Based on observation, interviews and record review, facility failed to implement fall precautions to prevent falls with injuries. This applies to 2 out of 3 residents (R2, R3) reviewed for fall precautions.The findings include:1.On 8/19/25 at 10:25 AM, R2 was lying in bed. R2's left arm was in a bandage. R2 was alert with some confusion. Bed was at average height and not at its lowest position. There were no landing pads next to the bed. R2's call light was tied to the grab bar and was hanging downwards. R2 searched for her call light and stated she cannot find her call light. R2's table was towards the lower half of her body and she could not reach her cup of water. On 8/19/25 at 10:40 AM V6 (LPN-Licensed Practical Nurse) verified R2's bed was not in the lowest position and her call-light was out of her reach. On 8/19/25 at 11:30 AM V10 (CNA- Certified Nursing Assistant) observed and stated R2's water was out of her reach and bed was not in lowest position. On 8/20/25 at 8:45 AM, R2 was lying in bed. R2's bed was at average height and not at the lowest level. R2's call light was under her upper back. R2 stated she is not able to find her call light and stated the call light should have been where she can reach for it.On 8/20/25 at 10:00 AM, V13 (PTA-Physical Therapy Assistant) and V4 (Director of Rehab) stated R2 need two people to transfer from bed to wheelchair and R2 can move her legs out of the bed, not her upper body. V13 and V4 stated it is recommended for R2 to have her bed in lowest position and have call lights within reach. R2's 6/9/25 fall risk evaluation showed a score of 19 with a scale that showed a score of 10 or higher means at high risk for falls. R2's care-plan dated 7/25/25 showed to ensure R2's personal items and call light were within reach and to use her call light when assistance is needed. R2's care-plan showed R2 had falls in the facility on 11/15/24, 12/21/24, 6/3/25 and 7/5/25. On 8/19/25 at 2:42 PM V3 (Restorative Nurse) stated one of the post fall interventions for R2 was to keep bed at lowest position. On 8/20/25 at 10:10 AM, V5 (NP - Nurse Practitioner) stated R2 had the potential to fall again as R2 does not follow the nursing instructions. V5 stated R2 must have her call light within reach, her bed in the lowest position, and have landing pads to minimize injuries. 2.On 8/20/25 at 9:27 AM, R3 was sitting on her bed with her feet on the floor on the left side of the bed. R3 stated she wanted to use the bathroom and then go to the dining room for breakfast and needed to call for help, but her call light is out of her reach. R3's call light was tied to the grab bar on the right side of the bed and hanging to the floor. V9 (CNA) verified R3's call light was out of her reach.On 8/19/25 at 9:50 AM, V8 (RN-Registered Nurse) and V12 (RN) stated fall precautions include keeping bed at lowest position, having the call light and other personal items near resident, and frequent monitoring/rounding.On 8/19/25 at 10:40 AM V6 (LPN-Licensed Practical Nurse) stated anyone with history of previous falls must have their beds in the lowest position and their call lights within their reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R117 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis due to cerebral infarction affecting the right dominant side, chronic obstructive pulmonary disease, essential hypertension, and dysphagia. R117's physician order summary showed an order initiated on November 5, 2024, apply R hand splint ON 9 AM and OFF PM. Check for integrity. continue to re-direct and motivate resident to participate in PROM and splint application. Monitor for pain. R117 was observed on December 16, 2024, at 10:50 AM, lying in bed. R117 was not wearing a right hand splint. R117 was not able to answer questions and only responded by opening her eyes. On December 17, 2024, at 11:42 AM, R117 was observed sitting in the dining room in a reclining wheelchair, not wearing a splint on her right hand. V5 (LPN MDS Coordinator) observed R117, and stated at 11:52 AM, R117 was not wearing a splint on her right hand. At 12:12 PM, V7 (CNA ) stated she had gotten R117 dressed and transferred her to the reclining wheelchair around 9:00 AM that morning and forgot to put on R117's right hand splint. The Facility's policy titled Application of splints or braces , dated November 2015, showed Policy: Adaptive devices will be used as ordered by the physician to prevent deformities or further contractures or to maintain an alignment on a limb or extremity .2. The splints or braces shall be applied according to physician's orders. Based on observation, interview, and record review, the facility failed to assess and treat a resident with a contracture of the left hand and failed to apply a splint in accordance with physician orders. This applies to 2 of 6 residents (R117 and R160) reviewed for