 6pm, or 6-2-24 6am to 6pm.

Based on observation, record review, and interview the facility failed to provide Registered Nurse/RN services eight hours daily and failed to employ a Director of Nursing (DON) to oversee the operation of the Nursing Department and ensure quality of care. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The facility's Nursing Services policy (undated) documents, Registered nurse services shall be available eight hours each day, seven days a week. The facility's Director of Nursing Job Description (undated) documents, Job Summary: To plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulation that govern our facility and as may be directed by the Administrator and the Medical Director to ensure the highest degree of quality care is maintained at all times. The facility's Facility Assessment Tool dated 3-1-24 documents the facility does not have a director of nursing. This same Facility Assessment Tool documents a director of nursing is needed to provide support and care for the facility's resident population. The facility's Nurse Master Schedule dated 5-1-24 through 6-3-24 documents the facility had no registered nurse coverage on 5-3-24, 5-4-24, 5-5-24, 5-9-24, 5-10-24, 5-11-24, 5-12-24, 5-13-24, 5-17-24, 5-18-24, 5-19-24, 5-23-24, 5-24-24, 5-25-24, 5-26-24, 5-27-24, 5-31-24, 6-1-24, and 6-2-24. On 6-2-24 from 7:00 AM through 2:15 PM there was no DON or RN present within the facility. On 6-3-24 from 7:45 AM through 3:20 PM, on 6-4-24 from 7:45 AM through 3:20 PM, on 6-5-24 from 7:45 AM through 3:20 PM, and on 6-6-24 from 7:45 AM through 2:20 PM there was no DON present within the facility. On 6-2-24 at 11:30 AM V2 (Administrator-In-Training) stated, (V8's/Prior DON) last day worked was 11-16-23. (V3's/Prior DON) only lasted a couple months from 12-18-23 through 2-29-24. I have not had a DON since 2-29-24. On 6-5-24 at 11:45 AM V4 (Resident Care Coordinator) stated, We (the facility) did not have any RN coverage on 5-3-24, 5-4-24, 5-5-24, 5-9-24, 5-10-24, 5-11-24, 5-12-24, 5-13-24, 5-17-24, 5-18-24, 5-19-24, 5-23-24, 5-24-24, 5-25-24, 5-26-24, 5-27-24, 5-31-24, 6-1-24, or 6-2-24.

Based on observation, interview and record review, the facility failed to employ a Certified Dietary Manager. This has the potential to affect all 36 residents living in the facility. Findings: The job description for the Food Service Manager, dated 4/17, states, Manages all aspects of the Food Service Department in the facility including but not limited to Food Service personnel, food production, supplies and equipment. Manages nutritional care of all residents in the facility. The Responsibilities of the Food Service Manager are: Orders all supplies necessary for the proper and efficient running of the department making sure to remain within budget; Ensures that all residents are served diets as ordered by physician; Ensures that the menus are followed and appropriate substitutions are made and recorded. Follows Consultant Dietitian/Regional Dietitian recommendations that are reviewed and approved by Administrator; Takes necessary measures to ensure that all food served to residents has been prepared in a safe, sanitary manner while also maintaining the highest quality; Makes sure that all food and supplies are stored properly and steps are taken to avoid theft; Checks all equipment for proper functioning and safety; Is responsible for overall sanitation of the department; Is responsible for knowing Local, State and Federal Regulations and policies and procedures which pertain to the department; Manages department employees including hiring, training, in-service and discipline; Prepares a work schedule that will enable all functions of the department to be carried out within the allotted hours; Visits resident upon admission, and periodically thereafter, to determine food preferences and discuss their diets. Communicate this information accordingly to other departments; coordinate and gather the information required by the dietitian, such as resident's weights, skin report, facility admissions tube feedings annual assessments, dialysis, etc .When appropriate information to dietitian prior to scheduled visit; Maintains all dietary records regarding resident likes and dislikes, tray cards, Minimum Data Set (MDS), Care Plans, quarterly/annual charting; coordinates and follows up with the dietitian's recommendations; Develops policies and procedures for the department as needed; Participators in interdisciplinary meetings and conferences as requested by the facility; Attend in-service meetings; Maintains a listing of those employees who have received the Food Handler Training; Other duties as assigned by the Administrator; Shall reference the Company's Health Care Dietary Operations Manual as amended from time to time. On 6/02/24 at 9:35 AM, V12, [NAME] and V13, Dietary Aide, were working in the kitchen. When inquiring for the Dietary Manager, both stated, We haven't had a Dietary Manager since August (2023). We split up the tasks that need to be done amongst us. You know, like ordering the food, food production sheets, and such. We all kinda have a hand in the scheduling. It's hard as we don't have enough staff anyway and then to add the rest onto us. We do our best. On 6/06/24 at 12:35, V2/Administrator in Training, stated, We haven't had a Dietary Manager for a while. No one wants the job. The facility's Daily Census dated 6/2/24 documents 36 residents currently reside within the facility.

Based on observation, interview and record review, the facility failed to: keep meat in the refrigerator overnight; date and label food that has been opened in both cold food and pantry storage; discard outdated food; use proper storage containers to prevent foods from contamination; maintain a clean kitchen; replace and maintain floor tiles; clean overhead vents and returns in both food preparation and dish room areas; repair and maintain walls and corners that have paint and plaster chipped away; date and label all food brought in from the outside for residents; keep 50 pound bags of salt (softener) off of the kitchen floor; close spaces between ceiling tiles and around pipes; keep boxes of paper supplies off of the floor; and keep the door to the outside closed. This has the potential to affect all 36 residents living in the facility. Findings: The document, Food from Outside Sources/Personal Food Storage, dated 4/17, states, All residents have the right to accept food brought to the facility by any visitors, however, the food must be handled in a way to ensure resident safety. Food and beverages brought in from outside sources, that are to be stored in the facility refrigerators and freezers, will be checked by a dietary staff member. Food and beverages will be labeled with the resident's name, food item and date. Facility food storage procedures apply. Housekeeping staff, or designee shall clean and sanitize the refrigerators once a month or as required. The document, Refrigerator and Freezer Storage, dated 10/14, states, It is the (facility) policy that any item to be placed in the refrigerators and freezers must be covered, labeled and dated with a date-marking system that tracks when to discard perishable foods. [NAME] the container with name of the item. [NAME] the date that the original container is opened or date of preparation. Label refrigerated, potentially hazardous food with the day/date by which the food shall be consumed or discarded (maximum of seven days from time of preparation). Clean up any spills immediately. Designated dietary employee is to check, pull and throw away any potentially hazardous foods that have been in the refrigerator for seven days. The document, Storage, dated 10/20, states, Food shall be stored for the appropriate lengths of time to protect quality of food. Store Leftovers in covered, labeled, and dated containers under refrigeration or frozen. When using only part of a product, the remaining product should be in the original package or airtight container and labeled and dated. Do not leave any serving utensils or tools in food containers. The document, Storage, dated 6/06, states, Store leftovers in covered, labeled and dated containers under refrigeration or frozen. When using only part of a product, the remaining product should be in the original package or airtight container and labeled and dated. The document, Cleaning Schedule, dated 10/14, states, The Food Service Manager shall develop a cleaning rotation from the lists all cleaning tasks required for proper sanitation of the food preparation and serving area. Tasks are divided into categories that must be completed daily, weekly, and monthly. Findings on 6/02/24 at 7:30 AM, during the initial kitchen tour are: two pans containing five pounds each of shredded ham were left out of refrigeration on the three compartment sink during the night; three Styrofoam containers, a glass with lid, all without date or labels; a black container with a label that could not be read (was in black marker on black surface), two pounds of luncheon meat in a container, pulled out of the freezer on 5/20/24; the door was open to the storage room which also had an opened outside door. Findings on 6/02/24 at 9:30 AM, are food items stored in plastic pitchers in the reach-in refrigerator contained fluid on top of the containers. V13, Food Service Worker, stated, The refrigerator is leaking fluid onto the pitchers. Sometimes it seeps into the food in the pitcher through the spout if it isn't closed right. Also noted: the reach in refrigerator in the storage room had resident food items that were not labeled or dated (case of soda and containers of yogurt); the base of the can opener has a buildup of black sticky grime; dust was visible on the outside of the large hood and baffles over the range, convection oven area; ceiling tiles have gaps in places and also around pipes coming into the kitchen; ceiling vents and returns have a buildup of dust and grime; floor tiles are missing from the floor three tile lengths from the wall out under the three compartment sink; two 50 pound bags of water softener (salt) were sitting by the clean side table of the dish machine; boxes of paper goods were sitting on the floor in the storage room; dust and grime was on the pipes and walls behind the range and convection oven; three lights were out in the ceiling of the food preparation room; one light cover had a large crack. V13 confirmed all of the observations. The facility's Daily Census dated 6/2/24 documents 36 residents currently reside within the facility.

