**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant was certified by verifying continuous employment on the Health Care Worker Registry. This has the potential to affect all 80 residents currently residing at the facility. Findings Include: The facility undated Resident Matrix provided to this surveyor on [DATE] documents 80 residents reside at the facility. The untitled and undated staff roster given to this surveyor on [DATE] documents V11 (Certified Nursing Assistant/CNA) was hired by the facility on [DATE]. V11's Health Care Worker Registry Check, dated [DATE], documents under Work Eligibility: Eligible. The registry documents the following statement. In addition to Work Eligitibility, Employers are responsible for checking Training and Work History and Certifications to determine if person is eligible to work in a position that requires certification, such as CNA. This same Health Care Worker Registry Check documents V11's employement was verified on [DATE] and again on [DATE]. There is no documentation on this Health Care Worker Registry Check verifying V11 was employed as a Certified Nursing Assistant after [DATE]. On [DATE] at 1:22 PM, V11 (Certified Nursing Assistant) stated she had worked at the facility since February 2024. When asked when she became certified as a nursing assistant, V11 stated, It has been a long time. V11 stated she had a break in her career as a CNA to be a stay at home mom for a few years, and then went back to work as a CNA. V11 stated she was employed during that time by individuals in a home setting as a private sitter. V11 stated she wasn't aware of any lapse in her certification. On [DATE] at 1:26 PM, V1 (Administrator) stated she wasn't aware of any certified staff working without the proper certification. V1 stated when they get an applicant they are interested in, the background checks and registry checks are all completed prior to the first interview. On [DATE] at 1:41 PM, V2 (Director of Nurses) stated she wasn't aware of any certified staff working without the proper certifications. When asked about V11 (CNA), V2 (DON) stated V11 had shown her a paper last week that said something about her employer needing to show work history. V2 stated she had V11 take it to the front office and she returned and told V2 everything was ok. On [DATE] at 1:47 PM, V13 (Medical Records/Office Assistant) stated she does all of the employee background checks. V13 stated V11 has worked at the facility off and on for years, and stated she didn't remember V11 showing her any paper related to the Health Care Worker Registry. On [DATE], V1 (Administrator) sent this surveyor a screen shot of the email V11 had recieved. There is no date documented on the screen shot, but it documents the email was from the Health Care Worker Registry and includes the following, Good evening, (name of facility) does not have the position category or position type listed on the registry for your work history. Your c.n.a. (certified nursing assistant) expired on -[DATE]. If you have missing work history, you could call the employers and ask them to update your work history This indicates V11 has not been a Certified Nursing Assistant since [DATE], and was hired by the facility as a CNA on [DATE]. On [DATE] at 10:53 AM, V1 (Administrator) stated she couldn't speak to what happened prior to her becoming the Administrator at the facility. V1 stated V13 (Medical Records/Office Assistant) checks everything including reference checks to make sure they are eligible, prior to offering someone employment. When asked if V11's reference and employment history was checked prior to her employment at the facility as a CNA, V1 stated V13 started working in that position two months ago, so she wasn't sure what the process was prior to that. V1 stated they have started auditing all of the employees and haven't found any other CNA's with a break in their employment history. On [DATE] at 12:45 PM, V1 stated they had not been able to locate any proof of employment as a CNA for V11 from 9/2014 until she was employed at the facility in February of 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) coding for 3 (R7, R63, R40) of 5 residents reviewed for MDS assessments in the sample of 42. Findings include: 1. R7's admission Record documented an admission date of 1/12/2022, with diagnoses including unspecified bipolar disorder, major depressive disorder, and paranoid schizophrenia. R7's MDS with an assessment reference date of 10/25/2024, documents under A1500. Preadmission Screening and Resident Review (PASRR), Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? with a response of No. R7's Care plan, dated 8/9/2024, documented a focus area of potential for communication problems related to diagnoses of dementia, hallucinations, panic disorder, paranoid schizophrenia, delusional disorders, bipolar disorder, depression, anxiety with appropriate interventions. R7's PASRR Level II, dated 4/26/2024, documented under Level II outcome that Level II approved with no special services or special treatments. PASRR Level II diagnoses listed for PASRR Level II evaluation included bipolar disorder, delusional disorder, generalized anxiety, major depressive disorder, panic disorder without agoraphobia, schizophrenia, dementia, primary insomnia. On 1/15/2025 at 12:53 PM, V9 (Minimum Data Set/MDS Coordinator) stated, There is a discrepancy with (R7's) annual information that had been entered into the MDS dated [DATE]. V9 stated, she should have marked R7 had been considered a Level II by the PASRR documentation, with a diagnosis of having a serious mental illness. 2. R63's admission Record documented an admission date of 7/10/24, with diagnoses including bipolar disorder, unspecified speech disorder and other visual disturbances. R63's MDS with an assessment reference date of 11/21/2024, documented under A1500. Preadmission Screening and Resident Review (PASRR), Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? with a response of No. R63's Care Plan documented a focus area of potential for drug related complications associated with use of psychotropic medications related to: Anti-psychotic medication with a diagnosis of bipolar with appropriate interventions. R63's PASARR Level II, dated 9/9/2024, documented under Level II outcome that Level II approved with no special services. PASRR Level II diagnoses listed for PASRR Level II evaluation included bipolar disorder and unspecified anxiety. On 1/15/2024 at 2:43 PM, V9 (MDS Coordinator) stated, There is a discrepancy with (R63's) admission information that had been entered into the MDS dated [DATE]. V9 stated she should have marked R63 had been considered a Level II by the PASRR documentation, with a diagnosis of having a serious mental illness. 3. R40's admission Record documented an admission date of 11/15/2024, with diagnoses including iron deficiency anemia, dysphasia, unspecified and chronic obstructive pulmonary disease with no diabetic diagnosis documented. R40's MDS documented with an Assessment Reference date of 11/22/2024, documented a Brief Interview for Mental Status Score of 15, indicating cognitively intact. This same MDS under Section N-Medications, N0350. Insulin documents, A. Insulin Injections-Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days with 1 day entered for the response. R40's Order Summary Report, dated 1/17/2025, with active orders documented no physician order for insulin to be administered. On 1/15/2025 at 9:55 AM, R40 stated she had never been diagnosed with diabetes and had never been given insulin. On 01/15/25 12:53 PM, V9 (MDS Coordinator) stated there is a discrepancy with R40's MDS information that had been entered into the MDS dated [DATE]. V9 stated she should have not marked that R40 had received 1 injection of insulin within the last 7 days. On 1/15/2025 at 1:59 PM, V1 (Administrator) stated she would expect to follow the facility's MDS Completion and Submission Timeframes policy when entering in information. The facility policy titled MDS Completion and Submission Timeframes, (revised July 2017) documents under Policy Interpretation and Implementation, step 1 The Assessment Coordinator or designee is responsible for ensuring that resident assessments are accurate and submitted to CMS' QIES (Centers for Medicare and Medicaid Services' Quality Improvement and Evaluation System). Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines.

Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosed mental disorder for 1 (R23) of 4 residents reviewed for PASRR Screening in the sample of 42. Findings Include: R23's admission Record documented an admission date of 12/30/2022, with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, dysphasia and an additional diagnosis of bipolar disorder added 8/28/24. R23's Annual Minimum Data Set (MDS) documented an assessment date of 11/18/2024. Under section I: Active Diagnosis: I5900 it documents a Psychiatric/Mood Disorder diagnosis of bipolar disorder. On 1/15/2025 at 1:14 PM, V5 (Business Office Manager/BOM) stated R23's electronic health record (EHR) documented a diagnosis of bipolar disorder entered on 8/28/2024. V5 stated she was not employed at the time of this diagnosis, but does verbalize R23 should have been referred for a Level II PASRR. R23's Order Summary, dated 1/17/2025, listed active orders that included Quetiapine Fumarate 50 milligrams. Give 1 tablet daily for bipolar disorder, with a start date of 7/1/2024 documented. The facility was unable to provide any reproducible evidence that the PASRR agency had been contacted to complete a Level II screening, given the mental health diagnoses of bipolar disorder, that are listed on his Order Summary . The facility policy titled Behavioral Assessment, Intervention and Monitoring (revised March 2019) documents under Assessment step 5. New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR Level II evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain range of motion for 1 of 1 (R52) residents reviewed for range of motion in a sample of 42. The Findings Include: R52's admission Record documents an admission date of 9/12/23. This same document includes the following diagnoses: major depressive disorder, anxiety disorder, other specified joint disorders, morbid obesity, and other intervertebral disc displacement, lumbar region. R52's quarterley MDS (Minimum Data Set), dated 2/23/24, documents in Section GG that her functional limitation in range of motion that she has an impairment on one side of lower extermity. R52's most recent quarterly MDS, dated [DATE], documents in Section C that R52 has a BIMS (Brief Interview of Mental Status) of 15, indicating R52 is cognitively intact. Section GG documents for functional limitation in range of motion that R52 has an impairment on both sides for lower extremities. Section GG also documents for self care that R52 is dependent on toileting and putting on/taking off footwear, substantial/maximal assistance for personal hygiene and lower body dressing and shower/bathe self, and partial/moderate assistance of upper body dressing and oral hygiene. The same section for mobility documents: resident is dependent for tub/shower transfer, toilet transfer, chair/bed transfer and substantial/maximal assistance for rolling to left/right and sitting to lying. Section O of this same MDS documents R52 received 7 days of passive range of motion (with a look back period of 7 days). On 1/16/25 at 2:20 PM, R52 stated Occupational Therapy works with her on using a sliding board and hand strengthening for her carpal tunnel, but no one does anything with her lower extremities, and she figures it is because she doesn't have a hip joint and won't ever walk again. R52 stated she has not had any type of lower body exercises, and she prefers to stay in her hospital gown until she gets up for the day. R52 stated she tries to sit up for 2-3 hours in a chair, but due to her healed pressure sore on her bottom, she is careful about putting too much pressure on it. R52 stated she requires the help of staff to get dressed, but even when they dress her, they do not do any type of passive range of motion. On 01/16/25 at 02:21 PM, V10 (Certified Nurse Assistant/CNA), V17(CNA), and V18 (CNA) state they do not have anywhere to chart if they do range of motion. V10, V17, and V18 stated they think restorative nursing does the range of motion, however, she does not see all the residents. V10, V17, and V18 all stated they do not give the residents passive range of motion, unless dressing them counts. Review of current R52's Care Plan does not have a focus area in regards to limited range of motion, receiving therapy, or exercises to prevent a decline. Review of R52's current Order Summary Report does not have an order for R52 to receive restorative nursing, and this was confirmed by V23 (Rehabilitation Director) on 1/17/24 at 3:00 PM. V23 also confirmed at this time, ]R52 only receives therapy on her upper extremities due to carpal tunnel and is not seen by restorative aide for exercises. The facility policy titled Resident Mobility and Range of Motion Policy, with a revision date of 7/15/24, documents: 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in ROM. Therapy services will assess per physician order and develop ROM plan as needed. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Residents may receive directed services with therapy which include ROM prior to resident being placed on restorative services 6. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. 7. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in , and/or improve mobility and range of motion

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 1 (R52) residents reviewed for unnecessary medications in a sample of 42. The Findings Include: R52's admission record documents an admission date of 9/12/23. This same document includes the following diagnoses: major depressive disorder and anxiety disorder. R52's Minimum Data Set (MDS), dated [DATE], documents in section C, Cognitive Patterns, that R52 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R52 is cognitively intact. R52's January 2025 Order Summary Report includes the following medication orders: Ativan 1 milligram tablet by mouth every 6 hours as needed related to anxiety disorder. Ativan has a start date of 1/7/25 and an end date of 1/21/25. Buspirone 10 milligrams tablet by mouth two times a day related to anxiety disorder. This had an original start date of 9/12/23. Escitalopram 20 milligrams tablet one time a day related to major depressive disorder with original start date of 9/12/23. R52's Care Plan has a focus areas of: The resident has depression related her advanced kidney disease and resident has anxiety related to advanced kidney disease. and Potential for adverse reaction related to antidepressant medication use with an initiation date of 7/23/24. Documented interventions include: administer medications as ordered and monitor/document for side effects and effectiveness, assist the resident in developing a program of activities that is meaningful and of interest, musical bingo, resident council, the resident needs adequate rest periods, the resident prefers to rest after meals, and the resident needs time to talk daily, 1:1 visits to allow resident to express feelings. R52's Behavior Monitoring and Interventions Report from 9/1/24-current shows two days of recorded behaviors. On 12/28/24, R52's behavior tracking documents she had one instance of being anxious and sad/tearful, with an intervention of redirect and documented improvement. R52's behavior tracking also documents on 10/6/24 she had one instance of being sad/tearful with interventions of reapproach, 1:1, offer food/drink, and provide comfort and the behaviors improved. A Consultant Pharmacist Medication Regimen Review Communication, dated 6/26/24, documents a recommendation to: Please assess risk versus benefit and if your patient would benefit from a dose reduction of Buspirone 10 milligrams, Escitalopram 20 milligrams, and Lorazepman 1 milligram every 6 hours. The Physician's response, dated 7/16/24, documents the checked box of I disagree and documented patient is stable for now. On 01/16/25 at 12:43 PM, R52 stated she is not sure why she is on Buspar, as she never had been prior to coming here. R52 went on to state no one has ever spoken to her in regards to trying to reduce her Buspar or Escitalopram. R52 stated she has always been on an anti-depressant even prior to admitting to the facility, but never the anti-anxiety. On 1/16/24 at 2:00 PM, V17 (Certified Nurse Assistant/CNA) stated R52 does not regularly have any type of behaviors that she is aware of. On 1/17/24 at 1:30 PM, V22 (CNA) stated he is not aware of R52 having any type of behaviors. The facility policy titled Psychotropic Medication Use and Reduction documents 1. Residents will only receive psychotropic medication when necessary to treat specific conditions for which they are indicated and effective. 2. The attending Physician and other staff along with input from the resident, will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and other. 3. The attending Physician will identify, evaluate and document, with input from other disciplines, resident and consultants as needed, symptoms that may warrant the use of psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide meals at a palatable temperature when delivering hall trays for 3 of 3 (R59, R69, and R74) residents reviewed for food palatability in a sample of 42. The The findings Include: 1. R59's admission record documents an admission date of 6/19/24, and includes the following diagnoses: Diabetes Mellitus Type 2, anxiety disorder, pressure ulcer of left heel, muscle weakness, and unspecified open wound to foot. R59's quarterly Minimum Data Set (MDS), dated [DATE] Section C, documents a BIMS (Brief Interview of Mental Status) score of 15, indicating he is cognitively intact. On 1/15/25 at 12:06PM, R59 stated he chooses to eat in his room for all meals. R59 stated most of the time, all of his food is cold when it is delivered to him. R59 went on to state he sees the tray get delivered to the hallway, but there are times it takes over 20 minutes for the nursing staff to then get the trays passed out. 2. R69's admission record documents an admisison date of 10/14/24, and includes the following diagnoses: hisotry of falling, unsteadiness on feet, and neuropathy. On 1/15/25 at 1:00 PM, R69 stated she eats in her room for all meals due to it being her preference. R69 stated when her tray is delivered to her, the majority of the time her food is cold. R69 stated she has not asked the staff to heat it up because she knows they are busy and does not want to bother them. 3. R74's quarterly MDS, dated [DATE] Section C, documents a BIMS of 15, indicating she is cognitively intact. On 1/15/24 at 2:00 PM, R74, who was alert to person, place, and time, stated she eats her meals in her room and the food is cold when it finally reaches her. Review of Resident Council meeting minutes from July 3, 2024, had a problem brought up that the meals are not warm when served on the hall. The resolution to this concern was V20 (Dietary Manager) explained that covers were being ordered to help solve the issue with the food. Resident Council meeting minutes from January 7, 2025 had a problem brought up that there was cold food being delivered on the hallways and the resolution was to ask the food delivery person to use the microwave to heat it up. On 1/16/24 at 10:09 AM, V19 (Social Services) stated she currently does the resident council meetings because they are looking to hire a new Activities Director. V19 stated during the January meeting, the residents decided on the resolution of asking the staff to reheat the plates if the food is too cold, because they cannot seem to get the food delivered hot enough after complaining. On 1/17/24 at 11:30 AM, V20 (Dietary Manager) stated she was unaware that the problem was brought up in January regarding cold food, and back in July she had told the resident council she would look into pricing covers for the plates for hall tray deliveries. V20 stated an in service was completed and she thought the temperatures had improved, so the covers were never actually ordered. V20 stated the hall trays have the plate covered with foil to keep the food warm, and the carts they use are open to air and not insulated. The facility policy titled In Room Dining documented a Guideline: Although we encourage long term residents to eat in the dining rooms to encourage socialization and monitoring, in room dining is offered to the resident that may refer to stay in their room or who might be so critically ill or physically unable to go to the dining room. Procedure: .3. meals served in rooms may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 degrees Fahrenheit or greater to promote palatability for the resident. If there is a concern about the temperature or palatability of the meal, a new meal should be ordered from dining services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide activities to residents for 4 of 4 (R31, R43, R52, and R129) residents reviewed for activities in a sample of 42. The Findings Include: R31's admission record documents an admission date of 7/16/24, and includes the following diagnoses: muscular dystrophy, cerebral palsy, and depression. R31's quarterly Minimum Date Set (MDS), dated [DATE], documents in Section C a BIMS (Brief Interview of Mental Status) score of 15, indicating R31 is cognitively intact. On 1/16/25 at 9:30 AM, R31 complained there is not enough to do in the facility, especially on the weekends. R31 stated they sometimes get coloring sheets printed off to color on over the weekend, but not every weekend. During the resident council meeting on 1/15/25 at 10:21AM, R31, R43, R52, and R129, who were all alert to person, place, and time, all stated there is not enough to do on the weekend for activities. Review of resident council minutes for 12 months has no documentation of complaints of lack of activities. On 1/17/24 at 11:30 AM, R52 stated she is the president of the resident council, and they most certainly have complaints every month on the lack of activities that occur, especially on the weekend. On 01/16/25 at 12:05 PM, V24 (Certified Nurse Assistant/CNA) stated she works day shift every other weekend. This past weekend, on 1/11/25 and 1/12/25, V24 said she worked both Saturday and Sunday. V24 stated sometimes there are activity staff there on the weekend, but she has never been asked to do activities on the weekend, nor would she have time to do them, not even to start a movie. V24 went on to state this past weekend, there were no activity staff present that she saw, and most residents usually sit in front of the TV on the weekend. Review of the January 2025 activities calendar shows there are activities planned on the weekend. On 12/11/25 they were supposed to have 1. what are we thankful for? 2. Sip and Sit 3. Thank You goodies for staff 4. Would you rather? On 12/12/24 activities listed as planned: 1. Back in the day. 2. Back porch chatter 3. Memory Lane Social Hour 4. Noodle ball. On 1/17/24 at 11:00 AM, V19 (Social Services) stated she is the interim Activities Director until they can find someone to hire for the position. V19 stated the CNA's are supposed to ensure activities are offered over the weekends.