range of motion in the sample of 35. Findings include: 1. R160's face sheet showed him to be a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Dominant side, Dysphagia, Anxiety Disorder, Seizures, and Dementia with Moderate Agitation. R160's Minimum Data Set (MDS) section C dated November 12, 2024 showed R160 to be severely cognitively impaired. The same MDS section GG showed R160 to be dependent or require substantial/maximal assistance for self-care activities. On December 16, 2024 at 10:14 AM, R160's left hand was contracted closed,with fingers touching the palm, and no splint or positioning device was in his hand. On December 17, 2024 at 1:49 PM, while V4 (Certified Nursing Assistant/CNA) and V25 (CNA) were providing care and R160 left hand remained without a positioning device or splint. On December 17, 2024 at 3:00 PM, V22 (Restorative Nurse) stated that she was not aware that R160 had any contractures, but she would assess him and have occupational therapy assess him also. V22 stated that R160 does not wear any kind of splint. On December 18, 2024 at about 9:20 AM, V22 stated that her assessment showed that R160 could benefit from a splint. On December 18, 2024 at 11:30 AM, V26 (CNA) and V23 (Licensed Practical Nurse/LPN) attempted to open R160's left contracted hand and R160 screamed in pain. On December 18, 2024 at 12:49 PM, V27 (Occupational Therapist) stated that she assessed R160 this morning because the staff was concerned with changes to his left arm. V27 stated that R160's left hand 3rd and 4th fingers Interphalangeal (IP) joints were contracted. V27 stated she recommended that R160 have a resting hand splint and occupational therapy. V27 stated, the resting hand splint was the best option for R160 because it would leave his hand in a neutral position, will not cause him to clamp down, and will prevent more deterioration. R160's Occupational Therapy Evaluation & Plan of treatment dated December 18, 2024, showed the following: Assessment Summary: Clinical impression/Reason for Skilled Services: Patient currently presents for skilled Occupational Therapy with changes to the proximal interphalangeal (PIP) joint and the distal interphalangeal (DIP) joints of digits 3 and 4 on the left hand, as well as mild changes in the metacarpophalangeal (MP) Joints (The knuckles) of all left digits. Patient will benefit from skilled (OT) to address range of motion, hand pain/stiffness, and possible splinting needs. Recommend splinting trials and range of motion with skilled OT.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R42's face sheet included diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified dementia, unspecified severity, with other behavioral disturbance, dysphagia, oropharyngeal phase, anorexia, unspecified protein-calorie malnutrition. R42's quarterly MDS (minimum data set) dated November 27, 2024 showed that R42 was moderately impaired in cognition. R42's diet order on Physician's order summary included mechanical soft texture, regular/thin consistency, no rice/beans, feeding assist alternate consistencies, small bites/sips, no straw. On December 16, 2024 at 12:34 PM, R42 was propped up in bed at around 45 degree angle and received a lunch tray set up on a bedside table. Set up for lunch meal was provided by V8 CNA (Certified Nursing Assistant) and V8 left the room. V8 stated that R42 is resistive to feeding assistance. R42 was observed attempting to eat some of the ground meat and dessert with her left hand that was unsteady. R42's right hand appeared contracted. R42's meal ticket showed mechanical soft diet, feeding assist, alternate consistencies, small bites/sips, and no straw. On December 17, 2024 at 11:11 AM, R42 was propped up in bed with bedside tray with disposable cup (4 oz/ounce) of water with a straw in the cup. V8 stated that she gave R42 the water and put the straw in the cup. On December 17, 2024 at 12:43 PM, R42 was propped up in bed at around 45 degree angle and was attempting to eat lunch that was placed in front of her on a bedside table. R42 also had the disposable cup (4 oz) of water with a straw in it. No staff was present in the room. R42's meal ticket showed mechanical soft diet, feeding assist alternate consistencies, small bites/sips, no straw. R42 was seen eating some of the bread and then sucked up all of the dessert directly from the bowl with her mouth. V10 (Licensed Practical Nurse) who was in the hallway was notified of the directions listed on the meal ticket. R42's care plan initiated June 7, 2021 included that R42 has a swallowing problem related to swallowing assessment results secondary to diagnoses of dysphagia. Interventions for the same included alternate small bites and sips. Use a teaspoon for eating. Do not use straws. On December 18, 2024 at 12:16 PM, V16 (Speech Language Pathologist) stated that she last saw R42 in March, 2022 