Based on observation, interview, and record review the administration failed to ensure ongoing resident complaints were resolved, to ensure residents had an adequate amount of linens, to ensure an ongoing program of activities were provided to the residents daily, to ensure a full-time Director of Nursing, Activity Director, and Dietary Manager were employed to manage and oversee everyday nursing, activity, and dietary services, to ensure the facility had sufficient nursing staff, to ensure the most up-to-date infection control practices were implemented, to ensure resident council meetings were provided monthly, to ensure large dietary appliances were in good repair and working order, to ensure all required QAPI (Quality Assurance and Performance Improvement) members met monthly, to ensure plans were implemented to correct and/or improve identified areas of concern, and ensure all CNAs (Certified Nursing Assistants) were provided annual required abuse, QAPI, and Dementia in-service training. These failures have the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The Job Description Administrator (undated), documents JOB SUMMARY The Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting, and the physical management of the facility, residents & (and) equipment in a way that the purpose of the facility shall be maintained in accordance with all established practices, policies, laws, and applicable State Regulations. The Administrator will manage and conduct the business of the facility in a manner that protects the facility license and certification at all times. The major goal of the Administrator is to provide an atmosphere in which residents may achieve their highest physical, mental, and social well-being. QUALIFICATIONS The Administrator must be qualified through a combination of education, experience, and training to manage a Nursing Facility. Knowledge of business administration, nursing care and human relations is necessary. He/she must hold, or be eligible for, a Nursing Home Administrators license in the State which he/she is practicing. RESPONSIBILITIES 1. Operate the facility in compliance with all federal and state rules and regulations; 2. operate the facility in accordance with established policies and procedures; 4. Appoint a Director of Nursing and other department heads; ADMINISTRATOR QUALIFICATIONS: 1 Must have successfully completed all educational requirements as required by federal and state regulations. 2 Must possess a current, unencumbered Nursing Home Administrators license or meet the licensure requirements of the State. 3 Must possess the ability to work harmoniously with and supervise other People. JOB SUMMARY: The Administrator is responsible for directing day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines and regulations that govern long-term care facilities to assure that appropriate care is provided to the residents in the facility. The Administrator is responsible for delegating the administrative authority, responsibility necessary for carrying out the assigned duties. Performance Evaluations Responsibilities: I. Administrative Functions 1 Plan, develop, organize, implement, and direct the facility's programs and activities. 2 Maintain written policies and procedures that govern the operation of the facility. 3 Assist department managers in the use of departmental policies and procedures and establish a rapport in and among departments so that each can realize the importance of teamwork. 14 Ensure that appropriate policies and procedures are followed when conducting background checks and when providing information to the Nurse Aide Registry. 15 Work with Admissions to ensure appropriate pre-screening takes place. III. Personnel Functions 1 assist in the recruitment and selection have competent department directors. 4 Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvements of service. 5 Ensure that an adequate number of appropriately trained professional and auxiliary personnel are on duty at all times to meet the needs of the residents. V. Safety 1 Ensure that all facility personnel, residents, visitors, etc. (etcetera), follow established safety regulations to include fire protection/prevention, smoking regulations, infection control, etc. V! Equipment and Supplies 1 Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services. 2 Ensure that adequate supplies and equipment are on hand to meet the day-to-day operational needs of facility and residents. VIII. Resident Rights 3 Resident complaints and grievances and make written reports of actions taken. 4 Review and respond to Resident/Family Council concerns as needed. The facility's monthly Resident Council Minutes dated 6-1-23 through 5-31-24 were reviewed and resident council was not offered for five months within this timeframe. The facility's Resident Council Meeting Minutes dated 6-2023, 7-2023, 8-2023, 9-2023, 10-2023, 11-2023, 3-5-24 all document resident complaints about not receiving church services. The facility's Resident Council Meeting Minutes dated 3-5-24 document, Activities-Would like more bingo and bags. The facility's Nurse Master Schedule dated 5-1-24 through 6-3-24 documents, Needs: 5-11-24 6am to 6pm, 5-12-24 6am to 6pm, 5-25-24 6am to 6pm, 5-26-24 6am to 6pm, 5-31-24 6am to 6pm, 6-1-24 6am to 6pm, and 6-2-24 6am to 6pm. The Quality Assurance quarterly sign-in sheets for the past twelve months 6-1-23 through 5-31-24 document a Director of Nursing was not present at any of these meetings. On 6-2-24 at 2:00 PM V4 (Infection Preventionist) provided a list of residents who should have been placed in enhanced barrier precautions but was not. The list included the following residents: R3, R15, and R32 due to having indwelling urinary catheters and R6, R7, R8, R18, R24, R33, R36, and R138 due to having wounds. The facility's Annual Required In-Service policy dated 09/2017 documents staff should receive Abuse Prevention and Alzheimer's Dementia Management in-servicing annually. The facility's QAPI Plan policy dated 1-10-24 documents, Annual training will be provided to all staff utilizing the annual QAPI report to summarize goals, progress, and PIPs (Performance Improvement Projects). V7 (CNA/Certified Nursing Assistant), V11 (CNA), V16-V18 (CNAs), V22 (CNA), and V24-V34's (CNA's) In-Service Training Logs dated 6-1-23 through 6-2-24 do not include evidence of V7, V11, V16-V18, V22, and V24-V34 receiving annual Abuse, Alzheimer's Dementia Management, or QAPI in-service training. On 6-2-24 from 7:00 AM through 2:15 PM no activities were observed being offered to the residents throughout the facility during this timeframe, no residents attended a church service outside of the building, no church service was provided within the building, there was no registered nurse within the building, there was no licensed administrator within the building, there was no activity director within the building, and there was no dietary manager within the building. On 6-2-24 from 7:00 AM to 9:00 AM a tour of the building was done. During this tour R3, R6, R7, R8, R15, R18, R24, R32, R33, R36, and R138's doors did not have signs indicating they were in enhanced barrier precautions and V6 (LPN/Licensed Practical Nurse), V7 (CNA/Certified Nursing Assistant), and V11 (CNA) were not wearing gowns while providing personal cares to R3, R6, R7, R8, R15, R18, R24, R32, R33, R36, and R138. On 6-2-24 at 9:12 AM a tour of the facility was done. No activity calendars or activity postings with listed activities were posted throughout the facility. On 6-2-24 at 9:35 AM, V12, [NAME] and V13, Dietary Worker, both stated, The convection oven doesn't work. It's been broken for months. We were told the part to fix it was too expensive. One of the two range ovens don't work right - it can be used as a warmer but won't get the temperature of foods up to the correct temperature. We have to maneuver food around in order to get everything ready for meals. If the oven we are using like a warmer doesn't keep the food hot enough, we have to reheat it before serving. It really is difficult. One of the wells in the steam table has a broken pipe. We're not sure how long it will be before that it fixed. The large hood with baffles doesn't work at all. We told (V2/ Administrator-In Training) about it six or seven months ago but no one no one has fixed that either. I've never seen a work order to fill out. We're supposed to tell (V2) when something needs to be fixed, so we tell (V2) right away. On 6/02/24 at 9:45 AM, it was noted that the door to the outside freezer has a totally rusted out external layer of metal across the width of the door and ten inches above the bottom. An area approximately 60 inches by 10 inches. The inner door material/insulation is visible. V13, Dietary Worker, stated, They can't fix it. They said they couldn't fit a piece of metal on it to stick. I don't think they will get a new door for it. On 6-3-24 from 7:45 AM through 3:20 PM the only activity offered to residents during this timeframe was bingo from 2:00 PM through 2:40 PM, there was no director of nursing within the building, there was no activity director within the facility, and there was no dietary manager within the building. On 6-3-24 at 11:10 AM during the resident council meeting R3, R14, R20, and R36 all stated that they did not know what a grievance was, where grievance forms are to fill out if needed, or who the facility's grievance official is. R3, R14, R20, and R36 also stated that complaints voiced during resident council are never resolved. R3, R14, R20, and R36 stated they have wanted church services for over a year, and no one has tried to get them to church or have a church come in to do services. All stated the facility needs more nursing staff in the morning. R3, R14, R20, and R36 stated when there is only one nurse medications are late. On 6-4-24 from 7:45 AM through 3:20 PM no activities were observed being offered to the residents throughout the facility during this timeframe, there was no director of nursing within the building, there was no activity director within the facility, and there was no dietary manager within the building. On 6-4-24 at 7:40 AM V17 (CNA/Certified Nursing Assistant) was providing a bed bath to R6. V17 was using a pillowcase to wash R6. V17 stated, We never have washcloths or towels to use. We have not had enough washcloths or towels for months. A lot of days there is only one or two washcloths in the building to use for all of the residents. R6 stated, There is never towels or washcloths to use. On 6-4-24 at 7:50 AM V17 opened the linen storage room. The linen storage room had no washcloths or towels. V17 stated there is only one linen storage room and there is never washcloths or towel available. On 6-2-24 at 11:30 AM V2 (Administrator-In-Training) stated, (V8's/Prior DON) last day worked was 11-16-23. (V3's/Prior DON) only lasted a couple months from 12-18-23 through 2-29-24. I have not had a DON since 2-29-24. On 6-6-24 at 9:30 AM V2 stated, The staff have not received abuse training, Alzheimer's Dementia management training, or QAPI training within the last 12 months. On 6-6-24 at 1:40 V2 stated, I was not aware that residents could fill out and submit their own grievances. We (facility staff) have not offered to take the residents to church and have had no luck getting someone to come out to the facility to perform church services. We have not developed a plan to get the residents church services. Usually, the activity director is responsible for submitting resident council concerns, but the facility does not have an activity director currently. On 6-3-24 at 3:00 PM V2 stated, There was no activity calendar developed or given to the residents for the months of May 2024, April 2024, January 2024, or December 2023. No activities were offered on 6-2-24 or 6-4-24 to the residents and only bingo was offered to the residents on 6-3-24. We have not had anyone in the activity department for two months. We do not offer activities on second shift or the weekends. On 6-4-24 at 9:44 AM V2 stated, The last activity director (V19) the facility had was hired 2-5-24 and quit on 3-12-24. We have not had an activity director here since 3-12-24. On 6-4-24 at 2:00 PM V4 (Resident Care Coordinator) stated, I am the infection preventionist and did not know anything about Enhanced Barrier Precautions. I just requested the policy from corporate today and the facility should have been using that policy. No residents were ever placed in Enhanced Barrier Precautions prior to today. On 6-4-24 at 2:30 PM V2 stated, I tried to order washcloths and towels from a vendor and was not allowed to order from that vendor. I am now using a new vendor but have not placed an order for washcloths or towels yet. On 6-5-24 at 1:00 PM V4 stated, I am responsible for scheduling the nurses. According to (V2/Administrator-In-Training) we (the facility) are supposed to have two full-time nurses on day shift, two full-time nurses on second shift, and one full-time nurse on night shift. We did not have enough nurses on 5-11-24 6am to 6pm, 5-12-24 6am to 6pm, 5-25-24 6am to 6pm, 5-26-24 6am to 6pm, 5-31-24 6am to 6pm, 6-1-24 6am to 6pm, or 6-2-24 6am to 6pm. On 6-6-24 at 12:40 PM V2 stated, No, we haven't had Resident Council Meetings. We didn't have anyone to run them. On 6-6-24 at 12:45 PM V2 stated, No, we didn't have a Director of Nursing to come to the Quality Assurance Meetings. V2 also verified the facility has not developed/implemented quality assurance performance plans to address the facility not having a director of nursing, activity director, dietary manager, not having meaningful daily scheduled activities, ensuring ongoing resident complaints were resolved, ensuring residents had an adequate amount of linens, ensuring the facility had sufficient nursing staff, ensuring the most up-to-date infection control practices were implemented, ensuring resident council meetings were provided monthly, ensuring large dietary appliances were in good repair and working order, ensuring all required QAPI (Quality Assurance and Performance Improvement) members met monthly, and ensure all CNAs (Certified Nursing Assistants) were provided annual required abuse, QAPI, and Dementia in-service training.

Based on observation, record review, and interview the governing body of the facility failed to employ a licensed administrator to oversee and manage the everyday operations of the facility. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The Job Description Administrator (not dated), documents QUALIFICATIONS The Administrator must be qualified through a combination of education, experience, and training to manage a Nursing Facility. Knowledge of business administration, nursing care and human relations is necessary. He/she must hold, or be eligible for, a Nursing Home Administrators license in the State which he/she is practicing. ADMINISTRATOR QUALIFICATIONS: 1 Must have successfully completed all educational requirements as required by federal and state regulations. 2 Must possess a current, unencumbered Nursing Home Administrators license or meet the licensure requirements of the State. On 6-2-24 from 7:00 AM through 2:15 PM, on 6-3-24 from 10:00 AM through 3:30 PM, on 6-4-24 from 10:00 AM through 3:30 PM, and 6-6-24 from 7:45 AM through 2:20 PM there was no licensed administrator within the building. On 6-2-24 at 11:40 AM V6 (LPN/Licensed Practical Nurse) stated, I work full-time. (V1/Administrator) has not been here in months. When (V1) does come here it is usually only one day a week. V2 (Administrator-In-Training) is the only administrator we have. On 6-3-24 at 10:40 AM both V16 (CNA/Certified Nursing Assistant) and V17 (CNA) stated they have not seen V1 in the facility in over two months and V2 is the only administrator they are aware of that runs the facility. On 6-2-24 at 10:00 AM V7 (CNA) stated V1 is never at the facility. On 6-4-24 at 8:30 AM V2 (Administrator-In-Training) stated, I have been the administrator here since November 2023. I do not have an administrator's license and I do not have the education yet to get a temporary administrator's license either. V1 (Administrator) has her license hanging here. (V1) comes to the building around once a week.