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 1 of 3 (R12) residents reviewed for abuse in the sample of 42. Findings Include: A facility Initial Report on R12 documents, On 10/28/24 at approximately 0830 am (8:30 AM), CNA (Certified Nursing Assistant) reported that she witnessed an unwanted contact between resident and staff member to his right shoulder. The resident was immediately assessed for injuries and none noted. The staff member was immediately removed from the floor and schedule until further notice. The PCP/POA/Police Department (primary care physician/power of attorney) and other reporting authorities notified Under investigation the report documents, The investigation in to this matter was conducted, and this is the result and final report. The alleged abuser (Activity Director/V6) was interviewed and she provided a statement saying that she walked by R12 and he reached out and slapped her on the bottom. She stated that she tapped him on the shoulder and exclaimed (R12), but did not do it with the intention of hurting him or in any mean fashion. As noted in the initial she was sent home on suspension once the statement was taken. After receiving that statement a review of the video in that area was conducted. There appears to have been an issue with the network during the time that the incident occurred and none of the cameras were functioning. After discovering the issue with the video the CNA that witnessed and reported the incident was interviewed. According to her when (R12) smacked the Activity Director (V6) on the bottom she turned and made contact with his shoulder. The Activity Director is still suspension and will be terminated. Consider this the final report on this incidents. The resident remains at his baseline. On 11/14/24 at 1:00 PM, V15 (CNA) stated she was walking up to the nurse's station when she observed R12 hit V6 (Activities Director) on her hip, and V6 hit R12 back on the shoulder. V15 stated she immediately told V2 (Director of Nursing) what had happened. V15 stated R12 was checked after the incident, but no one told her if there was an injury. V15 stated R12 had hit staff before, but he does it in a playful way. V15 stated she couldn't say if it was abuse, but she knows she is R12's advocate, so she reported it. On 11/21/24 at 1:51 PM, V2 (Director of Nursing) stated V15 (CNA) reported to her V6 (Activities Director) had hit R12. V2 stated she immediately took the information to V3 (Regional Clinical Director) who started the investigation. V2 stated V6 was immediately removed from contact with R12 and other residents. V2 stated R12 did not have any injury. R12 was observed throughout the survey process, including on 11/14/24 and 11/18/24; R12 was not interviewable and did not show any signs or symptoms of distress. R12's admission Record, with a print date of 11/12/24, documents R12 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, Severe Intellectual Disability, autistic disorder, impulse disorder, bipolar disorder, unspecified speech disturbance, and restlessness and agitation. R12's MDS (Minimum Data Set), dated 8/30/24, documents R12 has a severe cognitive deficit. R12's current Care Plan documents a Focus area, dated 8/30/24, of, Potential for communication difficulties d/x (diagnosis) I have the mentality of a three year old per my mother, severe intellectual disabilities, autism, anxiety, restlessness/agitation, non-verbal. This Focus area includes the following interventions, .I roll up to staff in my w/c (wheelchair) when I need to be changed. Date Initiated 8/30/24 . This same Care Plan documents a Focus area dated 8/30/24 of, I playfully will slap staff members bottoms, at times I do not realize how hard I slap. I do not mean any harm, I am just playing. The interventions for this Focus area all dated 8/30/24 are, Caregivers to provide opportunity for positive interaction and attention .I enjoy hugs and smiles from staff .Remove the resident from situations that may affect others negatively .Reward the resident for appropriate behavior .Speak to me in a calm, gentle voice if I slap too hard . The facility Abuse Prevention Policy and Procedures, dated 8/16/2019, documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure allegations of misappropriation of resident funds was reported to the Administrator for 1 of 26 (R4) residents reviewed for misappropriation of funds in the sample of 42. Findings Include: R4's admission Record documents R4 was admitted to the facility on [DATE], with diagnoses that include diabetes, pressure ulcer, anxiety disorder, and difficulty walking. R4's Minimum Data Set, dated [DATE] documents R4 has a Brief Interview for Mental Status score of 15, which indicates R4 is cognitively intact. An undated facility Initial Report documents, Date of incident: unknown: I received a report from a state surveyor that one of our residents (R4) is reporting having money missing from his wallet. After speaking with the surveyor I went to (R4's) room and asked him when this occurred and he told me one time was ten days ago and another time was Thursday of last week. This is the initial report with investigation and final to follow. This same report documents under Final Report: After notifying local police, Ombudsman, and POA (Power of Attorney) an investigation was started into this incident. Staff was interviewed and no one had any information on where the money went. The resident was also interviewed for specifics regarding the missing money. The facility video was also reviewed and provided no indication on what happened to the money. (R4) originally said that he had a total of 140.00 dollars taken from him involving two separate times within a fairly close period of time. (R4's) son informed us that he believes he probably gave his father the 100 dollars but reports not knowing anything about the other 40.00 that his father says is missing. The facility has replaced the 100.00 and at this time have not been able to determine what happened with the original 100.00. This report form was completed by V1 on 11/7/24. On 11/14/24 at 1:43 PM, V17 (LPN/Licensed Practical Nurse) stated R4 reported to her on Sunday (11/10/24) that he had money missing. V17 stated she reported the allegation of missing money to V2 (Director of Nursing). On 11/14/24 at 2:53 PM, V1 (Regional Director of Operations) stated he didn't have any investigations related to R4's missing money. On 11/20/24 at 9:45 AM, R4 stated the facility administration had spoke with him concerning the missing money and replaced $100.00. R4 stated he had reported the money was missing to two different staff members, but was not able to recall their names. On 11/21/24 at 1:51 PM, V2 (Director of Nursing) stated she did not have any recollection of V17 reporting to her R4 was missing money. The facility Abuse Prevention Policy and Procedures, dated 8/16/2019, documents, This facility affirms the rights of our residents to be free from abuse,neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion This same policy documents under, V. Internal Reporting Requirements and Identification of Crimes and Abuse. Employees are required to report any incident, allegation or suspicion of crime or potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect to the administrator .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent pressure ulcers and hand hygiene was performed per current standards of practice when administering treatments for 3 of 3 (R1, R4, and R7) residents reviewed for pressure ulcers in the sample of 42. Findings Include: 1. R1's admission Record, with a print date of 11/20/24, documents R1 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's Disease, atrial fibrillation, urinary incontinence, weakness, and dementia. R1's MDS (Minimum Data Set), dated 11/8/24, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive deficit. This same MDS documents R1 is at risk for pressure ulcers with treatments documented as pressure reducing device for chair and bed, turning and repositioning program, and application of ointments/medications. R1's current Care Plan documents a Focus area of, The resident has an ADL (Activities of Daily Living) Self Care Performance Deficit. Date Initiated: 08/09/2024. This Focus area includes the following interventions; .Bed Mobility: Substantial/maximal assist. Date Initiated: 08/31/2024 .Transfer: The resident requires total assistance with transfers. Date Initiated: 08/31/2024 R1's current Care Plan does not address how often R1 should be repositioned to prevent skin breakdown. R1's Braden Scale for Predicting Pressure Score Risk, dated 8/9/2024, documents a score of 16, indicating R1 is at low risk of skin breakdown. On 11/18/24 at 10:53 AM, R1 was observed with V23 (Licensed Practical Nurse/LPN/Infection Preventionist/ IP) present. R1 was sitting in his wheelchair and was assisted to a standing position by V25 (CNA/Certified Nursing Assistant) and V23 (LPN/IP). R1 had a bowel movement, so they assisted him to lay down and provided incontinence care. R1 had a red area on his right hip. V23 pressed on the red area, and the area did not blanche. V23 stated R1 had probably been sitting in his wheelchair since he got up that morning. V23 stated if day shift got R1 up, it would have been between 6:30 and 7:00 AM. On 11/18/24 at 11:10 AM, V24 (CNA) stated she was the CNA providing care to R1 that morning. V24 stated R1 was up in his wheelchair when she arrived to the facility at 6:00 AM. V24 stated she pushed R1 to breakfast and then left the facility and went to class. V24 stated V25 (CNA) covered her hall while she was gone. V24 stated when she got back from class, right before 10:00 AM, R1 was in the lobby in his wheelchair. V24 stated she took him to his room and was checking and changing residents, but hadn't gotten to R1 yet. V24 stated R1's pressure ulcer preventions were to keep him clean and dry and to turn and reposition him every two hours. V24 stated R1 was not able to reposition himself. On 11/18/24 at 11:16 AM, V23 (LPN/IP) stated R1 needed to be laid down between meals. When asked why R1 hadn't been put in bed after breakfast, V23 stated she thought the issue was V25 was covering two halls, and was buried in call lights. On 11/18/24 at 2:37 PM, V25 stated she wasn't told she was to cover R1's hall while V24 was gone. V25 stated she had not provided any care to R1 prior to the observation at 10:53 AM. 2. R4's admission Record, with a print date of 11/20/24, documents R4 was admitted to the facility on [DATE] with diagnoses that include diabetes, morbid obesity, hypertension, unstageable pressure ulcer of left heel, and acute osteomyelitis of left ankle and foot. R4's MDS, dated [DATE], documents a BIMS score of 15, which indicates R4 is cognitively intact. R4's current Care Plan documents a Focus area of, I have actual skin impairment to skin integrity/wound Date Initiated: 08/25/2024. The interventions documented for this Focus area include; .Administer treatments as ordered and monitor for effectiveness. Date Initiated: 08/25/2024 . On 11/18/24 at 1:59 PM, V23 (LPN/IP) was observed administering treatment to R4's left heel. V23 removed the old dressing, changed her gloves, cleaned the area with wound cleanser, changed her gloves, applied betadine and a clean dressing and doffed her gloves. V23 did not hand sanitize or wash her hands with each glove change. On 11/18/24 at 2:18 PM, V23 (LPN/IP) stated she didn't perform hand hygiene between glove changes, and it was probably because she was nervous. 