and at the time of discharge she recommended mechanical soft /ground meat, thin liquids, small sips, small bites and to alternate consistencies during meals. V16 stated that she recommended direct supervision at meals for safety of intake and carryover of swallow strategies and also for encouragement of oral intake. V16 also added that direct supervision is beneficial as R42 has Dementia and needs cueing and has also has tremors related to Parkinson's. V16's discharge progress notes dated March 11, 2022 included as follows: Recommendations discussed with patient/staff include mechanical soft/thin diet with aspiration precautions (upright for meals, slow rate, small bites, alternating consistence's, tray set up, offer alternate food options. The same summary also included direct supervision during meals to encourage intake. Based on observation, interview, and record review, the facility failed to provide safe transfer and feeding supervision to residents who required assistance for activities of daily living care. This applies to 3 of 4 residents (R24, R42, R58) reviewed for safety during ADL assistance in the sample of 35. The findings include: 1. Face sheet shows R58 is 84 years-old who has multiple diagnoses which include displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing, Parkinson's disease, unspecified fall, reduced mobility, needs for assistance with personal care. On December 17, 2024, at 4:35 PM, V18 (Certified Nursing Assistant/CNA) assisted R58 to the bathroom. V18 propelled R58 to the bathroom, R58 held onto the grab bar as she was standing up unsteadily while V18 supported her by holding on to the waistband of her pants. After R58 completed toileting, R58 stood up while V18 cleaned her perineum, and was assisted back to the wheelchair without use of a gait belt. R58's care plan with initiated date of May 2022 showed R58 has an ADL self-care performance deficit related to weakness and current medical condition which include radiculopathy of lumbar region, disorder of muscle, and Parkinson's disease. This same care plan shows R58 requires extensive assistance by two staffs to move between surfaces and as necessary. Use of gait belt by all staff whenever transferring. R58's fall assessment dated [DATE], showed R58 was at risk for fall. 2. Face sheet shows R24 is 92 years-old who had multiple medical diagnoses which include morbid obesity, Alzheimer's disease, abnormalities of gait and mobility, lack of coordination, and need for assistance with personal care. On December 18, 2024, at 10:23 AM, V17 (CNA) assisted R24 to the toilet. R24 was assisted to stand up and transfer from wheelchair to the toilet without a gait belt. After R24 used the toilet, she stood up and held on to the grab bar, while V17 provided peri-care, and was assisted back to the wheelchair without the use of gait belt. R24's active ADL care plan shows R24 has an ADL self-care performance deficit related to weakness and current medical condition including dementia, morbid obesity, and osteoarthritis. This same care plan shows R24 requires extensive assistance by two staffs to move between surfaces and the use of gait belt at all times especially during transfers and repositioning. R24's fall assessment October 15, 2024, shows R24 scored 13 which means she was at risk for fall. On December 18, 2024, at 4:10 PM, V2 (Director of Nursing/DON) stated the standard of practice for transferring resident who can stand up is for staff to apply gait belt to resident who requires assistance to ensure safety. Policy Statement Residents in the facility will be transferred safely from one location to another using the proper transfer technique.

Based on observations, interview and record review, the facility failed to provide double protein portion as ordered by the physician. This applies to 2 of 2 residents (R95 and R168) observed for dining in the sample of 35. The findings include: 1. On December 17, 2024 at 12:05 PM, during tray line service on the 4th floor, V12 (Dietary Aide) was platting the food and V13 (Dietary Manager) was checking meal trays. R168's meal ticket showed regular consistency, double protein and he received one serving portion (2 oz (ounces) with #16 scoop) of mechanical soft polish sausage and V13 was notified of the same. R168's diet order on POS (Physician Order Summary) showed LCS (Low Concentrated Sweets) diet, Regular texture, Regular/Thin consistency, double protein at lunch. R168's care plan initiated March 6, 2024 included that R168 requires a therapeutic diet and interventions included to provide ordered therapeutic diet. 2. On December 17, 2024 at 12:22 PM, R95 received one serving portion (2 oz with #16 scoop) of mechanical soft polish sausage. The facility diet order listing showed double protein at lunch for R95. When V13 was asked, why R95 only received one portion, V13 stated that