Based on observation, interview, and record review the facility failed to develop and implement QAPI (Quality Assurance and Performance Improvement) plans to address the lack of follow-up to resident complaints, to address the lack of department heads including the Director of Nursing, Activity Director, and Dietary Manager, to address the lack of linens, to address the lack of an ongoing program of activities, to address the lack of sufficient nursing staff, to address the lack of education regarding QAPI, Dementia care and treatment, infection control practices, and abuse, to address the broken dietary equipment, to address the lack of resident council meetings, and the lack of required employees attending QAPI meetings. These failures have the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The document, Quality Assurance and Performance Improvement (QAPI), dated 1/10/24, states, This facility will utilize the principles of QAPI to align all business and clinical care decisions, creating a model of care that centers its core values on individualized care and resident choices. The leadership, medical director and staff will embrace evidence-based strategies and utilize this data until the desired change is achieved and goals are sustained. The QAPI program is provided through a committee structure that is accountable to the Healthcare Leadership team. The QAPI committee has the responsibility for planning, designing, implementing and coordinating consumer care, service and selecting activities that meet the needs of the resident and families. The facility's monthly Resident Council Minutes dated 6-1-23 through 5-31-24 were reviewed and resident council was not offered for five months within this timeframe. The facility's Resident Council Meeting Minutes dated 6-2023, 7-2023, 8-2023, 9-2023, 10-2023, 11-2023, 3-5-24 all document resident complaints about not receiving church services. The facility's Nurse Master Schedule dated 5-1-24 through 6-3-24 documents, Needs: 5-11-24 6am to 6pm, 5-12-24 6am to 6pm, 5-25-24 6am to 6pm, 5-26-24 6am to 6pm, 5-31-24 6am to 6pm, 6-1-24 6am to 6pm, and 6-2-24 6am to 6pm. On 6-2-24 at 2:00 PM V4 (Infection Preventionist) provided a list of residents who should have been placed in enhanced barrier precautions but were not. The list included the following residents: R3, R15, and R32 due to having indwelling urinary catheters and R6, R7, R8, R18, R24, R33, R36, and R138 due to having wounds. The facility's Annual Required In-Service policy dated 09/2017 documents staff should receive Abuse Prevention and Alzheimer's Dementia Management in-servicing annually. The facility's QAPI Plan policy dated 1-10-24 documents, Annual training will be provided to all staff utilizing the annual QAPI report to summarize goals, progress, and PIPs (Performance Improvement Projects). V7 (CNA/Certified Nursing Assistant), V11 (CNA), V16-V18 (CNAs), V22 (CNA), and V24-V34's (CNA's) In-Service Training Logs dated 6-1-23 through 6-2-24 do not include evidence of V7, V11, V16-V18, V22, and V24-V34 receiving annual Abuse, Alzheimer's Dementia Management, or QAPI in-service training. On 6-2-24 from 7:00 AM through 2:15 PM no activities were observed being offered to the residents throughout the facility during this timeframe, no residents attended a church service outside of the building, no church service was provided within the building, there was no registered nurse within the building, there was no licensed administrator within the building, there was no activity director within the building, and there was no dietary manager within the building. On 6-2-24 from 7:00 AM to 9:00 AM a tour of the building was done. During this tour R3, R6, R7, R8, R15, R18, R24, R32, R33, R36, and R138's doors did not have signs indicating they were in enhanced barrier precautions and V6 (LPN/Licensed Practical Nurse), V7 (CNA/Certified Nursing Assistant), and V11 (CNA) were not wearing gowns while providing personal cares to R3, R6, R7, R8, R15, R18, R24, R32, R33, R36, and R138. On 6-2-24 at 9:35 AM, V12, [NAME] and V13, Dietary Worker, both stated, The convection oven doesn't work. It's been broken for months. We were told the part to fix it was too expensive. One of the two range ovens don't work right - it can be used as a warmer but won't get the temperature of foods up to the correct temperature. On 6/02/24 at 9:45 AM, it was noted that the door to the outside freezer has a totally rusted out external layer of metal across the width of the door and ten inches above the bottom. An area approximately 60 inches by 10 inches. The inner door material/insulation is visible. On 6-3-24 from 7:45 AM through 3:20 PM the only activity offered to residents during this timeframe was bingo from 2:00 PM through 2:40 PM, there was no Director of Nursing within the building, there was no Activity Director within the facility, and there was no Dietary Manager within the building. On 6-3-24 at 11:10 AM during the resident council meeting R3, R14, R20, and R36 all stated that they did not know what a grievance was, where grievance forms are to fill out if needed, or who the facility's grievance official is. R3, R14, R20, and R36 also stated that complaints voiced during resident council are never resolved. R3, R14, R20, and R36 stated they have wanted church services for over a year, and no one has tried to get them to church or have a church come in to do services. All stated the facility needs more nursing staff in the morning. R3, R14, R20, and R36 stated when there is only one nurse medications are late. On 6-4-24 from 7:45 AM through 3:20 PM no activities were observed being offered to the residents throughout the facility during this timeframe, there was no Director of Nursing within the building, there was no Activity Director within the facility, and there was no Dietary Manager within the building. On 6-4-24 at 7:40 AM V17 (CNA/Certified Nursing Assistant) was providing a bed bath to R6. V17 was using a pillowcase to wash R6. V17 stated, We never have washcloths or towels to use. We have not had enough washcloths or towels for months. A lot of days there is only one or two washcloths in the building to use for all of the residents. R6 stated, There is never towels or washcloths to use. On 6-4-24 at 7:50 AM V17 opened the linen storage room. The linen storage room had no washcloths or towels. V17 stated there is only one linen storage room and there is never washcloths or towel available. On 6-2-24 at 11:30 AM V2 (Administrator-In-Training) stated, (V8's/Prior DON) last day worked was 11-16-23. (V3's/Prior DON) only lasted a couple months from 12-18-23 through 2-29-24. I have not had a DON since 2-29-24. On 6-6-24 at 9:30 AM V2 stated, The staff have not received abuse training, Alzheimer's Dementia management training, or QAPI training within the last 12 months. On 6-3-24 at 3:00 PM V2 stated, There was no activity calendar developed or given to the residents for the months of May 2024, April 2024, January 2024, or December 2023. No activities were offered on 6-2-24 or 6-4-24 to the residents and only bingo was offered to the residents on 6-3-24. We have not had anyone in the activity department for two months. We do not offer activities on second shift or the weekends. On 6-4-24 at 9:44 AM V2 stated, The last Activity Director (V19) the facility had was hired 2-5-24 and quit on 3-12-24. We have not had an Activity Director here since 3-12-24. On 6-4-24 at 2:00 PM V4 (Resident Care Coordinator) stated, I am the infection preventionist and did not know anything about Enhanced Barrier Precautions. I just requested the policy from corporate today and the facility should have been using that policy. No residents were ever placed in Enhanced Barrier Precautions prior to today. On 6-4-24 at 2:30 PM V2 stated, I tried to order washcloths and towels from a vendor and was not allowed to order from that vendor. I am now using a new vendor but have not placed an order for washcloths or towels yet. On 6-5-24 at 1:00 PM V4 stated, I am responsible for scheduling the nurses. According to (V2/Administrator-In-Training) we (the facility) are supposed to have two full-time nurses on day shift, two full-time nurses on second shift, and one full-time nurse on night shift. We did not have enough nurses on 5-11-24 6am to 6pm, 5-12-24 6am to 6pm, 5-25-24 6am to 6pm, 5-26-24 6am to 6pm, 5-31-24 6am to 6pm, 6-1-24 6am to 6pm, or 6-2-24 6am to 6pm. On 6-6-24 at 12:40 PM V2 Administrator in Training stated the surveyors cannot have access to the facility's QAPI meeting minutes. V2 stated the facility has not addressed, developed, or implemented plans of corrections to address the facility not having a Director of Nursing, Activity Director, Dietary Manager, not having meaningful daily scheduled activities, ensuring ongoing resident complaints were resolved, ensuring residents had an adequate amount of linens, ensuring the facility had sufficient nursing staff, ensuring the most up-to-date infection control practices were implemented, ensuring resident council meetings were provided monthly, ensuring large dietary appliances were in good repair and working order, ensuring all required QAPI (Quality Assurance and Performance Improvement) members met monthly, and ensure all CNAs (Certified Nursing Assistants) were provided annual required abuse, QAPI, and Dementia in-service training.

Based on Interview and Record Review the facility failed to have a Director of Nursing or the required number of members at the quarterly Quality Assurance Meetings. This has the potential to affect all 36 resident living in the facility. Findings: The document, Members of Quality Assessment and Assurance, no date, states, (Members): Administrator; Administrator in Training; Resident Care Coordinator; Social Services Director/Business Office Manager; Medical Director; Therapy and Pharmacy. The Quality Assurance quarterly sign-in sheets for the past twelve months were reviewed. A Director of Nursing was not present at any of the meetings. The 1/19/24 meeting had five members; the 10/19/23 meeting had four members; the 7/21/23 meeting had four members. On 6/06/24 at 12:45, V2/Administrator in Training stated, No, we didn't have a Director of Nursing to come to the Quality Assurance Meetings. The number of members able to attend the meeting signed the attendance sheets. The facility's Daily Census dated 6/2/24 documents 36 residents currently reside within the facility.

Based on observation, interview and record review, the facility failed to make repairs to several large appliances: the reach-in refrigerator; range oven; convection oven; outside freezer door; steam table; large hood and baffles. This has the potential to affect all 36 residents living in the facility. Findings: The document Maintenance and Environmental Policy and Guidelines, no date, states, It is of the utmost importance to provide a safe, organized facility that is conducive to providing the best care. A well maintained building is also important for creating safe work surroundings across all departmental staffing and their ability to effective and efficiently provide care to all residents. Requested work orders completed in an acceptable manner and time. On 6/02/24 at 9:35 AM, V12, [NAME] and V13, Dietary Worker, both stated, The convection oven doesn't work. It's been broken for months. We were told the part to fix it was too expensive. One of the two range ovens doesn't work right - it can be used as a warmer but won't get the temperature of foods up to the correct temperature. We have to maneuver food around in order to get everything ready for meals. If the oven we are using like a warmer doesn't keep the food hot enough, we have to reheat it before serving. It really is difficult. One of the wells in the steam table has a broken pipe. We're not sure how long it will be before that it fixed. The large hood with baffles doesn't work at all. We told V1, Administrator about it six or seven months ago but no one no one has fixed that either. I've never seen a work order to fill out. We're supposed to tell V1 when something needs to be fixed, so we tell V1 right away. On 6/02/24 at 9:45 AM, it was noted that the door to the outside freezer has a totally rusted out external layer of metal across the width of the door and ten inches above the bottom. An area approximately 60 inches by 10 inches. The inner door material/insulation is visible. V13, Dietary Worker, stated, They can't fix it. They said they couldn't fit a piece of metal on it to stick. I don't think they will get a new door for it. On 6/06/24 at 12:50 PM, V2/Administrator in Training, stated, I wasn't aware that the hood and range ovens didn't work, or the freezer door needs to be fixed. The facility's Daily Census dated 6/2/24 documents 36 residents currently reside within the facility.

Based on record review and interview the facility failed to ensure direct care staff received annual Abuse and Prevention in-service training. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The facility's Annual Required In-Service policy dated 09/2017 documents staff should receive Abuse Prevention in-servicing annually. V7 (CNA/Certified Nursing Assistant), V11 (CNA), V16-V18 (CNAs), V22 (CNA), and V24-V34's (CNA's) In-Service Training Logs dated 6-1-23 through 6-2-24 do not include evidence of V7, V11, V16-V18, V22, and V24-V34 receiving annual Abuse training. On 6-6-24 at 9:30 AM V2 (Administrator-In-Training) stated, The staff have not received abuse training within the last 12 months.

Based on record review and interview the facility failed to ensure direct care staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The facility's QAPI Plan policy dated 1-10-24 documents, Annual training will be provided to all staff utilizing the annual QAPI report to summarize goals, progress, and PIPs (Performance Improvement Projects). V7 (CNA/Certified Nursing Assistant), V11 (CNA), V16-V18 (CNAs), V22 (CNA), and V24-V34's (CNA's) In-Service Training Logs dated 6-1-23 through 6-2-24 do not include evidence of V7, V11, V16-V18, V22, and V24-V34 receiving annual QAPI in-service training. On 6-6-24 at 9:30 AM V2 (Administrator-In-Training) stated, The staff have never received QAPI in-service training.

Based on record review and interview the facility failed to ensure direct care staff received annual Dementia Care in-service training. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The facility's Annual Required In-Service policy dated 09/2017 documents staff should receive Alzheimer's Dementia Management in-servicing annually. V7 (CNA/Certified Nursing Assistant), V11 (CNA), V16-V18 (CNAs), V22 (CNA), and V24-V34's (CNA's) In-Service Training Logs dated 6-1-23 through 6-2-24 do not include evidence of V7, V11, V16-V18, V22, and V24-V34 receiving annual Alzheimer's Dementia Management in-service training. On 6-6-24 at 9:30 AM V2 (Administrator-In-Training) stated, The staff have not received Alzheimer's Dementia Training within the last 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure physician ordered therapy services were provided for 1 resident (R1) of 3 residents reviewed for physical/occupational therapy. Findings include: R1's Minimum Data Set/MDS assessment dated [DATE] documents that R1 has a BIMs (Brief Interview for Mental Status) of 14 (cognition intact), had orthopedic surgery and was getting Occupational Therapy and Physical Therapy. On 3/8/24 at 12:03 PM, V5 (Assistant Director of Nursing) stated there is no therapy being done in the facility. It stopped in the middle of February. R1 admitted on [DATE] for a right femur fracture for therapy. R1 did not get to complete her therapy because therapy quit coming to the facility. On 3/8/24 at 1:15 PM, V2 (Administrator in Training) stated that therapy stopped coming to the facility near the middle of February 2024. V4 (Social Service Director) went and told R1 that R1's therapy was going to be discontinued. The facility does not have a Therapy policy. On 3/8/24 at 12:40 PM, R1 stated that she broke her leg in January and came to the facility for therapy. R1 was getting therapy and was pleased with her progress. R1 got therapy on Friday (2/16/24) then on Monday (2/19/24) she was expecting to have therapy, but the therapist did not come. R1 heard the therapy company quit coming to the facility. R1 is upset that she no longer gets therapy. R1 also stated It hurt my progress. I came here for therapy so I could get better and go home. Now I can't go home because my therapy stopped. I thought I would be home by now! On 3/9/24 at 10:31 AM, V14 (R1's Power of Attorney/POA) stated that R1 went to the facility for therapy. R1 was doing well with therapy then R1 was told therapy would not be coming to the facility anymore. Now R1 is being billed at private pay because therapy stopped. V14 told R1 that R1 may have to go somewhere else to get therapy so R1 can get better to go home. That upset R1 because R1 lives close to the facility and does not want to leave her hometown. R1 is still paying her bills for her home and, it is not fair that it is costing R1 extra money because the facility stopped providing therapy. On 3/9/24 at 11:32 AM, V1 (Administrator) stated that she was told by the corporate office that the contracted therapy company was sending a letter to the facility stating they would be ending their contract with the facility. V1 did not see the letter but believes the therapy service ended as of 2/19/24. R1's Physician Order dated 1/5/24 documents Physical Therapy/Occupational Therapy to evaluate and treat. The end date is indefinite. R1's Occupational Therapy Treatment Note printed 3/8/24 at 4:27 PM, documents on 2/16/24 Toileting this date with education on safe transfers and hand placement. (R1) with increased hesitancy and continues to require max assist with pulling pants up and down over hips. Effective 2/19/24 (contracted company) is no longer the therapy provider. R1's Social Service Note dated 2/22/24 at 12:59 PM, documents that V4 (Social Service Director) notified V14 (R1's POA) that therapy services were no longer available at the facility.