3. R7's admission Record, with a print date of 11/20/24, documents R7 was admitted to the facility on [DATE], with diagnoses that include Castleman's disease, dementia, heart disease, hypertension, atria fibrillation, and osteoarthritis. R7's MDS, dated [DATE], documents a BIMS score of 05, indicating R7 has a severe cognitive deficit. This same MDS documents R7 requires substantial/maximal assistance from staff for bed mobility, is at risk for skin breakdown and has the treatments to prevent skin breakdown are documented as; pressure reducing device for chair and bed and application of ointments/medications. R7's current Care Plan documents a Focus area of, Potential for impairment to skin integrity r/t (related to) incontinence, need for assistance with mobility. Date Initiated: 07/01/2024. This Focus area does not include an intervention to turn and reposition. This same Care Plan documents a Focus area of, Potential for episodes of bowel and bladder incontinence Date Initiated: 07/01/2024. The interventions for this Focus area include, Incontinent: Check every two hours and as required for incontinence .Date Initiated: 07/01/2024. On 11/19/24 at 2:32 PM, V38 (Family Member) stated she had cameras in R7's room to monitor his care. V38 stated R7 was assisted up in his wheelchair and taken out of his room for up to 12 hours one day. V38 stated R7 appeared exhausted when he was brought back to his room. V38 stated R7 could sit in his chair for a couple of hours, but then he would begin to get tired. On 11/20/24 at 3:14 PM, V34 (Assistant Director of Nurses) stated R7's daughter had a concern R7 had been left in his wheelchair for a long period of time. V34 stated she didn't know the outcome of the allegation since she frequently worked the floor and isn't always involved in the outcome of concerns. On 11/21/24 at 1:51 PM, V2 (Director of Nursing) stated she wasn't aware of any concerns related to R7 being left in the wheelchair for a long period of time. The facility Handwashing/Hand Hygiene policy, dated 8/2015, documents, This facility considers hand hygiene the primary means to prevent the spread of infection 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .after removing gloves .a The facility Prevention of Pressure Ulcers/Injuries policy, dated 7/2017, documents, The purpose of this procedure is to provide information regarding identification of pressure ulcers/injury risk factors and interventions for specific risk factors Mobility/Repositioning 1. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition, and tolerance, and the resident's stated preference. 2. At lease every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. 3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the shower rooms on 200 and 500 hall had hot water. This has the potential to affect all residents residing on halls 200 and 500. Findings Include: On 11/19/24 at 11:00 AM, this surveyor's and the facility's digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. On 11/19/24 at 11:03 AM, V1 (Regional Director of Operations) checked the water temperatures in the shower room at the shower head using a cup to hold the water on the 500 hall, and the reading was 79.7 degrees Fahrenheit. On 11/19/24 at 11:22 AM, V1 checked the water temperature in the shower room at the shower head using a cup on 200 hall, and the reading was 84.5 degrees Fahrenheit. R3's admission Record, with a print date of 11/20/24, documents R3 was admitted to the facility on [DATE] with diagnoses that include diabetes, morbid obesity, neuromuscular dysfunction, and chronic pain syndrome. R3's MDS (Minimum Data Set), dated 10/18/24, documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R3 is cognitively intact. This same MDS documents R3 requires substantial/maximal assistance with showers. On 11/20/24 at 9:48 AM, R3 stated the water in her shower in her room was warm enough to take a shower some days and not on other days. R3 stated regional staff and V33 (Maintenance Director) had worked on it recently, and it was currently warm enough to shower, but that it typically would go back to being cold after a few days. R3 stated she was hopeful it was fixed this time. R3 stated when it wasn't working, the facility staff would have to take her to another hall to shower, since the common shower room on her hall did not have hot water either. R3 stated when they took her to another hall to shower, she would have to go through the common area where visitors and other residents sat and it was degrading. R3 stated the shower on her hall hadn't worked for awhile. R11's admission Record, with a print date of 11/21/24, documents R11 was admitted to the facility on [DATE], with diagnoses that include traumatic brain injury, major depressive disorder, need for assistance with personal care, and reduced mobility. R11's MDS, dated [DATE], documents a BIMS score of 15, indicating R11 is cognitively intact. This same MDS documents R11 is dependent on staff for showers. On 11/19/24 at 1:51 PM, R11 stated they didn't have hot water in the shower room on his hall. R11 stated the facility staff would take him to another hall to shower. On 11/20/24 at 1:40 PM, V31 (LPN/Licensed Practical Nurse) stated they did have hot water most places, but she had complaints that one hall didn't have hot water. On 11/20/24 at 2:37 PM, V32 (CNA/Certified Nursing Assistant) stated they sometimes have hot water. V32 stated she couldn't remember the last time they could use the shower on 500 hall. On 11/20/24 at 2:52 PM, V33 (Maintenance Director) stated they had some issues with the hot water in the shower rooms on the 200 and 500 hall. V33 stated the highest he could get the temperature of the water in the 500 hall shower was 89 or 90 degrees Fahrenheit. V33 stated he has been working on the hot water for the 500 hall shower room for about a month. V33 stated he would get the temperature where it should be and it would stay for a couple of days, and then it would get cold again. The facility Matrix, dated 11/14/24, documents 18 residents reside on the 200 hall, and 13 residents reside on the 500 hall. The facility Water Temperatures, Safer of Policy, dated December 2009, documents, Tap water in the facility shall be kept within a temperature range to prevent scalding to residents. Policy Interpretation and Implementation 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than (no temperature documented), or the maximum allowable premature per state regulation .

Based on interview and record review, the facility failed to ensure residents were free from misappropriation of funds for 25 of 26 (R2, R5, R11, R21-R42 ) residents reviewed for misappropriation of funds in the sample of 42. Findings Include: A facility Initial Report documents: Date of incident 11/4/24. Under Status: At approximately 7:25 a (7:25 AM) it was reported by surveyor (name of surveyor) that she had a complaint about Administration at the facility stealing money. There were no specifics to the complaint, but the facility has opened an investigation into this matter. At this point there have been no reports of missing money. Quarterly trust statements were sent out on October 1, 2024, with no concerns reported. Investigation started, Medical Director, Local Police and Ombudsman have been notified. Final report will be sent within 5 days . After reviewing the trust, resident ledger, deposits, withdraw batches and bank statements, we do find some discrepancies with the trust. The local police have been updated on the findings at this point. Administrator (V4), resigned on, 10/18/24, and Business Office Manager, (V5) was terminated on 10/21/24, for theft of company time. We found that the Administrator (V4) was manually adding time to the Business Office Managers payroll on days that she did not work. After receiving a complaint from (State Survey Agency) on November 4th regarding the trust, a thorough investigation began. As stated, we have found some discrepancies with the trust account and are cooperating with the local police Administrator (V4) was removed from the account at the time of resignation, everyone authorized to sign from the trust account has been removed except Owner/CEO (Chief Executive Officer) (V37) .Final Report A complete audit of the resident trust fund was completed and it was noted that several residents had purchases listed in their account that the facility did not have the proper receipts for the transaction in question. The review of the entire trust fund revealed a total of $5,124.97 unaccounted for by receipts. The entire amount was replaced by the facility. All POA's (Power of Attorney's), Family members and responsible parties were notified of the situation and informed that the facility replaced the funds. This is the final report on this incident. A spreadsheet titled, (name of facility) Trust Fund documents the following discrepancies in the resident trust fund accounts, R11-$1627.37, R21 - $166.72, R22- $139.68, R23 - $33.76, R24- $47.20, R25 - $16.99, R2 - $121.09, R26 - $74.06, R5 - $81.81, R27 - $117.33, R28 - $216.48, R29 - $57.21, R30 - $143.79, R31 - $129.85, R32 - $14.88, R33- $26.75, R34 - $1826.00, R35 - $138.00, R36 - $18.00, R37 - $18.00, R38 - $28.00, R39 - $18.00, R40 - $18.00, R41- $18.00, R42 - $28.00. On 11/4/24 at 6:35 AM, V3 (Regional Clinical Director) stated they hadn't had any reports of resident funds missing. V3 stated they did discover V4 (former Administrator) added time to V5 (former Business Office Manager) time card that she hadn't worked. V3 stated V5 was terminated and V4 resigned. On 11/18/24 at 10:03 AM, V1 (Regional Director of Operations) stated they did discover there were amounts out of resident trust funds with no receipts to account for them. V1 stated they started the investigation and V4 (former Administrator) came to the facility to talk with him, and then went to the local police to talk with them. V1 stated the funds have all been put back into the accounts and are no longer missing. V1 had a check in his hand from V4 to replace the missing funds. V1 stated the amount that was was not able to be accounted for and was replaced was $5,124.00. On 11/18/24 at 11:22 AM, when asked about the allegations of misappropriation of resident funds, V4 (former Administrator) stated she had a need and saw an opportunity to take the funds. V4 stated then it just got out of hand. V4 stated she came to the facility this morning and paid in full the amount V37 (CEO/Owner) said was owed. V4 stated no one else was knowingly aware of or involved in taking the resident funds. On 11/19/24 at 9:41 AM, when asked about money being taken from his trust found account by a staff member and replaced, R24 who was alert and oriented, stated he didn't have any issues or concerns with his money being taken. On 11/19/24 at 9:50 AM, when asked about money being taken from her trust found account by a staff member and replaced, R25 who was alert and oriented, stated she didn't have any issues or concerns with staff taking her money. On 11/19/24 at 1:51 PM, when asked about money being taken from his trust found account by a staff member and replaced, R11 who was alert and oriented, stated he didn't have any concerns with his money being taken by staff. On 11/19/24 at 2:25 PM, when asked about money being taken from his trust found account by a staff member and replaced, R37 answered yes/no questions, and answered no when asked if she had any concerns/issues with anyone taking her money. The facility Abuse Prevention Policy and Procedures, dated 8/16/2019, documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure incontinence care was provided timely and shampoo/body wash was readily available for 6 of 6 (R1, R3, R8, R10, R11, and R16) residents reviewed for Activities of Daily Living in the sample of 42. Findings Include: 1. R3's admission Record, with a print date of 11/20/24, documents R3 was admitted to the facility on [DATE], with diagnoses that include diabetes, morbid obesity, neuromuscular dysfunction of the bladder, anxiety disorder, chronic pain syndrome, and pressure ulcer of right buttock. R3's MDS (Minimum Data Set), dated 10/18/24, documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R3 is cognitively intact. This same MDS documents R3 is dependent on staff for toileting hygiene. R3's current Care Plan documents a Focus area of, The resident has an ADL (Activities of Daily Living) Self Care Performance Deficit. Date Initiated: 07/30/2024. This Focus area includes the following interventions. Transfer: Mechanical Lift with staff assist x (times) 2 with all transfers. This care plan does not address R3's bowel and bladder care needs. On 11/4/24 at 8:50 AM, R3 stated it can take up to thirty minutes for the staff to answer call lights. R3 stated she had incontinence episodes a couple of times while waiting for staff to answer the call light. 