the meal ticket only shows one portion of the same. V13 was notified at a later time that the diet order on POS shows double protein at lunch, and V13 responded that he will update the meal ticket. R95's diet order on POS showed LCS diet, Mechanical Soft texture, Regular/Thin consistency, double protein at lunch. R95's care plan revised January 22, 2024, included that R95 has nutritional problem or potential nutritional problem of weight changes related to disease process of Depression, Bipolar disorder, Dementia, Anxiety disorder. Intervention included to serve diet as ordered. On December 18, 2024 at 12:41 PM, V15 (Dietitian) stated that she recommended double protein for R168 related to his request for the same as a food preference. V15 added that R95 was recommended double protein for lunch as he has had a history of weight loss. Diet spreadsheet for lunch (week 4 Tuesday) included kielbasa [polish sausage] (1 portion=2 oz/ounce protein). The same spreadsheet also included portion serving size of 2 oz protein +1 oz broth of ground kielbasa for mechanical soft diet. Facility serving scoop equivalent chart showed that #16=2 oz portion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to offer residents the pneumococcal vaccine. This applies to 3 of 5 residents (R63, R79, and R118) reviewed for immunization in the sample of 35. The findings include: 1. The EMR (Electronic Medical Record) showed R63 was admitted to the facility on [DATE], with multiple diagnoses including dementia, Alzheimer's disease, chronic bronchitis, chronic obstructive pulmonary disease, and hypertension. On December 17, 2024, at 2:26 PM, V3 (Infection Preventionist Nurse) said the facility offers the PCV20 (20-valent Pneumococcal Conjugate Vaccine) to eligible residents. V3 continued to say R63 had only received the PCV13 (13-valent Pneumococcal Conjugate Vaccine) and had not been offered the PCV20. V3 said R63 should had already been offered the vaccine. R63's Immunization Audit Report dated December 17, 2024, at 2:50 PM, showed R63 received the PCV13 on March 19, 2022. The report did not show R63 had been offered or refused another pneumococcal vaccine. As of December 17, 2024, at 2:50 PM, the facility does not have documentation to show R63 was offered an additional pneumococcal vaccine. 2. The EMR showed R79 was admitted to the facility on [DATE], with multiple diagnoses including chronic atrial fibrillation, chronic obstructive pulmonary disease, asthma, and hypertension. On December 17, 2024, at 2:26 PM, V3 said R79 received the PCV13 on March 29, 2022. V3 continued to say R79 had not been offered the PCV20. V3 said R79 should had already been offered the PCV20. R79's Immunization Audit Report dated December 17, 2024, at 2:56 PM, showed R79 received the PCV13 on March 29, 2022. The report did not show R79 had been offered or refused another pneumococcal vaccine. As of December 17, 2024, at 2:56 PM, the facility does not have documentation to show R79 was offered an additional pneumococcal vaccine. 3. The EMR showed R118 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, chronic kidney disease, and peripheral vascular disease. December 17, 2024, at 2:26 PM, V3 said R118 received two PCV13, one in 2018 and a second in 2019. V3 said R118 should had been offered the PCV20. R118's Immunization Audit Report dated December 17, 2024, at 2:54 PM, showed R118 received the PCV13 on October 12, 2019. The report did not show R118 had been offered or refused the PCV20. As of December 17, 2024, at 2:54 PM, the facility does not documentation to show R118 was offered or refused the PCV20. On December 17, 2024, at 2:26 PM, V3 said the facility follows CDC (Centers for Disease Control and Prevention) guidelines for pneumococcal vaccine timing. The CDC's Pneumococcal Vaccine Timing for Adults dated October 2024, showed adults [AGE] years of age or older who have only received the PCV13 should receive the PCV20 after one year of receiving the PCV13. The facility's policy titled Pneumococcal Vaccine revised November 2017, showed Policy Statement: Residents in the facility will be offered a pneumococcal vaccine to air in preventing pneumococcal infections. Policy Interpretation and Implementation: .6. Administration of the pneumococcal vaccine or re-vaccinations will be made by current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide incontinence care, oral care, and grooming to residents who depend on the facility for care. The facility also failed to shave female and male resident's long facial hair and trim and clean resident's long fingernails. This applies to 13 of 13 residents (R16, R21, R42, R61, R77, R80, R106, R115, R134, R160, R167, R190, R199) reviewed for ADL (Activities of Daily Living) in the sample of 35. The findings include: 1. R160's face sheet showed him to be a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Dominant