Based on record review and interview, the facility failed to provide requested Medical Records for 1 resident (R1) of 3 residents reviewed for records requested in the sample of 13. Findings include: The Resident Rights Handbook dated 11/18 documents Your facility must allow you to see your records within 24 hours of your request (excluding weekends and holidays). You may purchase a copy of part or all of your records at a reasonable copy fee within two working days of your request. On 1/13/24 at 8:20 AM, V2 (Administrator in Training/AIT) stated V6 (R1's Power of Attorney) requested R1's medical records about a month ago. The request was sent to the Corporate Office, and V2 is waiting for the approval. V6 was told we (the facility) are having some system problems because we were hacked, but he will get the records. On 1/12/24 at 4:06 PM, V6 (R1's Power of Attorney) stated I asked (V2/AIT) for (R1's) Medical Records in November and haven't heard anything more about getting them. An Electronic E-Mail sent by V2 dated 1/16/24 at 11:40 AM, documents that V6 requested R1's complete chart. Not sure how many pages yet but just needing to know the cost per page or if it's one flat charge. On 1/16/24 at 12:22 PM, V2 stated this was the first time she had requested the price information from the Corporate Office and had not told V6 what the cost would be. V2 confirmed V6 has not received the Medical Records he requested back in October 2023. V1 stated, It fell through the cracks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the correct size (disposable briefs) for 3 residents (R3, R5, and R9) of 7 residents reviewed for supplies in the sample of 13. Findings include: The Resident Rights Handbook dated 11/18 documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. 1. R3's Minimum Data Set assessment dated [DATE], documents R3 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact) and is always incontinent of bowel and bladder. On 1/12/24 at 2:23 PM, R3 stated there have been several times the facility has run out of disposable briefs in her size. It's because they don't order far enough ahead. When they run out, I'm given disposable underwear. I don't like them because they are too small, and tight across my stomach and they leak. 2. R5's Minimum Data Set assessment dated [DATE], documents R5 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact) and is frequently incontinent of bladder and occasionally incontinent of bowel. On 1/13/24 at 3:30 PM, R5 stated It is not unusual for the facility to run out of disposable briefs. They might have some but not big enough for me. When they give me the smaller size it rubs in my folds and is uncomfortable. 3. R9's Minimum Data Set assessment dated [DATE], documents R9 has a BIMs (Brief Interview for Mental Status) of 12 (mildly impaired cognition) and is always incontinent of bowel and bladder. On 1/13/24 at 3:51 PM, R9 stated Usually around the end of the month they (the facility) start running out of disposable briefs. When that happens, they use disposable underwear. They tear the sides of them and put two or three together to make it wide enough to use. They don't absorb as well, and they are uncomfortable. On 1/12/24 at 4:41 PM, V3 (Director of Nursing) stated When I first worked here as an agency nurse in November, we almost ran out of all the disposable briefs. How could that be? V4 (Resident Care Coordinator) did the ordering of disposable briefs. V4 was ordering them once a month. I am going to start ordering supplies, so I was asking questions. V2 (Administrator in Training) said they could be ordered twice a month. V4 was not aware that disposable briefs could be ordered twice a month. On 1/12/24 at 12:46 PM, V8 (CNA) stated We use what we have. If we run out of disposable briefs then we use disposable underwear until we get more. They are ordered once a month. I have had to use the wrong size on residents. On 1/12/24 at 1:00 PM, V9 (CNA) stated We run out of disposable briefs. One time I didn't have any disposable briefs or disposable underwear and had to use a disposable bed pad. I wrapped it around the resident and pulled his pants up. I have had to use bath blankets to put on the bed when there are no supplies for incontinent care. The bed gets soaked. We are told we can buy the disposable briefs but we should not have to buy supplies. On 1/16/2024 at 12:35 PM V1 (Administrator) stated, If they (the facility) run out of disposable briefs, I always go to a retail store or a pharmacy to purchase them and take them back to the facility. V1 confirmed the disposable briefs that are purchased outside of their normal ordering company may not be the correct sizes for the residents based off of what those stores have in stock at the time. On 1/12/24 at 10:28 PM, V17 (CNA) stated that the facility frequently runs out of disposable briefs and disposable underwear must be used. It is harder to change a resident using the disposable underwear. Plus, there are times a resident will have to wear the wrong size because that is all that is available. Staff have been told the reason there is not enough disposable briefs is because we are stealing them. On 1/12/24 at 1:20 PM, V10 (CNA) stated that sometimes the facility runs out of disposable briefs and only has disposable underwear and some CNAs have had to use a disposable bed pads. V10 has had to use the wrong size disposable briefs on some residents. R9 is a resident V10 knows has been given the wrong size. V10 stated it is the larger residents there is a problem having the right size for. Sometimes they complain that it is too tight and how do you expect me to wear that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide assistance for transportation to medical appointments for 1 residents (R8) of 6 residents reviewed for transportation needs in the sample of 13. Findings include: The Transportation Protocol (not dated) documents Protocol for the facility regarding transportation requests for outside vendor appointments. The social service director will assist residents in arranging transportation to appointments and outside excursions. If other arrangements cannot be made the facility will provide transportation as the schedule allows. The residents receiving hemodialysis will take precedence of the facility van transports. The Resident Rights Handbook dated 11/18 documents The facility must provide services to keep your physical and mental health, at their highest practical levels. R1's current Medical Record, documents R1 was admitted to the facility on [DATE] with diagnoses which included Other Psychoactive Substance Dependence with Psychoactive Substance Induced Psychotic Disorder with Hallucinations, Social Phobia, Attention Deficit Hyperactivity Disorder, Predominantly Inattentive Type, Disorientation, Opioid Dependency, Anxiety Disorder and Depression. On 1/12/24 at 1:20 PM, V10 (CNA) stated that residents are missing appointments. V10 has been driving the van and working the floor as a CNA. R8 has missed a couple of psych appointments and they were not going to fill R8's prescription. V10 took R8 to the psych appointment a few days ago so R8 could continue getting medication. On 1/13/24 at 10:00 PM, V19 (LPN) stated that R8 has missed a couple of Psych appointments, V19 is not sure of the dates. The Appointment Calendar for 2023, documents R8 had appointments on 9/26/23 at 1:30 PM, with V24 (Psych Counselor), 9/28/23 at 9:15 AM with V23 (Psych Nurse Practitioner), 10/10/23 at 2:00 PM with V24, 10/24/23 at 2:00 PM with V24, and 12/20/23 at 2:15 PM (no provider listed). The Transportation Log for 2023, does not document an entry that R8 was transported to his appointment on 9/26, 9/28, 10/10, 10/24, and 12/20/23. On 1/16/24, V5 presented four pages of appointments for 2024. There was no organization to the pages or appointments listed. It documented (R8) missed an appointment on 12/29 and his last scheduled appointment also. On 1/16/23 at 10:07 AM V22 (V23's Receptionist) stated, (R8) missed two of his scheduled appointments on 12/20/23 and 12/29/23. I called the facility on 12/20/23 to see why (R8's) appointment was canceled and (the facility) reported they let the transportation driver go home for the day and forgot about (R8's) appointment. (R8) was supposed to see (V24/Psych Counselor) during this appointment. On 12/29/23 (R8's) appointment was canceled once again. I spoke to (the facility) and they stated the driver was too busy and couldn't accommodate (R8) for the day. This appointment was to see (V23/Psych Nurse Practitioner) which is who controls (R8's) medications. On 1/13/24 at 4:30 PM, V5 (Business Office Manager/Social Services) stated Some residents have missed appointments. We should get the residents to their appointments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide assistance for transportation to dental appointments for 1 residents (R2) of 6 residents reviewed for dental service needs in the sample of 13. Findings include: The Transportation Protocol (not dated) documents Protocol for the facility regarding transportation requests for outside vendor appointments. The social service director will assist residents in arranging transportation to appointments and outside excursions. If other arrangements cannot be made the facility will provide transportation as the schedule allows. The residents receiving hemodialysis will take precedence of the facility van transports. The Resident Rights Handbook dated 11/18 documents The facility must provide services to keep your physical and mental health, at their highest practical levels. R2's Minimum Data Set assessment dated [DATE], documents R2 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact). On 1/13/24 at 4:00 PM, R2 stated I missed another dental appointment on 1/11/24 because they said they had another person to take to an appointment so I couldn't go to mine. V5 helps me get my appointments scheduled. I go to her office and call the dentist and have V5 write the appointment down. I need a lot of dental work done and I was upset I couldn't go to the appointment. I have missed a lot of dental appointments and it is frustrating. On 1/12/24 at 4:41 PM, V3 (Director of Nursing) stated that yesterday (1/11/24) there were two appointments scheduled for the same day. There was no way both residents could get to their appointments so R2 did not go to his appointment. V3 also stated the problem with transportation is organization. There is not a planner to write the appointments on at this point and an appointment might get missed. On 1/12/24 at 1:00 PM, V9 (Certified Nursing Assistant) stated that R2 did not get to go to his dental appointment on 1/11/24, because R13 had an appointment at about the same time. Only one of them could go to their appointment and R13 got to go. On 1/13/24 at 10:00 PM, V19 (Licensed Practical Nurse) stated that R2 has missed at least a couple of dental appointments. V19 does not remember the dates. The Resident Council Meeting Minutes for October 2023, documents Resident complained about his appointments being canceled due to no transportation driver. The Grievance/Complaint Report for R2 dated 10/5/23, documents (R2) complained about his appointments being canceled due to not having a transportation driver. Method of Correction dated 10/9/23 documents that V2 (AIT) Spoke to (R2) about were trying to get a driver hired. Will work with a sister facility to see if they can help us get the appointment rescheduled. On 1/16/24 at 10:29 AM, V27 (Dental Patient Service Representative) stated that R2 did miss his dental appointment on 1/11/24. On 1/16/24 at 2:10 PM, V5 (Business Office Manager/Social Services) presented four pages of appointments for 2024. There was no organization to the pages or appointments listed. It did not list the appointment on 1/11/24 for R2. On 1/16/24 at 2:10 PM V5 (Business Office Manager/Social Services) stated that she has just taken over Transportation scheduling and is trying to get it organized. V5 verified that R2 did have an appointment on 1/11/24 for the dentist but it was not documented on the Transportation Schedule. V5 also stated that R2 did not go to the 1/11/24 appointment. On 1/12/24 at 1:20 PM, V10 (CNA) stated that residents are missing appointments. V10 has been driving the van and working the floor as a CNA. Yesterday (1/11/24), R2 missed a dental appointment. The Transportation Log for 2023, does not document an entry that R2 was transported to his appointment on 1/11/24.

Based on observation, interview, and record review the facility failed to provide activities daily for the residents. This failure has the potential to affect all 40 residents in the facility. Findings include: The Activity Policy dated 9/17 documents It is the policy of (the facility) to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interest and the physical, mental, and psychosocial well-being of each resident. The program is under the direction of an Activity Director, who shall have a specified planned program of group and individual activities based upon the resident's needs and interest. Residents shall have the opportunity to contribute to planning, preparation, conducting, clean up and critiquing of programs. There were no residents observed doing any activities during this survey (1/12-1/16/24). On 1/13/24 at 8:20 AM, V2 (Administrator in Training/AIT) stated that there is not an Activity Director. The last one that was hired worked for three days and quit. We (the facility) try to do Bingo two times a week. There are no other activities available for the residents. On 1/12/24 at 2:23 PM, R3 stated There needs to be some activities. There was supposed to be Bingo today, but the room is locked and (V2/AIT) is not here to unlock the door. There is nothing else to do and I get bored. I need something to keep my mind sharp. On 1/12/24 at 4:41 PM, V3 (Director of Nursing) stated We do not have an Activity Director, V10 (Certified Nursing Assistant/CNA) does Bingo on Monday-Wednesday-Friday if she can. V10 also works the floor and drives the Transportation Van so if she is needed for one of those jobs she can't do the Bingo. On 1/12/24 at 4:20 PM, V4 (Resident Care Coordinator) stated that there is Bingo once a week. There isn't an Activity Calendar. The residents complain about not having any activities. On 1/12/24 at 4:25 PM, V5 (Business Office Manager/Social Services) stated There is not an Activity Calendar. The Activity Director quit in October. The next person was here about a week. (V10) does Bingo on her own time when she can. On 1/12/24 at 12:46 PM, V8 (CNA) stated There is no activities, there is no activity person. CNAs are staying on their own time to do activities with the residents. On 1/12/24 at 1:00 PM, V9 (CNA) stated There are not any activities unless (V10/CNA) stays on her own time. It has been this way for over a month. On 1/12/24 at 1:20 PM, V10 (CNA) stated I can't do Bingo today because (V2/AIT) is not here and (V2) has the key to the room the game is in. There is no activity person. I stay over to do Bingo on my own time. On 1/16/2024 at 12:32 PM, V1 (Administrator) confirmed that activities are not being provided to residents on a daily bases, residents are not receiving an activity calendar monthly, and they still have no Activity Director. The Midnight Census report signed by V1 dated 1/16/24 at 12:00 PM, documents the census for 1/12/24 was 40 residents.