2. R8's admission Record, with a print date of 11/14/24, documents R8 was admitted to the facility on [DATE], with diagnoses that include fracture of right femur. R8's MDS, dated [DATE], documents a BIMS score of 13, which indicates R8 is cognitively intact. This same MDS documents R8 requires partial/moderate assistance for toileting hygiene. R8's current Care Plan documents a Focus area of, I have episodes of bowel and bladder incontinence r/t (related to) need for assistance with ADL's, ulcerative colitis, hx (history) of UTI's (urinary tract infections), celiac disease, overactive bladder. Date Initiated: 10/17/2024. This Focus area includes the following interventions, .Incontinent: Check every two hours and as required for incontinence Date Initiated: 10/17/2024 .Answer call light promptly. Date Initiated: 10/17/2024 . On 11/14/24 at 11:37 AM, R8 stated it takes forever for staff to come to the room when she needs something. R8 stated she has pooped and peed on herself waiting for them. 3. R16's admission Record, with a print date of 11/20/24, documents R16 was admitted to the facility on [DATE], with diagnoses that include chronic respiratory failure, morbid obesity, heart failure, shortness of breath, and need for assistance with personal care. R16's MDS, dated [DATE], documents a BIMS score of 15, indicating R16 is cognitively intact. This same MDS documents R16 is dependent on staff for toileting hygiene. R16's current Care Plan documents a Focus area of, The resident has an ADL Self Care Performance Deficit. Date Initiated: 07/30/2024. This Focus area includes the following intervention, Transfer: Mechanical lift with staff assist x 2 with all transfers. Date Initiated: 07/30/2024. This Care Plan does not address R16's toileting care needs. On 11/4/24 at 8:37 AM, R16 stated, Yeah, they don't seem to care if I am sitting in piss. I sat for two hours from 5:00 to 7:00 PM. R16 stated she told staff she had to go and no one responded because they were getting the residents from the dining room first. R16 stated they would come in and turn her call light off and then never come back. On 11/4/24 at 5:05 AM, V7 (CNA/Certified Nursing Assistant) stated staffing isn't too good. V7 stated when they only have one CNA on a hall, call lights aren't answered timely. On 11/4/24 at 5:19 AM, V9 (CNA) stated they had five halls and one CNA per hall. V9 stated when they only have one CNA per hall, the residents needs aren't met timely. When asked what needs weren't met timely, V9 stated bed checks get done late. On 11/14/24 at 1:52 PM, V18 (CNA) stated he spoke with V2 (Director of Nursing/DON) last week about the hall that he normally works on. V18 stated the hall has vocal, needy residents. V18 stated when he is providing care for the more vocal residents, the other residents have to wait. On 11/14/24 at 2:03 PM, when asked if they had enough staff to meet the needs of the residents timely, V20 (CNA) stated they didn't. V20 stated when they only have one CNA per hall then they have to help each other out, which puts them behind providing timely care for the residents on their hall. V20 stated incontinence care is not provided timely and call lights aren't answered timely. On 11/14/24 at 2:23 PM, V21 (CNA) stated they don't have enough staff to provide timely care. When asked what care wasn't provided timely, V21 stated incontinence care was not provided timely. On 11/14/24 at 2:27 PM, V22 (CNA) stated incontinence care was not provided timely when they had one CNA working on each hall. On 11/20/24 at 3:14 PM, V34 (Assistant Director of Nursing) stated there are times they only have one CNA working on each hall. On 11/21/24 at 10:17 PM, V36 (Registered Nurse) stated she works night shift and most nights they have one CNA per hall. V36 stated if they have anyone call in then they are short handed and it makes it harder to provide timely care, including incontinence care. On 11/21/24 at 1:51 PM, when asked if one CNA per hall was enough to meet the needs of the residents timely, V2 (Director of Nursing) stated she believed that changed daily. V2 stated she was sure it didn't feel like enough staff to accommodate them. V2 stated two minutes can seem like twenty, and twenty minutes can seem like two hours. When asked if she had any reports of staff not being able to provide timely care, V2 stated she had not had any complaints they weren't able to complete a specific task. V2 stated she tries to have extra staff during hours that it is needed. V2 stated it was hard to judge with CNA's since we all gripe and complain. The facility undated Perineal Care policy documents, The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. 4. R1's admission Record, with a print date of 11/20/24, documents R1 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, cardiac arythmia, atrial fibrillation, and weakness. R1's MDS, dated [DATE], documents a BIMS score of 04, which indicates a severe cognitive deficit. This same MDS documents R1 is dependent on staff for showers. R10's admission Record, with a print date of 11/21/24, documents R10 was admitted to the facility on [DATE] with diagnoses that include osteomyelitis, diabetes, contractures of muscle, and Alzheimer's disease. R10's MDS, dated [DATE], documents R10 has a severe cognitive deficit. This same MDS documents R10 is dependent on staff for showers. R11's admission Record, with a print date of 11/21/24, documents R11 was admitted to the facility on [DATE] with diagnoses that include traumatic brain injury, major depressive disorder, need for assistance with personal care, and reduced mobility. R11's MDS, dated [DATE], documents a BIMS score of 15, indicating R11 is cognitively intact. This same MDS documents R11 is dependent on staff for showers. On 11/19/24 beginning at 2:34 PM, the facility storage supply closets including the clean utility rooms were observed with V2 (Director of Nurses) present throughout the observations. There were no bottles of shampoo body wash observed in the brief room, the clean utility room on the 500 hall, and the clean utility on the 600 hall. There was one bottle of shampoo/body wash located in the clean utility room on the 300 hall, and one bottle located in the clean utility room on the 200 hall. There were large bottles of body wash/shampoo located in the shower room on the 400 hall that appeared to have been purchased at a local store. On 11/19/24 at 2:48 PM, V27 (Unit Director) stated the body wash located in the shower room on the 400 hall had been purchased by staff and/or family. V27 stated she wasn't sure how long it had been since they had facility purchased shampoo/body wash on the 400 hall. On 11/19/24 at 2:44 PM, V35 (CNA/Certified Nursing Assistant) stated she brings her own shampoo and body wash into the facility to use, and denied issues with supplies. On 11/19/24 at 2:51 PM, V24 (CNA) stated they have some body wash/shampoo in resident rooms and in the brief room. V24 stated they sometimes have issues with having enough wipes, but they usually have enough shampoo/body wash. On 11/19/24 at 2:53 PM, V2 (Director of Nursing) observed R1's room including in his bathroom, bedside table, and dresser drawers, with no shampoo/body wash located. On 11/19/24 at 2.55 PM, R10 and R11's room was observed by V2 (DON) including the bathroom, bedside table, and dresser drawers, with no body wash/shampoo located. On 11/19/24 at 2:55 PM, V2 (DON) stated they should have body wash/shampoo, and two bottles would not be enough for the residents currently residing at the facility, but she was sure they had more in other resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there was sufficient staff to meet the needs of the residents timely. This failure has the potential to affect all 78 residents currently residing at the facility. Findings Include: The facility Resident Matrix dated 11/14/24 documents 78 residents currently reside at the facility. 1. R1's admission Record, with a print date of 11/20/24, documents R1 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's Disease, atrial fibrillation, urinary incontinence, weakness, and dementia. R1's MDS (Minimum Data Set), dated 11/8/24, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive deficit. This same MDS documents R1 is at risk for pressure ulcers with treatments documented as pressure reducing device for chair and bed, turning and repositioning program, and application of ointments/medications. R1's current Care Plan documents a Focus area of, The resident has an ADL (Activities of Daily Living) Self Care Performance Deficit. Date Initiated: 08/09/2024. This Focus area includes the following interventions; .Bed Mobility: Substantial/maximal assist. Date Initiated: 08/31/2024 .Transfer: The resident requires total assistance with transfers. Date Initiated: 08/31/2024 R1's current Care Plan does not address how often R1 should be repositioned to prevent skin breakdown. R1's Braden Scale for Predicting Pressure Score Risk, dated 8/9/2024, documents a score of 16, indicating R1 is at low risk of skin breakdown. On 11/18/24 at 10:53 AM, R1 was observed with V23 (Licensed Practical Nurse/LPN/Infection Preventionist/ IP) present. R1 was sitting in his wheelchair and was assisted to a standing position by V25 (CNA/Certified Nursing Assistant) and V23 (LPN/IP). R1 had a bowel movement so they assisted him to lay down and provided incontinence care. R1 had a red area on his right hip. V23 pressed on the red area, and the area did not blanche. V23 stated R1 had probably been sitting in his wheelchair since he got up that morning. V23 stated if day shift got R1 up, it would have been between 6:30 and 7:00 AM. On 11/18/24 at 11:10 AM, V24 (CNA) stated she was the CNA providing care to R1. V24 stated R1 was up in his wheelchair when she arrived to the facility at 6:00 AM. V24 stated she pushed R1 to breakfast and then left the facility and went to class. V24 stated V25 (CNA) covered her hall while she was gone. V24 stated when she got back from class, right before 10:00 AM, R1 was in the lobby in his wheelchair. V24 stated she took him to his room and was checking and changing residents, but hadn't got to R1 yet. V24 