side, Dysphagia, Anxiety Disorder, Seizures, and Dementia with Moderate Agitation. R160's Minimum Data Set (MDS) section C dated November 12, 2024 showed R160 to be severely cognitively impaired. The same MDS section GG showed R160 to be dependent or require substantial/maximal assistance for self-care activities. On December 16, 2024 at 10:14 AM, R160 was lying in his room and his finger nails were long and there was a black substance under the nails. On December 17, 2024 at 1:49 PM, V4 (CNA) and V25 (CNA) came in to perform incontinence care for R160. R160's incontinence brief was visibly soiled from the front. When V4 opened R160's incontinence brief, it was heavily saturated with urine soiled from mid front and went all the way up his back. Under the brief there was a yellow pad that had a brown ring around the wetness on the pad. R160 had stool that was dry, pasty and stuck to resident's inter-gluteal cleft and buttocks, because of this, V4 had to use almost a full pack of large wipes to clean R160. The fitted sheet that was underneath the yellow pad, was also wet with brown tinged urine. When V4 removed the socks, there was a copious amount dead skin that fell onto R160's bed. R160's feet were extremely dry, scaly and flaky. R160's finger nails were still overgrown, with black substance under his nails. R160's skin care plan shows the following: Keep skin clean and dry. May apply lotion or moisturizer cream as part of daily skin care. 2. R61 Face Sheet documents a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Parkinson Disease, Encounter for Attention to Gastrostomy, Dysphagia, Congestive Heart Failure, and Dementia. Minimum Data Set (MDS) section C dated October 22, 2024 showed R61 to be severely cognitively impaired. The same MDS section GG showed R61 to be dependent or require substantial/maximal assistance for self-care activities. On December 16, 2024 at 10:47 AM, R61 was sitting in the dining room and has long facial hair above her upper lip and at the corners of her mouth. R61's finger nails were long with brown substance underneath the nails. On December 17, 2024 at 1:30 PM and 1:45 PM R61, was sitting in the dining room displaying curly facial hair on the upper lip and below her lower lip. R61 also had long fingernails with chipped nail polish and black brown substance underneath her nails. 5. R16's face sheet included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, arthropathy. R16's quarterly MDS dated [DATE] showed that R16 had impairment on both sides for range of motion on upper extremities and was dependent on staff for personal hygiene. On December 16, 2024 at 10:52 AM, R16 was lying in bed sleeping and both of her arms appeared deformed with very dry skin. R16 had both hands with fingers formed into fists and therefore the finger nails were not visible. V8 CNA (Certified Nursing Assistant), who was in the vicinity, stated that R16 is dependent on staff for ADLs. On December 17, 2024 at 9:23 AM, R16 was lying in bed with arms tucked under the blankets and was unable to respond coherently to queries. V6 (Restorative CNA) who was in the room assisting R16's roommate was requested to remove the blanket from R16's arms. R16's fingers on both hands were curled into fists and on opening them by V6, it was noted that R16's right hand and left hand pinky and middle fingers had very long and hardened finger nails that were curled in. R16's care plan initiated on October 19, 2021 showed that R16 has an ADL self-care performance deficit related to weakness secondary to above stated diagnoses. The care plan intervention for personal hygiene included that the resident requires (extensive assistance) by (1) staff with personal hygiene. 6. R42's face sheet included diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified dementia, unspecified severity, with other behavioral disturbance, dysphagia, oropharyngeal phase, anorexia, unspecified protein-calorie malnutrition. R42's quarterly MDS dated [DATE] showed that R42 was moderately impaired in cognition for decision making and dependent on staff for oral hygiene and personal hygiene. On December 16, 2024 at 10:30 AM, R42 was propped up in bed and did not respond to queries but only smiled. R42's upper teeth that were visible were coated with extensive debris. R42's CNA (V8) stated that she provides cup and water set up only to R42 to brush her teeth and that R42 does not brush her teeth properly. R42's thumb nail on left hand was very long (about 1/2 inch) with blackish substance underneath. R42's right hand was contracted and holding paper towels that were crumpled up. On request R42's right hand fingers were opened by V9 (LPN, Licensed Practical Nurse) and R42's middle finger nail on right hand was also very long with blackish substance underneath. V8 and V9 were notified that R42's nails need to be trimmed. On December 17, 2024 at 9:25 AM, R42 was propped up in bed. R42's teeth remained with extensive debris built up and R42's middle finger nail on right hand and thumb nail on left hand remained long with blackish substance underneath. V8 was notified again about the observations. R42's care plan revised March 12, 2024 included that R42 has ADL self care performance deficit related to weakness with interventions showing that R42 requires extensive assistance by one staff for personal hygiene and oral care. R42's care plan initiated June 7, 2021 also included to check mouth after meal for pocketed food and debris and report to nurse and to provide oral care to remove debris. 