Based on Observation, Interview and Record Review, the facility failed to respond to resident call lights in a timely manner for three of seven residents (R3, R10, R11) reviewed for call lights in the sample of 10. Findings include: 1. The facility's resident council minutes, dated November 2023, documents Complaints: Resident complained that call lights are not being answered in a timely manner, causing residents to start yelling. R11's Grievance/ Complaint Report, dated 11/2/23, documents R11 complained that staff are not answering call lights in a timely manner, therefore causing residents to start yelling. This same report documents Method of correction or disposition of complaint or grievance: Let (R11) know that at times CNA's (Certified Nursing Assistants) are in other rooms when call lights are going off. 2. On 12/4/23 at 10:00 AM, R10's call light was observed to be alarming and continued for 25 minutes from 10:00 AM-10:25 AM. At 10:30 AM R10 stated It typically takes them 30 minutes or so to answer my light. 3. On 12/4/23 at 10:05 AM, R3's call light was observed to be alarming and continued for 20 minutes from 10:05 AM-10:25 AM. At 10:35 AM R3 stated, I have to wait most of the time around 30 to 40 minutes for my call light to be answered and I need changed now. R3 stated that she requires extensive staff assistance for incontinence care and hygiene. On 12/5/23 at 10:45 AM, V1 (Administrator) stated We don't have a policy on call lights. They should be answered within a couple of minutes. Anyone can answer the light and should but if they need a nurse or CNA, the person can go get them. So, they (call lights) shouldn't be going off for long periods. 20 minutes is too long for someone to wait for a call light to be answered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and Record Review, the facility failed to develop a comprehensive care plan for four of eight residents (R4, R7, R8, R9) reviewed for care plans in the sample of 10. Findings include: The facility's Comprehensive Care Planning policy, dated 11/1/17, documents It is the policy of (The facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. The Comprehensive Care Plan (CCP) shall be developed within 7 days of the completion of the RAI. The CCP shall be reviewed after each Annual, Significant Change and Quarterly MDS (Minimum Data Set assessment) and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified by the IDT. The Resident Care Plan may be kept electronically or in hard copy printed format. 1. R4's admission Record facesheet documents R4 was admitted to the facility on [DATE]. R4's electronic medical record and physical chart does not contain a Comprehensive Care Plan for R4 for his diagnoses and medical care needs. 2. R7's admission Record facesheet documents R7 was admitted to the facility on [DATE]. R7's electronic medical record and physical chart does not contain a Comprehensive Care Plan for R7 for her diagnoses and medical care needs. 3. R8's admission Record facesheet documents R8 was admitted to the facility on [DATE]. R8's electronic medical record and physical chart does not contain a Comprehensive Care Plan for R8 for his diagnoses and medical care needs. 4. R9's admission Record facesheet documents R9 was admitted to the facility on [DATE]. R9's electronic medical record and physical chart does not contain a Comprehensive Care Plan for R9 for her diagnoses and medical care needs. On 12/4/23 at 2:45 PM, V1 (Administrator in Training) confirmed R4, R7, R8 and R9 do not have Comprehensive Care Plans in the facility. V1 stated (V9, Corporate MDS Coordinator) is working on them and will send them to us. They should be completed after a resident's admission and placed on the charts. I am not sure why they didn't get done.

Based on Interview and Record review the facility failed to provide Registered Nurse services eight hours daily. This failure has the potential to affect all 42 residents residing in the facility. Findings include: The facility's Midnight Census Report dated 12/4/23 and provided by V1 (Administrator in Training) documents 42 residents currently reside within the facility. The facility's Nursing Services policy (undated) documents, It is the policy of (the facility) to assure sufficient qualified nursing staff is available and on duty on a daily basis to provide nursing and related serviced to attain or maintain each resident's highest practical physical, mental, and psychosocial well-being as determined by resident assessment and plans of care. Nursing services shall be provided on a 24-hour per day basis. Registered nurse services shall be available eight hours each day, seven days each week, except when waived by proper authorities. The facility's Nurse Schedule dated 11/10/23-11/30/23 documents the facility had no Registered Nurse (RN) coverage on 11/19/23, 11/23/23, 11/24/23 and 11/26/23. The facility's Nurse schedule dated 12/1/23-12/5/23 documents the facility did not have RN coverage on 12/5/23. On 12/5/23 at 12:55 PM, V1 (Administrator in Training) confirmed the nursing schedule for November and December 2023 were accurate and the facility did not have RN coverage on 11/19, 23, 24, 26 and 12/5/23.

Based on record review and interview the facility failed to provide Registered Nurse/RN services eight hours daily. This failure has the potential to affect all 38 residents within the facility. Findings include: The facility's Midnight Census Report dated 11-7-23 documents 38 residents currently reside within the facility. The facility's Nursing Services policy (undated) documents, It is the policy of (the facility) to assure sufficient qualified nursing staff is available and on duty on a daily basis to provide nursing and related serviced to attain or maintain each resident's highest practical physical, mental, and psychosocial well-being as determined by resident assessment and plans of care. Nursing services shall be provided on a 24-hour per day basis. Registered nurse services shall be available eight hours each day, seven days each week, except when waived by proper authorities. The facility's Nurse Schedule dated 10-1-23 through 10-31-23 documents the facility had no RN coverage on 10-1-23, 10-7-23, 10-8-23, 10-14-23, 10-15-23, 10-21-23, and 10-22-23. On 11-7-23 at 11:30 AM V8 (Resident Care Coordinator) stated, There was no RN coverage on seven days (10-1-23, 10-7-23, 10-8-23, 10-14-23, 10-15-23, 10-21-23, and 10-22-23) in October 2023. On 11-7-23 at 2:45 PM V2 (Administrator in Training) stated, I am aware that we do not have a registered nurse available every day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain blood glucose orders, failed to follow physician orders for obtaining blood glucose levels in a timely manner, and failed to document blood glucose orders, for one (R2) resident reviewed for physician orders in a sample of three. Findings include: The facility's Glucose Monitoring Policy, Dated 3/17/23, documents: Purpose: To monitor resident's blood glucose to assist in the development of an appropriate medication and treatment regime for resident's with a metabolic disorder caused by an imbalance between insulin supply and demand. R2's Diagnosis Report, Dated 8/2023, documents: Type 2 Diabetes Mellitus without complications. R2's 8/24/23 Progress Note documents: Situation: Accucheck's; Background: Resident's friend/V21 reports (R2) has a history of (Diabetes Mellitus) after arriving today and finding out about (R2's) fall yesterday, (V21 Friend to R2) thought this might be related. Per (V16 Medical Director), Please check patient's blood glucose morning and at (night), daily at this time. On 9/1/23 at 10:30am, R2 stated that he was diabetic; that he thought he let the (facility staff) know this when he was admitted ; that he had accuchecks done at home prior to admit to facility on 8/10/23; and stated that the facility staff did not start doing his accuchecks at the facility until yesterday (8/31/23). R2's August 2023 Order Recap Report, Dated 8/2023, does not documents blood glucose accucheck orders for R2. R2 was admitted to the facility on [DATE]. R2's Treatment Administration Record/TAR and Medication Administration Record/MAR, dated 8/2023, do not document blood glucose monitoring accuchecks or signage. R2's Hospital Note Dated 8/23/23 documents vitals: Blood pressure 124/70, Heart rate 102, Oxygen saturation 97 percent, Temperature 98.2. There are no documentation notes indicating R2's blood glucose level. On 8/30/23 at 12:10pm, V15 Licensed Practical Nurse/LPN, stated that when R2 was sent to the Emergency Department a week ago, there were no accucheck or insulin orders for him at that time. V15 stated that (R2) does have a diagnosis of diabetes; that he does have an as needed/PRN order for glucose oral tab chewable PRN if sugar was low. V15 stated, I don't know if his blood sugar was low when he fell on 8/23/23; and I don't know if it was checked. On 8/30/23 at 12:15pm, V2 Director of Nursing/DON stated: (R2) is a new resident, admitted 8/10; his neighbor (V21 Friend to R1) visited him after he was sent to hospital and was upset, she was not notified; stated that (R2) had been diabetic for 30 years. I searched his orders and found his diagnosis for his diabetes was in his chart. V2 stated at this time, When (R2) fell on 8/23/23 he was sent to (Emergency Department), had altered level of consciousness; I don't know if his altered level of consciousness was due to diabetic episode; he had therapy and therapy said he was very lethargic; found on the floor after therapy in his room. There were no orders to check his blood sugars, and this was not checked when he fell; don't know why there is no order in the computer; we got an order from (V16 Medical Director) and we failed to put this in the computer. On 8/30/23 at 1:00pm, V5 Licensed Practical Nurse/LPN; stated that she got a verbal order on 8/24/23 from (V16 Medical Director) for accuchecks twice a day for (R2) after R2 fell on 8/23/23; V5 stated that she was the only nurse on the floor at that time; that she put the information about the order in the progress notes but did not put the order in the computer. At this time, V5/LPN stated: I was in the middle of my medication pass and I told the DON I got the order; I did a progress note but I did not put the order in. (R2) had just come back from therapy; then there was a change in him, glassy eyes, he was not acting himself; within a few minutes, he had a fall. On 9/1/23 at 1:35pm, V22 Physical Therapist Assistant/PTA, stated that on 8/23/23, R2 was noted to have a decline during therapy; a notable change, eyes droopy, sluggish, seemed like he was exhausted; and that day prior, (R2) had stated, I feel really tired. At this time, V22 stated that she found out the next day (8/24/23) when V21 Friend to R2, came to see him while he was in therapy and (V21) said that (R2) was diabetic. V22/PTA stated, (V21) said, well, (R2's) diabetic; did anyone bother to check his blood sugar; he was insulin dependent at home; had to check his blood sugars several times a day. I then went to talk to R2's nurse (V5/LPN) about this. On 9/1/23 V4 Quality Assurance stated, For any new orders, we should have checked the diagnosis and if resident had diabetes, checked to see what orders would have been there for insulin or sliding scale; if none, I would have called the doctor and followed up with the admitting physician regarding any blood sugar checks. At this time, V4 stated that she documented the accucheck order for R2 that the facility got on 8/24/23. V4 stated, I don't know why (V5 Licensed Practical Nurse/LPN) or (V2 Director of Nursing/DON) had not put the order in when V5 got the order from (V16 Medical Director).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its Fall Prevention Policy, failed to monitor, and failed to ensure fall prevention safety precautions were in place and followed to prevent a fall for one (R2) of three residents reviewed for falls; these failures resulted in R2 falling and sustaining a soft tissue hematoma to his forehead. Findings include: The facility's Fall Prevention Policy, Dated 11/10/18, documents: Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. All staff must observe residents for safety. If residents with a high risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. R2's Fall Risk assessment dated [DATE] documents: R2's Fall Risk Assessment score: 14. (10 points or more equal high fall risk score). R2's Fall Analysis Log, Dated August 2023, documents: Date of Incident 8/23/23: Injury type, bump head. Interventions: Sent to emergency room and education provided. R2's Progress Note, Dated 8/23/23 documents: Resident sent to emergency room for evaluation following change in consciousness, face first fall out of his wheelchair. He did hit his head without visible injury-he is complaining of left shoulder pain. R1's Hospital CT (Computerized Tomography) Scan, dated 8/23/23 documents: Clinical Impression: Minor closed head injury. Unknown whether a loss of consciousness occurred; single contusion with soft tissue hematoma to the forehead. R2's diagnoses include: Acute respiratory failure with hypoxia, pneumonia, chest pain, chronic atrial fibrillation, atherosclerotic heart disease, chronic congestive heart failure, Type 2 diabetes mellitus, cerebrovascular disease, chronic obstructive pulmonary disease. R2 was admitted to the facility on [DATE]. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 13. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R2's current Care Plan documents: Transfers, Assist of one. On 8/30/23 at 12:05pm, R2 stated that he had a recent fall (8/23/23); that he fell off his wheelchair and hit his head on the floor. R2 stated, I was just sitting in my wheelchair and fell out; got a knot on my head; went to hospital to get checked out and they sent me right back. On 9/1/23 at 11:15am, V4 Quality Assurance stated, We put interventions in place for R2 after his fall, for the staff to monitor (R2); he does self transfer. We also educated him and reminded him to call for assist. On 9/1/23 at 12:05pm, V18 Occupational Therapist/OT stated, (R2) is one assist, contact guard to minimal assist with one staff; he is not to transfer by himself and he is educated not to but sometimes he forgets; and he should be assisted with transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident's Practitioner Order for Life-Sustaining Treatment (POLST) was transferred to the current Physician order sheet for one of sixteen residents (R11) reviewed for advance directives in the sample of 29. Findings include: The facility's Advance Directive policy, dated [DATE], documents The Patient Self Determination Act states that individuals have the right to make their own decisions, and to formulate advance directives to serve as decisions when the individual is incapacitated. It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments whenever possible. This facility shall take all steps necessary to comply with state and federal legislation relating to advance directives. Any decision made by the resident shall be indicated in the chart in the manner easily understood by all staff. Advance directives specifying full code/ Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation), or the absence of determination shall be recorded as a Full Code. Those residents indicating Do Not Attempt Resuscitation/ DNR but requests limited Additional Interventions shall be recorded as signifying DNR- Comfort as indicated on the Uniform DNR Advance Directive Form. Code status shall also be recorded on the resident's Physician Order Sheet. R11's Uniform DNR Advance Directive POLST, dated [DATE] and signed by R11, documents R11 wishes to be a DNR if cardiopulmonary resuscitation is required. R11's Current Physician Order Sheet (POS), dated [DATE]-[DATE], documents Code Status, Full Code. On [DATE] at 8:30 AM, V1 (Administrator) and V2 (Assistant Administrator) confirmed that the POLST and POS for R11 should match and they don't, and both stated they were unaware. V1 stated Nurses should look at the POLST when someone codes but it could be confusing if the order doesn't match and that wouldn't be accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview and Record Review the facility failed to immediately report an allegation of misappropriation to the state agency and local law enforcement for one of sixteen residents (R7) reviewed for abuse in the sample of 29. Findings include: The facility's Abuse Prevention Program policy, dated 11/28/16, documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This policy also documents Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. External reporting of potential abuse: Initial reporting of allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. Possible Theft. There are two specific instances where theft should be considered: The theft value of a piece of property. Any missing money, jewelry, watches, or large fixed property such as radios or televisions should be considered and treated as a possible theft, until there are clear indications that the property was mislaid or lost by means other than theft. On 4/30/23 at 11:27 AM, R7 was lying in bed in her room. R7 stated I have money that has been taken. I got it for Christmas, and it totaled 58 dollars. I had two twenties, two [NAME] and eight ones and sometime in March it was stolen. (V2, Assistant Administrator) said they'd look into it. I haven't heard or seen it since. Of the 58 dollars, only five was left over. No one has told me where or who took it. I had missing stamps as well but those were found, but my money is in a bag, and I keep it in my table. There is no reason to move it because I cannot get to the nightstand or other areas in the room on my own. R7's Grievance/ Complaint report, dated 3/20/23 and signed by V1 (Administrator), documents (R7) missing envelope with three books of stamps, later found in nightstand. Missing 58 dollars: two twenties, two [NAME] and eight ones. On 5/03/23 at 8:20 AM, V1 and V2 confirmed there is no misappropriation report to the State agency or notification of local law enforcement involving R7's alleged missing money. V1 stated (R7) makes allegations like this sometimes, but there's no way to know how much money she has because she takes care of it all on her own. So, no we didn't do any reporting for possible abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview and Record Review the facility failed to immediately report an allegation of misappropriation to the state agency and local law enforcement for one of sixteen residents (R7) reviewed for abuse in the sample of 29. Findings include: The facility's Abuse Prevention Program policy, dated 11/28/16, documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This policy also documents Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. External reporting of potential abuse: Initial reporting of allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. Possible Theft. There are two specific instances where theft should be considered: The theft value of a piece of property. Any missing money, jewelry, watches, or large fixed property such as radios or televisions should be considered and treated as a possible theft, until there are clear indications that the property was mislaid or lost by means other than theft. On 4/30/23 at 11:27 AM, R7 was lying in bed in her room. R7 stated I have money that has been taken. I got it for Christmas, and it totaled 58 dollars. I had two twenties, two [NAME] and eight ones and sometime in March it was stolen. (V2, Assistant Administrator) said they'd look into it. I haven't heard or seen it since. Of the 58 dollars, only five was left over. No one has told me where or who took it. I had missing stamps as well but those were found, but my money is in a bag, and I keep it in my table. There is no reason to move it because I cannot get to the nightstand or other areas in the room on my own. R7's Grievance/ Complaint report, dated 3/20/23 and signed by V1 (Administrator), documents (R7) missing envelope with three books of stamps, later found in nightstand. Missing 58 dollars: two twenties, two [NAME] and eight ones. On 5/03/23 at 8:20 AM, V1 and V2 confirmed there is no misappropriation report to the State agency or notification of local law enforcement involving R7's alleged missing money. V1 stated (R7) makes allegations like this sometimes, but there's no way to know how much money she has because she takes care of it all on her own. So, no we didn't do any reporting for possible abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident in COVID-19 isolation was offered an activities program to meet their assessed needs which affected two of 16 residents (R18, R33) reviewed for activities in a sample of 29. Findings include: An Activity Policy dated 9/2017 states, It is the policy of (this) facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial wellbeing of each resident. The program is under the direction of an Activity Director, who shall have a specific planned program of group and individual activities based upon the resident's needs and interests. 1. R18's Minimum Data Set (MDS) assessment dated [DATE] documents that R18 is rarely or never understood. R18's MDS documents a staff assessment indicates R18 is moderately cognitively impaired. This assessment documents that R18's preferences for customary routines and activities includes listening to music, being around animals such as pets, doing things with groups of people, spending time outdoors, and participating in religious activities or practices. R18's care plan dated 2/26/20 states R18's activity involvement is limited because of cognitive impairment secondary to dementia. The interventions to address R18's activity needs includes inviting or escorting activities, reminding R18 about daily activities, offering R18 a 1:1 activity program for socialization and stimulation, assess R18 for interest in daily activities. R18's Activity Attendance Record dated 4/2023 documents R18 participated in four 1:1 visits from 4/1/23 to 4/25/23, bingo, a movie with popcorn, reading, trivia, and daily socialization in addition to watching or listening to TV/radio. R18's Activity Attendance Record documents starting 4/26/23 to 4/30/23, R18 only watched TV or listened to the radio because of COVID-19 isolation. On 4/30/23 at 12:10p.m. R18's room door was closed and indicated that R18 was in COVID-19 isolation. R18 was in his room seated in a chair, asleep and did not wake up with verbal stimulation. R18's TV was on during this observation. 2. R33's Minimum Data Set (MDS) assessment dated [DATE] documents R33 is severely cognitively impaired and is dependent on staff for all activities of daily living. This assessment documents that R33's preferences for customary routine and activities includes having books, newspapers, and magazines to read; listen to music, be around animals such as pets, doing things with groups of people, going outside to get fresh air, participating in religious services or practices. R33's care plan dated 4/21/22 states, (R33) is unable to voice preferences and unable to participate in activities because of cognitive limitations. This care plan gives as its goal, (R33) will remain awake during three activities per week. R33's Activity Attendance Record dated 4/2023 documents from 4/1/23 to 4/20/23 R33 attended pet therapy almost daily, socialization daily, watched/listened to TV/radio daily, had 1:1 visits, attended parties, watched a movie with popcorn, and read mail. R33's Activity Attendance Record dated 4/21/23 to 4/30/23 documents R33 watched tv or listened to the radio daily and had one 1:1 visit during that time because of COVID-19. On 4/30/23 at 12:08p.m. R33's door to his room was closed and indicated R33 was in COVID-19 isolation. R33 was in his room seated in a specialized wheelchair with the television on. R33 was alert and sitting in front of the TV. R33 was only able to answer most questions with yes and no during conversation. An activities calendar dated 4/2023 located on V8's (Activity Director) office door documents that during the days R18 and R33 were in COVID-19 isolation the facility had the following activities: 4/21/23 Bingo, 1:1 visits, Outside, Dirt Cups; 4/22/23 Games, 1:1 visits, Outside, Games; 4/23/23 1:1 visits, Outside, games; 4/24/23 Bingo, 1:1 visits, Outside, Yahtzee; 4/25/23 Family Feud, Outside, Bags; 4/26/23 Bingo, 1:1 visit, Outside, Birthday Party; 4/27/23 Pretty Nails, Outside, Popcorn and Movie; 4/28/23 Games, 1:1 visits, Outside, Games; 4/29/23 Bingo, 1:1 visits, Outside, Cards; 4/30/23 1:1 visits, Outside, Cards. On 5/1/23 at 11:45a.m. V8 stated, that both R18 and R33 are currently in COVID-19 isolation and cannot come out of their rooms for activities. V8 stated that R18 and R33 usually just watch TV as their daily activity. V8 stated that because of R18 and R33's cognitive status, they can't really participate in activities. V8 stated she thinks she may have given R33 and R18 a 1:1 visit one time approximately one week ago. V8 stated that when R33 is not in isolation, he can come to the dining room where residents listen to music. V8 stated that she doesn't usually play the kind of music R33 likes because most of the other residents don't care for that kind of music. V8 stated that R18 is cognitively impaired and should have a busy board to keep him occupied. V8 stated the facility does not have a busy board to give R18 for stimulation. V8 stated that other than having the TV on in R18 and R33's room and the one 1:1 visit she has provided, R18 and R33 have not been given any other activities to occupy their time or provide stimulation.