stated R1's pressure ulcer preventions were to keep him clean and dry and to turn and reposition him every two hours. V24 stated R1 was not able to reposition himself. On 1/18/24 at 11:16 AM, V23 (LPN/IP) stated R1 needed to be laid down between meals. When asked why R1 hadn't been put in bed after breakfast, V23 stated she thought the issue was V25 was covering two halls and was buried in call lights. On 11/18/24 at 2:37 PM, V25 stated she wasn't told she was to cover R1's hall while V24 was gone. V25 stated she had not provided any care to R1 prior to the observation with this surveyor at 10:53 AM. 2. R3's admission Record, with a print date of 11/20/24, documents R3 was admitted to the facility on [DATE], with diagnoses that include diabetes, morbid obesity, neuromuscular dysfunction of the bladder, anxiety disorder, chronic pain syndrome, and pressure ulcer of right buttock. R3's MDS (Minimum Data Set), dated 10/18/24, documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R3 is cognitively intact. This same MDS documents R3 is dependent on staff for toileting hygiene. R3's current Care Plan documents a Focus area of, The resident has an ADL (Activities of Daily Living) Self Care Performance Deficit. Date Initiated: 07/30/2024. This Focus area includes the following interventions. Transfer: Mechanical Lift with staff assist x (times) 2 with all transfers. This care plan does not address R3's bowel and bladder care needs. On 11/4/24 at 8:50 AM, R3 stated it can take up to thirty minutes for the staff to answer call lights. R3 stated she had incontinence episodes a couple of times while waiting for staff to answer the call light. On 11/4/24 at 8:50 AM, R3 stated they don't have enough staff to meet the needs of the residents. R3 stated she is currently using a mechanical lift for transfers, but is learning how to use the sliding board. When asked if they had ever only had one staff to transfer her when using the mechanical lift, R3 stated, Unfortunately. When asked if she knew why they only had one staff for the transfer, R3 stated, lack of staff. 3. R4's admission Record, with a print date of 11/20/24, documents R4 was admitted to the facility on [DATE], with diagnoses that include diabetes, morbid obesity, hypertension, unstageable pressure ulcer of left heel, and acute osteomyelitis of left ankle and foot. R4's MDS, dated [DATE], documents a BIMS score of 15, which indicates R4 is cognitively intact. R4's current Care Plan documents a Focus area of, The resident has an ADL Self Care Performance Deficit Activity Intolerance, Pain. Date Initiated: 07/30/2024. This Focus area includes an intervention of, Transfer: Mechanical lift with assist x 2 for transfers. Date Initiated: 07/30/2024. On 11/4/24 at 9:01 AM, R4 stated he uses the mechanical lift to transfer. R4 stated sometimes they only have one staff to do it. R4 stated one night one staff came in and got him rolled with the mechanical lift pad under him, laying flat on the bed, left to get help and didn't come back for 45 minutes. R4 stated his back began to hurt from laying flat so long. R4 stated yesterday they only had one staff to transfer him. R4 stated sometimes they will hand him the control to hit the button while they pull him back in his chair, when they only have one staff for the transfer. On 11/4/24 at 5:05 AM, V7 (CNA/Certified Nursing Assistant) stated he has had to transfer residents who use a mechanical lift by himself at times due to not having enough staff. On 11/4/24 at 5:15 AM, V8 (CNA) stated she has had to transfer residents who use a mechanical lift by herself at times. On 11/4/24 at 5:19 AM, V9 (CNA) states she transfers residents who use a mechanical lift by herself quite often, due to not having enough staff. On 11/14/24 at 1:52 PM, when asked if he had ever transferred a resident who required a mechanical lift by himself, V18 (CNA) stated he signed papers on Tuesday night that he wouldn't. On 11/20/24 at 3:14 PM, V34 (Assistant Director of Nursing) stated there should be two staff transferring residents who require a mechanical lift for transfers. On 11/21/24 at 1:51 PM, V2 (Director of Nursing) stated there should be two staff present when transferring a resident using a mechanical lift. V2 stated she wasn't aware staff were transferring residents with only one staff, and once she became aware of it she retrained staff. 4. R8's admission Record, with a print date of 11/14/24, documents R8 was admitted to the facility on [DATE], with diagnoses that include fracture of right femur. R8's MDS, dated [DATE], documents a BIMS score of 13, which indicates R8 is cognitively intact. This same MDS documents R8 requires partial/moderate assistance for toileting hygiene. R8's current Care Plan documents a Focus area of, I have episodes of bowel and bladder incontinence r/t (related to) need for assistance with ADL's, ulcerative colitis, hx (history) of UTI's (urinary tract infections), celiac disease, overactive bladder. Date Initiated: 10/17/2024. This Focus area includes the following interventions, .Incontinent: Check every two hours and as required for incontinence Date Initiated: 10/17/2024 .Answer call light promptly. Date Initiated: 10/17/2024 . On 11/14/24 at 11:37 AM, R8 stated it takes forever for staff to come to the room when she needs something. R8 stated she has pooped and peed on herself waiting for them. 5. R16's admission Record, with a print date of 11/20/24, documents R16 was admitted to the facility on [DATE], with diagnoses that include chronic respiratory failure, morbid obesity, heart failure, shortness of breath, and need for assistance with personal care. R16's MDS, dated [DATE], documents a BIMS score of 15, indicating R16 is cognitively intact. This same MDS documents R16 is dependent on staff for toileting hygiene. R16's current Care Plan documents a Focus area of, The resident has an ADL Self Care Performance Deficit. Date Initiated: 07/30/2024. This Focus area includes the following intervention, Transfer: Mechanical lift with staff assist x 2 with all transfers. Date Initiated: 07/30/2024. This Care Plan does not address R16's toileting care needs. On 11/4/24 at 8:37 AM, when asked if she had any concerns with the care she received at the facility, R16 stated, Yeah, they don't seem to care if I am sitting in piss. I sat for two hours from 5:00 to 7:00 PM. R16 stated she told staff she had to go and no one responded because they were getting the residents from the dining room first. R16 stated they would come in and turn her call light off, and then never come back. On 11/4/24 at 5:05 AM, V7 (CNA/Certified Nursing Assistant) stated staffing isn't too good. V7 stated when they only have one CNA on a hall, call lights aren't answered timely. On 11/4/24 at 5:19 AM, V9 (CNA) stated they had five halls and one CNA per hall. V9 stated when they only have one CNA per hall the residents needs aren't met timely. When asked what needs weren't met timely, V9 stated bed checks get done late. On 11/14/24 at 1:52 PM, V18 (CNA) stated he spoke with V2 (Director of Nursing/DON) last week about the hall that he normally works on. V18 stated the hall has vocal, needy residents. V18 stated when he is providing care for the more vocal residents the other residents have to wait. On 11/14/24 at 2:03 PM, when asked if they had enough staff to meet the needs of the residents timely, V20 (CNA) stated they didn't. V20 stated when they only have one CNA per hall then they have to help each other out which puts them behind providing timely care for the residents on their hall. V20 stated incontinence care is not provided timely and call lights aren't answered timely. On 11/14/24 at 2:23 PM, V21 (CNA) stated they don't have enough staff to provide timely care. When asked what care wasn't provided timely, V21 stated incontinence care was not provided timely. On 11/14/24 at 2:27 PM, V22 (CNA) stated incontinence care was not provided timely when they had one CNA working on each hall. On 11/20/24 at 3:14 PM, V34 (Assistant Director of Nurses) stated there are times they only have one CNA working on each hall. On 11/21/24 at 10:17 PM, V36 (Registered Nurse) stated she works night shift and most nights they have one CNA per hall. V36 stated if they have anyone call in, then they are short handed and it makes it harder to provide timely care, including incontinence care. On 11/21/24 at 1:51 PM, when asked if one CNA per hall was enough to meet the needs of the residents timely, V2 stated she believed that changed daily. V2 stated she was sure it didn't feel like enough staff to accommodate them. V2 stated two minutes can seem like twenty, and twenty minutes can seem like two hours. When asked if she had any reports of staff not being able to provide timely care, V2 stated she had not had any complaints they weren't able to complete a specific task. V2 stated she tries to have extra staff during hours that it is needed. V2 stated it was hard to judge with CNA's since we all gripe and complain. The facility Assignment sheet for RN/LPN/CAN/NA (sic) documents one CNA per hall on 11/11 and 11/12/24 from 6 PM to 6 AM and one CNA per hall 11/16 and 11/17/24 from 12:00 AM until 6:00 AM.

2. R27's Face Sheet documented an admission date to the facility as 8/3/23. R27's Minimum Data Set (MDS), with an Assessment Reference Date of 11/3/23, documented in Section I, Active Diagnoses including Renal Insufficiency, Renal Failure, or End-Stage Renal Disease. R27's Physician Orders for January 2024 document her diet order as being, Liberal Renal CCHO (consistent controlled carbohydrate diet) , Mechanical Soft Diet with thin liquids. 1500 cc (cubic centimeter) fluid restriction. R27's undated Baseline Care Plan documented an admission date to the facility as 8/3/23. This care plan documented Dietary Orders as being Renal. Review of R27's Comprehensive Care Plan as provided by the facility with a print date of 1/25/24, documented no plan of care in place regarding R27's need for a renal diet due to dialysis needs. On 01/25/24 at 11:45 am, V4 (Care Plan Coordinator) reviewed R27's Comprehensive Care Plan and confirmed R27's renal dietary needs was not encompassed in her Plan of Care. V4 verified R27's diet needs should have been incorporated and stated she just missed it. The Therapeutic Diets policy, with a revision date of October 2017, documented, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. The Care Planning - Interdisciplinary Team policy, with a revision date of September 2013, documented, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). Based on interview and record review, the facility failed to care plan residents renal diets and fluid restriction for 2 of 18 residents (R11,R27) whose care plans were reviewed in the sample of 37. Findings include: 1. R11's Face Sheet documented an admission date of 9/20/23, and listed diagnoses including Acute Kidney Failure and Diabetes Type 2. R11's Physicians Order Sheet documented an order for hemodialysis Monday, Wednesdays, and Fridays at a local dialysis provider, and a diet order for a renal diet, low in fiber, with thin liquids and and a 1000 ml(milliliter) total per day fluid restriction. On 1/23/24 at 12:09pm, R11, who was alert and oriented, stated she is on dialysis and is to receive a renal diet and fluid restriction. R11's 12/20/23 Care Plan did not document problem areas, goals, or interventions related to the diet and fluid restriction. On 1/25/24 at 11:46am, V4, Care Plan Coordinator, stated she was not sure why R11's Care Plan did not address the renal diet and the fluid restriction, But it should have.