7. R134's face sheet included diagnoses of primary generalized (osteo)arthritis, adult failure to thrive, dorsalgia, gastro-esophageal reflux disease without esophagitis. R134's admission MDS dated [DATE] showed that R134 is moderately impaired in cognition and is dependent on staff for personal hygiene. On December 16, 2024 at 12:05 PM, R134 was seated in dining room for lunch meal and noted to have several very long chin hairs and stated that she would like it removed. On December 16, 2024 at 1:57 PM, R134 was seated in common activity room on first floor and the long chin hairs remained on her chin. This was relayed to V2 (Director of Nursing) who stated that the CNAs are supposed to provide grooming assistance per request or as needed. R134's care plan initiated November 1, 2024 included that R134 has an ADL self-care performance deficit related to activity Intolerance. 8. R199's face sheet included diagnoses of cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery, difficulty in walking, not elsewhere classified, need for assistance with personal care, other reduced mobility. On December 16 2024 at 10:37 AM, R199 lying in bed with hair and beard overgrown, and finger nails very long with blackish substance underneath. R199 stated that that he returned to facility in October, 2024. R199 stated that he wanted his hair cut and beard and nails trimmed and did not know if the facility offers these services. R199 remarked My hair is usually not this long. My nails are longer than I have ever had. On December 17 2024 at 9:21 AM, R199 was lying in bed and his hair, beard and nails remained long and this was relayed to V9 (LPN) who stated that R199 needs assistance with ADL care. R199's care plan revised on October 1, 2024 included that R199 has ADL self-care performance deficit related to above listed diagnoses with a goal that ADL needs will be met on a daily basis until next review. 3. Face sheet shows that R21 is 79 years-old who has multiple medical diagnoses which include dementia, lack of coordination, and need for assistance for personal care. MDS (Minimum Data Set) dated November 6, 2024, shows that R21 is totally dependent on staff for dressing, and grooming and hygiene. On December 16, 2024, at 10:54 AM, R21 was sitting in the dining room along with other residents. R21 was unkempt and disheveled. His clothes have flaky substances all over from his top down to his pants, he displayed overgrown fingernails with black/brown substances underneath, his nail beds have yellowish/brownish discoloration, hair was uncombed, unkept overgrown mustache and beards, and he had overgrown hairs in the ears and nostrils which was sticking out. R21's ADL (activities of daily living) care plan with revision date of March 25, 2024, showed R21 had an ADL self-care performance deficit related to diagnoses which include Vascular Dementia. The goal was to meet R21's ADL daily. This same care plan shows R21 is totally dependent on staff for dressing, and to check nail length, trim, and clean on bath day and as necessary, 4. Face sheet shows that R190 is 94 years-old who has medical diagnoses which include Alzheimer's disease. MDS October 18, 2024, shows R190 requires maximum assistance with grooming/hygiene. On December 17, 2024, at 4:45 PM, R190 was sitting in the dining room displaying facial hair and long fingernails which has chipped nail polish and black/brown substance underneath the nails. R190 touched her face and felt her long facial hair on the upper lip and chin, then she looked at her fingernails. R190 stated that she would like her facial hair shaven, and fingernails clipped. 