Based on observation, interview, and record review the facility failed to ensure a wound treatment was applied as per physician's order, and hand hygiene was performed before applying a clean dressing for one of two residents (R3) reviewed for pressure ulcers in a sample of 16. Findings include: An Aseptic Wound and Skin Treatment Procedure policy dated 3/16/23 gives as its purpose, To prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore, and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structures, and to promote resident comfort. In addition, this policy documents for staff to replace soiled dressings in the following order: wash hands, put on clean gloves, clean the wound as ordered, remove the soiled gloves and place in a bag, wash hands again, apply clean gloves, then apply the wound treatment and a clean dressing as ordered by the physician. A (Facility) Weekly Wound Tracking log dated 4/24/23 documents R3 has a stage 3 pressure ulcer to R3's right thigh which measures 1.7cm (centimeters) long x 1.6 cm wide x 0.1cm deep. R3's physician' orders (POS) dated 4/13/23 document R3 was ordered a treatment for R3's pressure ulcer which included for staff to cleanse R3's right posterior thigh wound, apply collagen powder, cover with Calcium Alginate then cover the wound and treatment with a silicon border dressing daily and as needed. R3's current care plan dated 11/22/22 documents R3 is at high risk for the development of pressure ulcers, but the plan does not address R3's actual skin impairment or provide interventions for the treatment of R3's wound. On 5/1/23 at 9:54a.m. V3 (Director of Nurses) stated she would be changing R3's stage 3 pressure ulcer dressing sometime after lunch. By 3:00p.m. R3's dressing change had not been completed. On 5/2/23 at 9:19a.m. R3's Treatment Administration Record (TAR) did not have a nurse's signature indicating R3's treatment had been completed on 5/1/23 as ordered. At 9:20a.m. V3 verified R3's treatment had not been completed from the previous day because she was busy with other tasks. V3 verified the treatment is supposed to be applied daily as ordered. At 9:38a.m. V3 entered R3's room to remove R3's soiled dressing to his posterior right upper thigh pressure ulcer. R3 was lying in bed on his right side. V3 proceeded to pull R3's pants down so she could remove the old dressing. R3's wound was not covered with a dressing and had been covered with only R3's pants and underwear. V3 verified R3's wound did not have a dressing in place. V3 applied clean gloves then proceeded to cleanse R3's wound then remove her soiled gloves. Without washing her hands or performing hand hygiene, V3 proceeded to apply new gloves then apply R3's new wound treatment and dressing. Once V3 was finished she removed the soiled gloves before leaving R3's room. At 9:55a.m. V3 stated that she normally washes her hands before and after changing wound dressings but V3 stated she does not wash her hands or perform hand hygiene when changing out of soiled gloves after cleansing a wound and before applying clean gloves to apply a clean dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received individualized treatment and services based on their physician's order, comprehensive assessment, and Range of Motion Assessment to maintain, improve, or prevent further decrease in range of motion for three of four residents (R3, R33, R21) reviewed for range of motion in a sample of 29. Findings include: The facility's Range of Motion Program (ROM) Protocol, states It is the policy of (the facility) to provide Range of Motion exercises for residents who through assessment demonstrate the need for exercise to prevent functional decline in range of motion. 1) The Interdisciplinary team will identify those residents in need and consider the resident's age, diagnosis, prognosis, current joint condition, functional ability and any mobility restrictions. 2) Parts of the body on which range of motion exercises can be performed include all body joints or only those affected by disease process and may include the fingers, wrist, forearm, elbow, shoulder, toes, foot, ankle, knee, hip and trunk. 7) Range of motion exercises should be repeated approximately 5-10 times as per resident's tolerance. 9) Documentation of response to the range of motion exercises and resident abilities will be documented at least quarterly by licensed personnel. 1. R33's Minimum Data Set (MDS) assessment dated [DATE] documents R33 is severely cognitively impaired, is dependent on staff for all activities of daily living (ADLs), does not walk, and has functional limitation in range of motion to his extremities. This same MDS documents R33 is not receiving physical/ occupational therapy and is not on a restorative nursing program to maintain, improve or prevent further decline in R33's range of motion. R33's Range of Motion (ROM) assessment dated [DATE] and 4/21/23 documents R33 is at high risk for functional limitations in range of motion because R33 has a Serious problem with mobility, functional ability, mentation, predisposing diseases, a present joint condition, and contractures are already present. R33's physician' orders (POS) documents R33 was prescribed to use a left-hand splint and a right palm protector appliance as a treatment for R33's functional limitation in range of motion. R33's care plan dated 4/07/21 documents R33 has the potential to decline in movement of joints related to decreased strength and mobility. This care plan also documents R33's goal is to actively participate in moving/exercising joints with verbal cues twice daily but does not specify which of R33's joints need range of motion exercises. R33's Restorative Nursing Program Documentation dated 4/2023 documents R33 has, the potential to decline in movement of joint (related to) dementia/contractures. This documentation gives as its goal that R33 will participate in both upper and lower extremity exercises, however, this documentation does not provide any individualized instructions for which joints should be exercised. In addition, this restorative documentation has an area for staff to document each time the restorative exercise program is offered to R33, how many minutes were provided, and whether R33 declined to participate. This documentation shows that either no minutes of range of motion exercises were provided or the dates on the form were left blank. There is no documentation that R33 declined to participate in the range of motion exercises. On 4/30/23 at 12:26 p.m. R33 was seated in a wheelchair in his room. R33's hands were contracted with the wrists flexed inward and with R33's fingers contracted in a closed fist. R33 was not wearing a splint on his left hand or a right palm protector, but instead, R33 had a wadded washcloth placed between R33's fingers and palms. On 5/1/23 at 10:45 a.m. and on 5/2/23 at 10:00 a.m., and on 5/3/23 at 11:35 a.m. R33 was observed seated in his wheelchair with washcloths placed in each hand but no left-hand splint present. On 5/1/23 at 10:32 a.m. V19 (Certified Nurse Aide/ CNA) and V18 (CNA) were in the hallway outside of R33's room. V19 and V18 (CNA) stated that R33 is supposed to have wash clothes in his hands between R33's fingers and palms because of contractures. V18 stated that she thinks R33 has some exercises R33 is supposed to have but V18 thinks those exercises were done by the night shift CNAs before they left. On 5/3/23 at 11:20a.m. V10 (CNA) stated that R33 has very contracted hands. V10 stated that staff try to do some range of motion exercises to R33's hands and legs when staff dress R33 in the mornings. V10 stated there are no specific joints staff are supposed to exercise and there are no specific exercises staff are supposed to provide. On 5/3/23 at 11:30a.m. V9 (CNA) stated, (R33) is very stiff. His arms and legs are very stiff. V9 stated that CNA staff are supposed to exercise R33's arms and legs but that there are no specific joints staff are supposed to exercise and there are no specific exercises staff are supposed to provide. 2. R3's Minimum Data Set (MDS) assessment dated [DATE] documents R3 is dependent on staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene; does not walk, and has functional limitations to his extremities. R3's Range of Motion assessment dated [DATE] and 4/27/23 documents R3 has a moderate risk for a functional limitation in range of motion because of R3's poor mobility, functional ability, and mentation; and R3 has a serious problem with predisposing diseases and R3's present muscle tone. R3's current care plan documents that as of 3/24/23 R3 is on a restorative program for toileting, however, this care plan does not address R3's limitation in range of motion or provide interventions to prevent further decline, maintain or improve R3's functional limitations in range of motion. R3's Restorative Nursing Program Documentation states that R3 has the potential to decline in movement of his joints related to R3's upper and lower extremity weakness. This documentation gives as its goal that R3 will actively participate in both upper and lower extremities exercises, however, it does not provide any individualized instructions for which joints should be exercised. On 4/30/23 at 12:02p.m. R3 was seated near the dining room in a wheelchair. R3 was able to move his arms but appeared to have little control over the movement. R3 was able to propel himself very slowly forward in the wheelchair a few inches at a time. On 5/2/23 at 9:38a.m. R3 was in bed while V3 (Director of Nurses) prepared to apply a clean dressing to R3's posterior right upper thigh stage 3 pressure ulcer. Although R3 was able to make small movements to his arms and legs, these movements were weak, making R3 require extensive assistance to turn and reposition in the bed. On 5/3/23 at 11:20a.m. V10 (Certified Nurse Aide/CNA) stated that R3 is not on a range of motion program. On 5/3/23 at 11:30a.m. V9 (CNA) stated that R33 just moves his arms and legs around as his range of motion program. V9 stated R3 has no specific joints staff are supposed to exercise and there are no specific exercises staff are supposed to provide or assist with. On 5/3/23 at 2:00p.m. R3's wheelchair was situated at the lower end of R3's bed. R3 had crawled out of the wheelchair and was lying face-down across the lower part of the bed with his feet and legs hanging down towards the floor. On 5/2/23 at 3:00p.m. V4 (Resident Care Coordinator) stated she is also the facility's Restorative Nurse. V4 stated that both R3 and R33 have a limitation in range of motion. V4 stated that R33 has joints which are contracted, especially R33's hands and wrists. V4 stated that staff provide R33 range of motion exercises to R33's upper and lower extremities while dressing R33 in the mornings. V4 stated that staff will guide R33's arms into his shirt as part of R33's range of motion program. V4 stated that R33 does not have an individualized range of motion program with specific joints to be exercised. V4 stated that R3 has an active range of motion program with verbal cues from staff. V4 stated that R3's range of motion exercises mostly occur while R3 is dressing. V4 stated that R3's range of motion program does not include an individualized program identifying which joints need to receive the range of motion exercises. 3. On 4/30/23 at 10:40 a.m., R21 was lying in bed on his back. R21 stated he has had two strokes that resulted in right sided weakness of his upper and lower extremities, and he also had Polio as a child which causes his left leg to not work anymore. R21 demonstrated he is unable to move his right arm without using his left arm to move it. R21 also demonstrated he was unable to lift his right or left arm above his chest. R21 was only able to make slight movements to his bilateral legs/feet. R21 stated he does not receive any therapy or restorative programs at this time. R21 stated staff do not assist him with any type of exercises to his joints and that he would be unable to perform Active Range of Motion Exercises to all joints independently. R21's Physician Order Sheets dated 5/2023, document R21 has diagnoses which include History of Stroke and Polio. R21's Physician Orders do not include any orders for Restorative Services. R21's Minimum Data Set assessment dated [DATE] documents the following: R21 scored 15 out of 15 on the Brief Interview for Mental Status, indicating R21 is cognitively intact; R21 does not have a behavior of rejecting care; R21 requires total assistance of staff with all Activities of Daily Living (ADL's) except for eating; R21 has Functional Limitation of Range of Motion to upper and lower extremities; and R21 is on an Active Range of Motion Program. R21's Care Plan last revised on 9/22/22, does not document R21 is at high risk for loss of functional range of motion, contractures or that he has moderate limitation of range of motion to his bilateral shoulders. R21's Care Plan does not address R21's Active Range of Motion Restorative Program or any type of services to address his limitation of range of motion to his upper and lower bilateral extremities. R21's Care Plan documents R21 requires a full mechanical lift for all transfers. R21's Range of Motion (ROM) assessment dated [DATE], documents R21 scored fifteen (High Risk) for potential loss of functional range of motion and had moderate (50-80%) functional range of motion to his bilateral