2. R27's Face Sheet documented an admission date to the facility as 8/3/23. R27's Minimum Data Set (MDS), with an Assessment Reference Date of 11/3/23, documented in Section I, Active Diagnoses including Renal Insufficiency, Renal Failure, or End-Stage Renal Disease. R27's Physician Orders for January 2024 document her diet order as being, Liberal Renal CCHO (consistent controlled carbohydrate diet), Mechanical Soft Diet with thin liquids. 1500 cc (cubic centimeter) fluid restriction. On 01/24/24 at 12:06 PM, V5 (Certified Nurse Assistant) was observed delivering R27's meal tray to her room. R27 was observed lying in bed, drowsy. V5 reported R27 had dialysis this morning, which wears her out and requested her meal be saved for later. The food served was observed as being mechanical soft consistency chicken & dumplings, peas, a breadstick, and brownie. The meal tray contents observed reflected the foods printed on diet ticket, as well as the contents being confirmed by V5. On 01/24/24 at 2:03 PM, V3 (Dietary Manager) stated R27 should have received the renal diet as listed on the diet spreadsheet. Review of the diet spreadsheet documented the renal lunch menu that should have been served on 1/24/24 was to be, LS (low sodium) baked chicken breast with pasta, LS peas, bread/margarine, and brownie. On 01/24/24 at 2:21 PM, V3 confirmed there were a glitch in their computer system and R27 was not provided her renal diet as prescribed for lunch on 1/24/24. The Therapeutic Diets policy, with a revision date of October 2017, documented, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Based on observation, interview, and record review, the facility failed to provide therapeutic diets for two residents on dialysis (R11, R27) of four residents reviewed for therapeutic diets in the sample of 37. Findings include: 1. R11's Face Sheet documented an admission date of 9/20/23, and listed diagnoses including Acute Kidney Failure and Diabetes Type 2. R11's Physicians Order Sheet documented an order for hemodialysis Monday, Wednesdays, and Fridays at a local dialysis provider, and a diet order for a renal diet, low in fiber, with thin liquids and and a 1000 ml (milliliter) total per day fluid restriction. On 1/23/24 at 12:09 pm, R11, who was alert and oriented, stated she is on dialysis and is to receive a renal diet and fluid restriction. R11 stated she is often served foods she knows she is not supposed to eat, such as bananas and potatoes. R11 stated when this occurs, she does not say anything to staff, but she does not eat the food item. R11 was observed eating her lunch, which consisted of a sloppy joe on bun, french fries, baked beans, and a snickerdoodle cookie. The diet card was not with the plate. When the Surveyor asked R11 if these foods were allowed on her diet, R11 stated, Probably not, but they all taste good, so I am eating them. On 1/24/24 at 12:03 pm, R11 was again observed eating lunch in her room. The meal consisted of a bowl of chicken chunks in thickened broth, peas, a breadstick, and a brownie. The diet card was not with the plate. R11 stated she was not sure if any of the foods were not on her diet, but everything tasted good, so she decided she was going to eat it all. On 1/24/24 at 2:24 pm, V3, Dietary Manager, stated R11 should have been served a low fiber renal diet, which on 1/23/24 was to have been low sodium hamburger on bun, low sodium corn, and low sodium green beans, and a snickerdoodle cookie. V3 stated on 1/24/23, R11 should have been served baked chicken breast with pasta, low sodium peas, bread with margarine, and a brownie. V3 stated she was not sure why R11 did not receive the correct diet, but it may have been due to the diet cards being printed out without the correct diet on them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure mechanically altered diets were the appropriate consistency for two (R1 and R3) of seven residents reviewed for mechanically altered diets in the sample of seven. Findings include: 1. R1's Face Sheet documented diagnoses including Parkinson's Disease, Hypertension, and Chronic Kidney Disease. R1's Physicians Orders documented a 9/12/23 order for a mechanical soft diet with thin liquids and fortified foods and (nutritional supplement) shakes at all meals. R1's Minimum Data Set, dated [DATE], documented R1 requires extensive assistance from one staff member for eating, R1 has moderate deficits in cognitive functioning, and R1 requires a mechanically altered diet. A 9/14/23 Speech Therapy Evaluation authored by V11 (Speech Therapist) documented, Patient demonstrated difficulty swallowing with reports of coughing during noon meal on 9/13/23. It is still recommended that patient remain on the current ordered diet. An Illinois Department of Public Health Initial and Final Report, dated 9/13/23, documented, On 9/13/23 at approximately 4:30pm, nursing staff was called to the dining room in response to a possible choking resident. Upon arrival, (R1) was noted to be coughing frequently and leaning forward in her wheelchair. Resident was encouraged to continue coughing by staff. Resident was unable to cough forcefully enough to clear her airway. Nursing staff then administered 3-5 back blows to resident without success. At that time, resident was noted to have stridor and then no air movement. At that time, Heimlich maneuver was initiated by nursing staff. After three Heimlich thrusts, the food was expelled and respiratory status returned to WNL (Within Normal Limits). Order was received for Speech Therapy to evaluate by next meal regarding the safety of current diet consistency which is mechanical soft with thin liquids. Resident had been previously treated by Speech Therapy and was discharged on 9/12/23 with no dysphasia indicators noted. Speech Therapist recommended that resident remain on the current ordered diet with the following swallowing guidelines: Constant supervision with meals and assist as needed. Verbal cues should be made to take one bite per swallow and alternate liquids and solids. Resident should remain upright 20 minutes after eating or drinking. Investigation: Residents current diet order is for a mechanical soft consistency. It was validated that she was served the correct consistency. The facility menu documented the following recipe instructions for the potato salad: Chopped soft potato salad-no raw veg (vegetable) lists the following ingredients: potato (peeled, cooked and diced), eggs, hard cooked, chopped, onion powder, pickle relish, sweet, mayonnaise, mustard, and salt. This recipe documents to peel potatoes and cut into a small to medium dice. Place potatoes in a large stockpot or saucepan or steam jacketed kettle of cold water. Bring to boil, cook potatoes until fork tender or until desired internal temperature is reached. On 9/26/23 at 9:55am, V5 (Dietary Manager) stated her first day on the job was on 9/13/23. V5 stated after R1's choking episode at supper, it was discovered the potato salad served that day contained some potatoes which were not cooked until soft. V5 stated she did not know which staff member had made the potato salad. V5 stated kitchen staff are to now only use cooked canned potatoes for potato salad. On 9/27/23 at 10:55am, V9 (CNA/Transporter) stated she has frequently assisted R1 during meals, and R1 can self feed, but requires supervision and cueing. V9 stated on 9/13/23 at about 4:30pm, V9 walked into the dining room to get a resident who needed to be transported. V9 stated V10 (Activity Director) was assisting R1 with cueing. V9 stated she heard V10 say she thought R1was choking. V9 stated she did 4 back blows, but R1 was still not getting any air in. V9 stated V2 (Director of Nurses) got behind R1 and picked her up and did 3 abdominal thrusts. V9 did a finger sweep, and A hunk of potato came out. V9 stated R1's airway was reestablished, and she began breathing. V9 stated she did not think the potato was undercooked, it seemed soft and not very large. On 9/27/23 at 11:10am, V10 (Activity Director) stated she was sitting beside R1 at lunch on 9/13/23, giving R1 verbal cues to take small bites, chew them thoroughly, and eat slowly. V10 stated she is not a Certified Nursing Assistant (CNA), and does not feed residents, but is allowed to cue residents. V10 stated R1 had been eating potato salad, and suddenly was not getting any air. V10 stated she yelled for help and stepped away so that CNA and nursing staff in the room could assist R1. V10 stated she was shaken by the incident and left the room, so she did not witness staff performing the Heimlich maneuver. V10 stated she did not know if the potato salad contained pieces of undercooked potato. On 9/28/23 at 9:45am, V12 (CNA) stated she was not in the dining room on 9/13/23 when R1 choked, but she heard the calls for help and ran in just as R1's airway had been cleared. V12 stated it was reported R1 choked on the potato salad. V12 stated V12 had also eaten the potato salad earlier, and noted it contained pieces of undercooked potato. On 9/27/23 at 12:45pm, V11 (Speech Therapist) was observed assisting R1 with lunch. R1 was alert and oriented only to self. R1 was able to self-feed with some difficulty, as R1's upper extremities were very tremulous. V11 stated R1 has difficulty with self-feeding due to Parkinsonian tremors. V11 stated R1's goal is to try to continue to self-feed with supervision to maintain the abilities she has. V11 stated she was not working on 9/13/23 when R1 choked during lunch. V11 stated she was told by other staff members R1 had choked on the potato salad, which had undercooked pieces of potato. V11 stated she evaluated R1 on 9/14/23, and recommended no change in her mechanical soft diet, but that she should be supervised at all meals. On 9/28/23 at 10:15am, V2 (Director of Nursing) stated she was not in the dining room initially when R1 choked on 9/13/23. V2 stated she was summoned to help, and at the time, R1 was still taking in air, but something was obviously partially occluding the airway. V2 stated back blows had been administered which were ineffective, so she administered abdominal thrusts, which caused R1 to cough up partially chewed potato. V2 stated she could not ascertain if it was not thoroughly soft. On 9/28/23 at 10:40am, V1 (Administrator) stated the facility's investigation found R1 was served the correct diet at lunch on 9/13/23. V1 stated she was unaware of staff reports that the potato salad was undercooked, and it had caused R1 to choke. 2. R3's Face Sheet, with print date of 9/28/23, documents a diagnosis of Dysphagia, oral phase. R3's Speech Therapy (ST) note dated 9/22/23 documented treatment of swallowing dysfunction and/or oral function for feeding .This treatment of skilled ST in order to improve/analyze/assess pt.'s (patient's) po intake safety and swallow function and/or laryngeal strengthening to determine safest/least restrictive diet and/or to establish compensatory swallow strategies to reduce risk of aspiration/weight loss. Current diet mech soft with thin liquids. On 9/26/23 at 12:10pm, lunch service was observed, with a meal of cheese ravioli with meat sauce, soft-cooked chopped broccoli, and frosted cake being served. At 12:45pm, all the broccoli had been served and R3' tray still needed to go out. V6 (Cook) got out a frozen box of broccoli, and put it on the stovetop to cook. At 1:00pm, the broccoli was boiling and had reached a temperature of 204 degrees Fahrenheit. Without checking the broccoli for tenderness, V6 began plating the broccoli on R3's tray, and it was sent to the dining room. The surveyor obtained a sample of the broccoli and found it was still hard, in large chucks, and could not be cut with a fork. On 9/26/23 at 1:20pm, R3, who was alert and oriented, was sitting at a dining room table with an untouched portion of broccoli on her plate. R3's Diet Card read, Diabetic, Heart Healthy diet. R3 stated she had been unable to eat the broccoli because it was not soft enough. R3's Physicians Orders documented a 7/27/23 diet order for Diabetic Heart Healthy diet with 1800 ml(milliliter) fluid restriction. On 9/27/23 at 10:05am, R3 stated she is a choking risk, and has choked on foods previously while living here. A Therapeutic Diets Policy, dated October 2017, documented, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.