shoulders. This same assessment documents a resident that score 5-14 (Moderate Risk) Treatment Options may include: Range of Motion, positioning, turning, ambulating, as indicated by individual resident needs. Residents that score 15-21 (High Risk) Treatment Options may include: Recommended by therapies with physician approval-may include splinting. R21's Range of Motion Assessment does not document that R21 is not a candidate for Restorative Programming. R21's Restorative Nursing Program Documentation dated 4/2023 documents R21 has, the potential to decline in movement of joint (related to) left sided weakness. This form does not document anything about R21's right sided weakness. This documentation gives as its goal that R21 will actively participate in both upper and lower extremity exercises, however, this documentation does not provide any individualized instructions for which joints should be exercised. In addition, this restorative documentation has an area for staff to document each time the restorative exercise program is offered to R21, how many minutes were provided, and whether R21 declined to participate. This documentation shows that either no minutes of range of motion exercises were provided or the dates on the form were left blank. There is no documentation that R21 declined to participate in the range of motion exercises. This documentation does not show V27 (Certified Nurse Aide) has ever provided this Restorative program for R21. R21's Occupational Therapy (OT) Plan of Care dated 2/13/23, states (R21 demonstrates) decline in bed mobility and grooming/hygiene. Skilled OT is necessary to increase strength, ROM, activity tolerance and balance in order to maximize ADL's. Without therapy services (R21) is at risk for skin breakdown and contractures of (bilateral upper extremities). (R21) has Polio on (left lower extremity) with foot drop and external rotation during weight bearing activities. R21's OT Progress Notes dated 3/6/23, document R21 requires maximum assistance with performing Home Exercise Programs. On 5/3/23 at 11:00 a.m., V27 (Certified Nurse Aide) stated she is taking care of R21 today and frequently has him on her assignment. V27 stated R21 is not on any type of exercise programs or restorative services. On 5/3/23 at 11:10 a.m., V4 (Resident Care Coordinator) stated R21 is on an Active Range of Motion program daily. V4 stated she was aware that R21 has minimal use of his upper and lower extremities and requires total assist with all cares except for eating. V4 stated the services of Passive Range of Motion may be more appropriate for R21 since he has minimal movement independently. V4 stated she was not aware that staff were not providing the Active Range of Motion program for R21. V4 stated there is no quarterly documentation of R21's response to the range of motion exercises or of R21's abilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the Care Plan and assist a resident while ambulating for one resident (R31) of two residents reviewed for falls in a sample of 29. Findings include: The facility Fall Prevention policy dated 11/10/18, documents To provide the resident safety and to minimize injuries related to falls; decreases falls, and still honor each resident's wishes/desires for maximum independence and mobility. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. R31's Face Sheet dated 5/3/23, documents R31 is [AGE] years old and was admitted to the facility on [DATE]. R31's Minimum Data Set assessment dated [DATE], documents that R31 has osteoporosis, severe cognitive impairment, uses a walker on the unit, is not steady and is only able to stabilize with human assistance needing the assistance of one staff. R31's Nurses Notes dated 2/5/23 at 12:15 AM, documents that a noise was heard coming from the hall and R31 was lying on the floor with the walker on top of her. R31 had a small hematoma behind her right ear. R31's Quality Assurance Progress Notes dated 2/7/23 at 9:30 AM, documents that the Quality Assurance Team met regarding R31's fall on 2/5/23. R31 was walking in the hallway by herself and was observed on the floor. The root cause was determined to be related to decreased safety awareness and ambulating without assistance. The intervention was put in place for R31 to have assistance by staff while walking with her walker. R31's current Care Plan dated 4/6/23 documents that R31 has risk factors that require monitoring and interventions to reduce the potential for self-injury. Risk factors include age, confusion, needing assistance with activities of daily living, transfers, medication, history of falls, mental illness, dementia, and osteoporosis. As evidenced by the fall risk assessment. R31 will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors thru the next 90 days. R31 is to have staff assistance while ambulating with her walker as she allows. R31's Fall Risk assessment dated [DATE], documents R31 is at a high risk for falls. On 5/1/23 at 10:33 AM, R43 stated that her roommate R31 is in and out of their room several times during the day and night. R31 uses a walker but is unassisted by staff. On 5/3/23 at 8:47 AM, V9 (Certified Nursing Assistant) stated that R31 uses a walker and walks by herself most of the time. If the staff notice R31 being unsteady they will help her. On 5/3/23 at 8:54 AM, V10 (Certified Nursing Assistant) stated (R31) walks on her own. (R31) is like a cat on a hot tin roof, she is up and gone. On 5/3/23 at 2:35 PM, V6 (Infection Preventionist/Care Plan Coordinator) stated that when an intervention is on a residents Care Plan it should be followed. On 5/2/23 at 10:50 AM, R31 was observed walking from her room unassisted by staff to the nurse's station. R31 left the nurses station and went into the dining room. R31 then left the dining room at 11:05 AM and walked back to her room. On 5/3/23 at 9:45 AM, R31 was observed walking from her room to the nurse's station and back to her room with no assistance from staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview and Record review, the facility failed to ensure an oxygen humidity bottle contained liquid, complete physician ordered oxygen tubing and humidifier changes, clean an oxygen concentrator and CPAP (Continuous Positive Airway Pressure) equipment and care plan a CPAP for two of two residents (R4, R5) in the sample of 29. Findings include: 1. The facility's Oxygen Therapy policy, dated 3/2019, documents Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Procedure: Change oxygen tubing/mask/cannula/and or tracheostomy mask on a weekly basis. Date tubing changes and document on the treatment sheet. If humidification is indicated, date pre-filled bottles when changed. If using unfilled humidifier bottles; empty, rinse and refill daily with distilled water, and wash with soap and water as needed. Humidifier changes and cleaning is to be documented on the treatment sheet at the time of occurrence. R5's Current Physician Order sheet, dated 5/1/23-5/31/23, documents R5 has order for Oxygen at two liters per nasal cannula. This same sheet also documents R5 has an order for O2 tubing/humidifier to be changed weekly on Saturday. On 4/30/23 at 11:16 AM, R5 was lying in bed in her room with Oxygen on her face via nasal cannula tubing. R5 stated she wears Oxygen all of the time. R5's nasal cannula tubing was dated 4/2/23 and R5's humidity bottle was dry and did not contain any liquid. On 4/30/23 at 11:26 AM, V12 (Licensed Practical Nurse) confirmed R5's tubing on her Oxygen was dated 4/2/23 and that the connected humidity bottle was completely empty. R5's Treatment Administration Record (TAR), dated 4/1/23-4/30/23, documents a treatment order for Filter, O2 concentrator clean weekly on Saturday. This TAR does not document that R5's concentrator was cleaned for the entire month of April (totaling five missed cleanings). This same TAR documents a treatment order for O2 tubing/humidifier change weekly on Saturday. This TAR documents the only time this order was completed was on 4/2/23 for the entire month of April (totaling four missed changes). On 5/03/23 at 8:25 AM V1 (Administrator) confirmed that the humidity bottle for R5 should've been filled and not dry and that R5's tubing should be changed weekly and that it is not being done. 2. R4's Face Sheet documents that R4 is [AGE] years old and admitted to the facility on [DATE] with diagnosis which include Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Obstructive Sleep Apnea. On 4/30/23 at 10:15 AM, R4 was sleeping on her bed wearing a CPAP (Continuous Positive Airway Pressure) mask that covered her nose and mouth. On 5/1/23 at 10:50 AM, R4 was sitting on her bed. Her CPAP machine was on a bedside table to the left side of R4's bed. There were several items stacked around the CPAP machine. The mask was uncovered laying on top of the machine with the tubing hanging down from the table. The mask was not clean. It had finger smudges and what looked like dried condensation that caused water spots or a film on the mask. On 5/1/23 at 10:50 AM, R4 stated that she uses the CPAP whenever she wants to sleep. The mask has not been changed for 6 to 8 months and is dirty. The staff do not clean the mask or machine. When R4 complains about the mask being dirty she is told to clean it herself. The only thing the staff will do is put water in the machine when R4 asks and must ask several times before it is done. R4 also stated I try to clean the mask, but I don't know what I am doing. The facility policy for Continuous Positive Airway Pressure (CPAP) dated 3/8/13, documents that a CPAP provides continues positive pressure to the airways of spontaneously breathing residents. CPAP is delivered via circuit (6 feet of non-disposable corrugated tubing) to a nasal mask, full face mask or nasal pillows. The circuits (tubing) are to be cleaned every week and as needed. The external filters should be cleaned once a week and as needed. On 5/1/23 at 11:05 AM, V4 (Resident Care Coordinator/Licensed Practical Nurse) stated that she has not cleaned or changed R4's CPAP tubing or mask and does not know when it is supposed to be done. There is nothing documented on the Physicians Order Sheet or Treatment Administration Record about cleaning or changing the tubing or mask. R4 came from the hospital with the CPAP in October of 2022. There are no manufacturer's instructions for R4's CPAP. V4 also stated I don't see a CPAP Care Plan for (R4) but there should be. I know the tubing was changed once when (V15/Previous Director of Nursing) was here because it had a split in it. There is no documentation of when the tubing was changed. R4's current Care Plan was reviewed and does not document a Care Plan for R4's CPAP. A Physician Concern written by V4 (Resident Care Coordinator/Licensed Practical Nurse) dated 5/2/23 documents a request to have an order to change the CPAP tubing every 6 months. In the comments it is documented that V13 (R4's Primary Physician) approved the request. There is nothing on the form about cleaning the tubing or mask. On 5/3/23 at 8:47 AM, V9 (Certified Nursing Assistant/CNA) stated The CNA's do not do anything with R4's CPAP. The nurses take care of that. I have seen the nurses put water in it but not clean it. On 5/3/23 at 9:20 AM, V4 (Resident Care Coordinator/Licensed Practical Nurse) stated that yesterday (5/2/23) she requested an order for changing the tubing on R4's CPAP from V13 (R4's Primary Care Physician). The order documents to change the tubing every 6 months but does not document when to clean the tubing or mask. On 5/3/23 at 10:10 AM, V12 (Licensed Practical Nurse) stated that she has not cleaned the mask or tubing for R4's CPAP. V12 has put water in it and thinks the night shift might clean it but is not positive. R4's Physician's Orders Sheets dated 5/1/23- 5/31/23 documents May change CPAP tubing every 6 months. The order was a handwritten telephone order by V13 (R4's Primary Care Physician) dated 5/2/23. There is not an order or instructions for cleaning the mask or tubing. R4's Treatment Administration Record dated 5/1/23-5/31/23 documents (date 11/11/20) CPAP at bedtime 8 CM (Centimeter) H2O (Water) Heated. Clean the mask daily, air dry, store covered and replace as needed is handwritten below the CPAP instruction, not dated, or signed. The handwritten information was not on the TAR for March 2023, and the April 2023 TAR was not provided. On 5/3/23 at 2:16 PM, V6 (Infection Preventionist\Care Plan Coordinator) stated that she has only been at the facility for about two months and did not know much about R4's CPAP machine. If the CPAP machine is not kept clean it could cause respiratory problems for R4. V6 did not know when the CPAP machine was supposed to be cleaned or the tubing and mask replaced. V6 also stated that she was not aware there was not a Care Plan in place for R4's CPAP machine. V6 was also not aware that there was not a Physicians Order on when to replace the tubing until 5/2/23. On 5/3/23 at 2:36 PM, V6 stated that she contacted the CPAP manufacturer and was told the tubing and filter should be replaced every three to six months. The mask should be washed with soap and water daily and as needed. The tubing should be cleaned weekly, and the staff should be doing the cleaning of the equipment. V6 also stated there needs to be an order for the care of the CPAP machine and she will contact V13 (R4's Primary Physician) for orders.

Based on interview and record review the facility failed to provide documented proof of 12 hours of Certified Nursing Assistants training in a twelve-month period. This includes Dementia Management, Abuse Prevention, and Impaired Cognition Training for Certified Nursing Assistants. This has the potential to affect all 40 residents living in the facility. Findings: The document, Abuse Prevention Program Policy, dated 11/28/16, states, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by (including) dementia management and resident abuse prevention. During orientation of new employees, the facility will cover staff obligations to prevent and (how to) immediately report abuse. Additional training (will also include) Dementia Management and Resident Abuse Preventions. Annually, each covered individual (staff) will receive a review of this training. The Facility Assessment, updated 12/27/22, states, The purpose of this assessment is to review the resources needed to provide the necessary person-centered care and services. This includes required staff education and training for nurse aides. In-service training must: be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours; include dementia management training and resident abuse prevention training; for the nurse aides providing services to individuals with cognitive impairments, address the care of the cognitively impaired. On 5/03/23 at 1:25 PM, V1, Administrator, stated, I am unable to provide any CNA (Certified Nursing Assistant) training prior to 11/2022. I'm not sure how many hours of education or what topics of education were given to the CNAs prior to that date. On 5/02/23 at 1:15 PM, V2, Assistant Administrator, stated, (V23), CNA (Certified Nursing Assistant), is in school and (V23) isn't at the facility when the education is provided so she doesn't get it. The other CNAs aren't always available for training. Ten of the facility CNA's (Certified Nursing Assistants) training records (V9, V16, V17, V18, V21, V22, V23, V24, V25, V26) were reviewed for a twelve-month period during the time these CNAs were actively employed by the facility. Six of the CNA's had not had dementia training; five of the CNA's had not had abuse training. No specified training for any of the ten CNA's who may care for a resident who is cognitively impaired was indicated. V9, DOH (Date of Hire) 9/08/21, seven hours of education; V16, DOH 12/09/21, eight hours of education, no dementia training; V17, DOH 10/13/89, eight hours of education; V18, DOH 2/01/01, eight hours of education, no abuse training; V21, DOH 11/27/18, ten hours of education; V22, DOH 2/15/22, seven hours of education, no dementia training; V23, DOH 6/26/20, zero hours of education, zero hours of abuse or dementia training; V24, DOH 3/30/18, five hours of education, no dementia or abuse training; V25, DOH 10/26/12, three hours of education, no dementia or abuse training; V26 DOH 1/10/22, three hours of education and no dementia or abuse training. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents Report, form 672, dated 5/01/23 and signed by V2, Assistant Administrator, documents that at the time of the survey 40 residents live in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident from verbal/mental abuse for one (R2) of three residents reviewed for abuse in a sample of three. Findings include: Facility Abuse Prevention Program, revised 11/28/2016, documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. This will be done by: orienting and training employees on how to deal with stress & difficult situations and establishing an environment that promotes resident sensitivity. This facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff. Abuse: Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents cause physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff that would demean or humiliate a resident(s), harassment, humiliation and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame agitation, or degradation. Orientation and training of employees during orientation of new employees, the facility will cover at least the following topics: Sensitivity to resident rights and resident needs, and how to recognize and deal with burnout, frustration, and stress that may lead to inappropriate responses or abusive reactions to residents. Facility Certified Nurse's Aide policy, undated, documents Job Summary: Working under the direction of the staff nurses, the Certified Nurse's Aide (C.N.A.) provides personal care and assistance to residents to assure their safety and comfort. Provides for the psychosocial needs of residents. Facility document dated 10/14/22 by V1 Administrator and addressed to (State Agency), documents Final report for incident that occurred on 10/8/22 regarding abuse/neglect for (R2). On October 8, 2022, about 8:45pm staff reported resident wanted to speak with nurse on duty. The nurse (V2 RN DON/Registered Nurse Director of Nursing) spoke with (R2) who reported two CNAs/Certified Nurse Aides (V3 and V5) were short with him because he had been having bowel movements and called several times to be changed. He noted they told him that if he kept putting his light on, he wouldn't get changed until morning. A third CNA not accused of this alleged abuse reported CNAs did comment they could not come in every five minutes to change him because he was smearing and not finishing the bowel movement completely. The accused CNAs admitted to telling resident that he needed to finish the bowel movement and they could not be in his room every five minutes because there were other residents that needed cares as well. Resident, witnesses, and accused reported resident telling CNAs he was reporting the incident to someone to which they replied they knew he would. CNAs suspended. The facility was able to substantiate the report per resident. Staff was found to have made the comments even though they did provide the appropriate cares, resulting in possible emotional distress. Staffing, dated 10/8/22, documents V3 and V5 were both working as CNAs. V5 CNA employee file documents the following: Supervisor Report of Counsel, dated 10/14/22 by V1 Administrator, documents Date of Occurrence 10/8/22; Description of Occurrence: telling a resident (R2) couldn't be in room to provide cares as needed; Potential or Actual Consequences: resident emotional distress; Counseling: we never tell a resident we cannot or won't provide cares in a timely manner; Disciplinary Action: Job in Jeopardy. V5's employee record documents V5 signed the Facility Abuse Reporting Policy Acknowledgement on 9/27/22. V3 CNA employee file documents the following: Supervisor Report of Counsel, dated 10/14/22 by V1 Administrator, documents Date of Occurrence 10/8/22; Description of Occurrence: telling a resident (R2) couldn't be in room to provide cares as needed; Potential or Actual Consequences: resident emotional distress; Counseling: we never tell a resident we cannot or won't provide cares in a timely manner; Disciplinary Action: Job in Jeopardy. V3's employee record documents V3 signed the Facility Abuse Reporting Policy Acknowledgement on 7/8/22. R2's medical record documents R2 was admitted on [DATE] with the diagnoses of Poliomyelitis and CVA/Cerebral Vascular Accident. R2's current careplan documents (R2) is at risk for skin breakdown related to incontinence, C-diff, decreased mobility, anemia, and history of skin breakdown prior to admission with an intervention of apply house stock incontinent barrier cream to peri area after every incontinent episode and as needed. Resident is in need of assistance to complete ADLs/Activities of daily living related to left leg weakness, CVA with right hemiparesis, C-Diff, and cellulitis with an approach of extensive assistance of two or more assist for bed mobility and toileting (Start date 3/8/22) and change every two hours and as needed when repositioning. Resident is incontinent of his bowels and bladder related to impaired mobility (start date 3/8/22). R2 IDT/QA notes, dated 9/23/22, documents Resident has stage 4 pressure ulcers (buttocks). R2's Bowel and Bladder Assessment, dated 6/1/22, documents Totally dependent for mobility and help required to find the bathroom and remove clothing. Incontinent day and night, diuretic, and no behaviors with toileting. R2's Psychosocial Assessment, dated 6/1, 8/6 and 9/1/22, documents R1 is cooperative and has no mood or relationship behaviors. R2's Mood Assessment, dated 9/1/22, documents R1 is moderately depressed. R2's Cognitive Assessment, dated 9/1/22, documents R1 is cognitively intact. R2's nurses noted, dated 10/8/22 by V2 RN DON, documents At approximately 8:45pm spoke with (R2) per (R2) request and (R2) stated two CNAs (V3 and V5) had stated We just been in here to clean you up and you're just smearing. On 11/1/22 at 11:00am, R2 was in bed in his room, alert and oriented, head of bed elevated, and lying on his right side. R2 stated Second shift is the worst for waiting for cares, I am incontinent of my bowels, I can't clean myself, I can't move my left leg it is completely paralyzed, and I don't get out of bed because I prefer to stay in bed and be off my bottom. Doctor was here yesterday for my wound on my buttocks, they use salve on it. Refused to answer any questions about the incident on 10/8/22 and appeared agitated (facial frowning and exaggerated hand movements when asked). On 11/1/22 at 12:15pm, V2 RN DON stated (V3) works second shift. I was the nurse working on the unit on 10/8/22 when (R2) reported to me that he was told by (V3 and V5) that they weren't going to see him every 15 minutes. I put them off work immediately, investigated the incident, and educated (V3 and V5). On 11/1/22 at 12:35pm, V1 Administrator stated (V2) had an incident on 10/8/22 at 8:45pm with (V3 and V5 both CNAs) and specifically stated (V6 CNA) was not a part of it. (V2) stated he put on his call light, staff came in the room and told him they could not be in there every 15 minutes, (V3 and V5) were walked out, and (V2 DON) was the nurse working with (R2) that night. (V6) was in the room when (V3 and V5) said what they did. (V3 and V5) both admitted to the statements and (V6) verified what they said about not being in the room every 15 minutes and he needed to finish smearing. I am the abuse coordinator and filed the report. (V3 and V5) were put off work on an unpaid five day suspension, and re-educated. Our CNA second shift staff work 1-9pm. (V3 and V5) completed cleaning (R2) up, made the statement while providing care, both made similar comments, and we substantiated the claim. On 11/1/22 at 1:30pm, V3 CNA stated Earlier this month I was suspended for five days for what I said to (R2), that is the first time I was ever off or disciplined as a CNA, I was talked to by (V1 and V2), and I work the opposite hall of (R2) now. (R2) needs assistance of two people for cares and is frequently incontinent of stool. Me and (V5) both were frustrated with (R2) on the call light so much and we should not have said we weren't going to see him every 15 minutes.