Based on observation, interview, and record review, the facility failed to provide nutritional supplements as ordered for 3 of 7 residents (R1, R2, R7) for therapeutic diets in the sample of 7. Findings include: 1. R2's Physicians Orders documented a Diet Order, dated 9/12/23, for a Diabetic diet, thin liquids, with health shake (nutritional supplement) at all meals. On 9/27/23 at 10:25am, R2, who was alert and oriented, stated for some reason, for the past two days there has been a carton of nutritional supplement on her lunch tray. R2 stated she was unaware this had been added to her diet, and does not know when it was ordered. 2. R7's Physicians Orders documented a 5/23/23 diet order for fortified pudding at lunch and supper and a (trade name) nutritional shake at every meal. On 9/26/23 at 10:15am, R7 was in his room with his family member (V4). R7 was awake and alert, but nonverbal. V4 stated R7 has dementia, and V4 comes daily to feed R7 lunch. V4 stated R7 is to receive fortified pudding and a nutritional shake at lunch, but often he doesn't. 3. On 9/27/23 at 12:45pm, V11 (Speech Therapist) was observed assisting R1 with lunch. R1 was alert and oriented only to self. R1 was able to self-feed with some difficulty, as R1's upper extremities were very tremulous. This surveyor noted R1's Diet Card documented, (Nutritional Supplement) shakes at all meals. There was no shake on the tray, so V11 went to get one. On 9/28/23 at 10:15am, V2 (Director of Nurses) stated she has been employed at the facility for approximately one year, and in that time, there has been an ongoing problem with kitchen staff not putting supplements and fortified foods on resident trays, despite V2 periodically auditing diet cards and doing teaching with kitchen staff. V2 stated the facility does not document administration or acceptance of nutritional supplements and fortified foods. A Therapeutic Diets Policy, dated October 2017, documented, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure call lights were answered timely for 3 of 3 (R14, R27, and R66) residents reviewed for dignity in the sample of 31. Findings Include: 1. R66's face sheet, print date 12/21/22, documents R66 was admitted to the facility on [DATE], with diagnoses that include reduced mobility and osteoarthritis. R66's MDS (Minimum Data Set), dated 12/09/22, documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R66 is cognitively intact. This same MDS documents under Section G that R66 does not ambulate, requires assist of staff for dressing, showering, personal hygiene, and toileting. On 12/18/22 at 12:19 PM, R66 stated it took staff over an hour to answer the call light this morning (12/18/22) when he needed assistance going to the bathroom. When asked if he had reported it, R66 stated he had not, and asked this surveyor to see if V1 (Administrator) would come to his room. The facility Grievance/Concern Form, dated 12/18/22, documents, (R66) spoke with administrator (V1) this morning. (R66) stated he had his call light on. (V19, CNA/Certified Nursing Assistant) entered room and asked what he needed. (R66) said he needed to use sit to stand to urinate. (V19) stated that she had to run a bag of dirty linens to laundry. (V19) then turned off the call light and left. After approximately 10 minutes (V19) did not return (R66) used his call light again. After 5-10 minutes call light was answered by (V19) and (R66) stated that she immediately apologized because she forgot about him earlier. Under Resolution the Grievance/Concern Form documents, Administrator (V1) spoke with (V19) and she was very apologetic. (V19) realized she was wrong to turn off (R66's) call light before she was able to help him. (V19) received a verbal counseling admin spoke to (R66) and he was pleased that we dealt with this so quickly. On 12/21/22 at 10:56 AM, R66 stated V1(Administrator) had come and talked with him after this surveyor spoke with R66, and the facility has resolved the issue and he hasn't had any more concerns with his call light not being answered timely. 2. R27's face sheet, print date of 12/21/22, documents R27 was admitted to the facility on [DATE], with diagnoses that include neuropathy and diabetes. R27's MDS, dated [DATE], documents a BIMS score of 15, which indicates R27 is cognitively intact. This same MDS documents under Section G that R27 requires assistance with locomotion, dressing, toilet use, personal hygiene, and showers. On 12/18/22 at 11:11 AM, R27 stated certain CNA's come to her room when she has a call light on and turns it off. R27 stated the staff leave, and sometimes it takes them an hour to come back. R27 stated she had complained about this at resident council. On 12/21/22 at 2:20 PM, R27 stated last night (12/20/22), she was incontinent and needed to be changed, and it took an hour and a half for them to answer the call light. When asked if she had reported this to administration, R27 stated she had not, but she had told the nurse. The facility Resident Council meeting minutes, dated 8/15/22, documents, .Still some concerns about call lights not being answered timely. However wait time has been improving . There is no resolution attached to this resident council meeting. The facility Resident Council meeting minutes, dated 9/8/22, documents, .Seems that some staff take longer to answer call lights than others . There is no resolution attached to this resident council meeting. The facility Resident Council meeting minutes, dated 12/1/2022, documents .Nursing: Concerns about night shift taking extended amount of time answering call lights . The undated facility December Resident Council Resolution documents, Only concern was call lights not being answered timely on night shift. This will be addressed by Administration. Administrator and DON (Director of Nursing) will alternate doing night shift pop ins at least 3 times a week for 3 months to ensure this is improving. 3. R14's face sheet, print date 12/21/22, documents R14 was admitted to the facility on [DATE] with diagnoses that include heart failure and lymphedema. R14's MDS, dated [DATE], documents a BIMS score of 15, which indicates R14 is cognitively intact. This same MDS documents under Section G that R14 requires assist with locomotion, dressing, toilet use, personal hygiene, and showers. On 12/18/22 at 12:48 PM, R14 stated it takes up to a couple of hours for facility staff to answer her call light. When asked what happens when it takes them that long to answer it R14 stated, I poop and pee in the bed. On 12/21/22 at 2:50 PM, V1 (Administrator) and V2 (Director of Nursing) stated they would expect the facility staff to answer call lights timely and to not turn them off until the resident need has been met

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure interventions to prevent falls were implemented for 1 of 7 (R19) residents reviewed for falls in the sample of 31. Findings Include: R19's facility face sheet, with a print date of 12/21/22, documents R19 was admitted to the facility on [DATE], with diagnoses that include muscle weakness, heart disease, anemia, unsteadiness on feet, history of falling, and reduced mobility. R19's MDS (Minimum Data Set), dated 12/14/22, documents a BIMS (Brief Interview for Mental Status) score of 08, which indicates R19 has a moderate cognitive impairment. This same MDS documents under Section G that R19 requires assist with locomotion, dressing, and toilet use. R19's Care Plan documents a Category of Falls, with a start date of 11/27/2020, documents interventions that include, fall interventions: offer snacks, alarms, skid strips, dycem in chair, after meals take to room, grab bars, gripper socks, safety mat on floor, low bed, with a start date of 11/4/22. R19's undated Physician Order List documents under Special Requirements an order, with a start date of 12/19/22 of Fall interventions: offer snacks frequently, alarm in place, skid strips, dycem to chair, grab bar, gripper socks, mat on floor, low bed. R19's Resident Incident Reports document the following: 12/17/22-R19 slid from her bed to her floor; 10/16/22- R19 was found sitting in the floor by bed after attempting to transfer self to bed; 9/2/22- R19 was observed laying on floor in front of bed; and 9/3/22 R19 attempted to transfer self to bed and fell. All of these Resident Incident Reports document R19 did not sustain significant injury when she fell, and document interventions were implemented after each fall. On 12/21/22 at 12:50 PM, R19 was assisted to stand up out of her wheelchair by V17 (Licensed Practical Nurse) and V18 (Registered Nurse). V2 (Director of Nursing/DON) was also present in the room. There was no dycem observed in R19's wheelchair during this observation. V2 placed a dycem in R19's wheelchair before she sat back down. On 12/21/22 at 2:26 PM, V2 (DON) and V1 (Administrator) both stated R19 should have had dycem in her wheelchair seat during the observation on 12/21/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide diet supplements as ordered by the physician for 1 of 8 (R59) residents reviewed for nutrition in a sample of 31. Findings Include: R59's Current Face Sheet documents R59 is an [AGE] year old female, with an admission date of 01/20/22, and a with a weight of 86 pounds. Diagnosis include: Dementia, Covid-19, Peptic ulcer, Hypothyroidism, Hyperlipidemia, Insomnia, and Essential Hypertension. R59's Current Physician Order Sheet (December 2022) documents: Health Shakes three times a day, 8:00 AM, 12:00 PM, and 5:00 PM, with an order start date of 09/07/22. Fortified Drinks at all Meals, with an order start date of 09/07/22. Fortified Pudding at lunch, with an order start date of 03/22/22. R59's Dietary Note by V18 (Registered Dietician/RD) documents on 11/26/2022 at 7:22 AM, RD Skin Note Resident (R59) has stage 2 pressure ulcer to sacrum, improving, per wound report. Wt (weight) 86.7lb. BMI (body mass index) 18.12, underweight. Resident (R59) had recent fall with no injuries, per nursing note. No labs to review. Resident (R59) on regular diet with thin liquids, super cereal at breakfast, fortified pudding at lunch, fortified drink at all meals. Intake ranges 50-75%, good. No diet changes recommended as intake is good and wound is improving. RD to follow prn (pro re nata (as needed)). On 12/20/22 at 11:40 AM, R59 received her lunch. There was no Health Shake, Fortified Drink or Fortified Pudding with her lunch. R59's room was observed until 1:00 PM; there were no additional food or drinks brought to R59. On 12/20/22 at 1:10 PM, R59 was asked if she had pudding or a shake for lunch; she stated, no. On 12/20/22 at 1:20 PM, V4 (Certified Nurse Aide) stated R59 did not receive supplements today. They have been having problems with the kitchen staff sending the supplements over to the unit on the cart. On 12/21/22 at 11:30 AM, R59's lunch was observed. There was no Health Shake, Fortified Drink or Fortified Pudding with her lunch. R59's room was observed until 1:00 PM; there were no additional food or drinks brought to R59. On 12/21/22 at 2:30 PM, V1 (Administrator) stated they have had problems getting the supplements over to the dementia unit; they will re-educate again.