9. Face sheet, dated December 2024, shows R77, a [AGE] year-old female resident with diagnoses that includes bipolar disorder, psychoses, Alzheimer's disease, arteriosclerotic heart disease, dementia, osteoarthritis, and right wrist drop. R77 was admitted to the facility on [DATE]. MDS (Minimum Data Set), dated October 24,2024 shows R77's cognition was severely impaired and required extensive to substantial assistance from staff for personal hygiene/grooming. R77's care plan dated October 24,2024 showed R77 was dependent on staff for assistance with ADLs. On December 16,2024 at 11:00 A.M., R77 was in the dining room on the third floor designated Memory Unit. R77 was attending recreational activity. R77 was observed with long chin hair approximately 2 inch long. R77 was also had long, jagged fingernails with black substance under the nails. During this time, V21 (Memory Care Coordinator) was present and said that the residents in the designated Memory Care Unit were low functioning residents and their cognition were severely impaired. At 12:30 P.M., R77 was still in the same dining room, eating her lunch. R77's hygiene and grooming were remained the same with long soiled nails and long chin hair. V20 (RN/Registered Nurse) was present during this observation. On December 17,2024 at 12:20 P.M., R77 was in the memory unit dining groom eating her lunch. R77's hygiene and grooming were not maintained, with long soiled jagged nails, and an unkempt chin hair. V20 (RN/Registered Nurse) was again present during this observation and was R77's assigned nurse. 10. Face sheet, dated December 2024, shows R80, a [AGE] year-old female resident with diagnoses that includes type 2 diabetes mellitus, dementia, heart disease, chronic kidney disease, bipolar disorder and major depressive disorder. R80 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R80's cognition was moderately impaired, and she required substantial/maximum assistance from staff for ADLs including hygiene and grooming. The care plan dated December 3,2024 shows that R80 was dependent on staff for assistance with ADLs. The POS (Physician Order Sheet) for the month of December 2024 shows Special Instructions: **Extensive assistance - one+ person physical. On December 16, at 10:50 A.M., R80 was in the dining room on the third floor designated Memory Unit. R80 was attending recreational activity. R80 was observed with long chin hair approximately 2 inch long. R80 was also had long, jagged fingernails. V20, the assigned nurse for R80 said that R80 was a total care for all ADLs. On December 17,2024 at 1:04 P.M., R80 was in the dining room on the third floor designated Memory Unit. R80 was eating her lunch. R80's personal hygiene remained unkempt, with long jagged fingernails, black substance under nail bed and chin hair that was unbecoming for a female resident. V20, was present during this observation. 11. The Face Sheet for the month of December 2024 show that R106, a [AGE] year-old female resident with diagnoses that includes dementia, Alzheimer's disease, major depressive and anxiety disorder. R106 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R106's cognition was severely impaired and required maximum/dependent on staff for assistance with ADLs. The care plan dated March 19, 2024 showed R106 be aided with ADLs. On December 16, at 1:34 P.M., R106 was in the dining room on the third floor designated Memory Unit. R106 was eating her lunch. R106 was observed with long chin hair approximately 2 inch long. R106 was also had long, jagged fingernails V20, the assigned nurse for R106 said R106 was a total care for all ADLs. On December 17,2024 at 1:10 P.M., R106 was in the dining room on the third floor designated Memory Unit. R106 was eating her lunch. R106's personal hygiene remained unkempt, with long jagged fingernails, black substance under nail beds and chin hair that was unbecoming for a female resident. V20, was present during this observation. 12. The Face Sheet for the month of December 2024 shows that R115, an [AGE] year-old female resident with diagnoses that includes Alzheimer's disease, schizophrenia and hypothyroidism. R115 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R115's cognition was severely impaired and required maximum/dependent on staff for assistance with ADLs. The care plan dated November 22, 2024 showed R115 be aided with ADLs. The POS for the month of December 2024 Special Instructions: POS *Extensive assistance - one+ person physical assist* On December 16,2024 at 12:30 P.M., R115 was in the dining room on the third floor designated Memory Unit. R115 was eating her lunch. R115 was observed with long chin hair approximately 2 inch long. R115 was also observe with long, jagged fingernails V20, the assigned nurse for R115 had said that R115 was a total care for all ADLs. On December 17,2024 at 1:15 P.M. R115 was in the dining room on the third floor designated Memory Unit. R115 was eating her lunch. R115's personal hygiene remained unkempt, with long jagged fingernails, black substance under the nails and chin hair that was unbecoming for a female resident. V20, was present during this observation. 13. The Face Sheet for the month of December 2024 shows that R167, a [AGE] year-old female resident with diagnoses that includes multiple sclerosis, dementia, obstructive hydrocephalus, urinary tract infection, anxiety disorder, depression, psychosis and type 2 diabetes mellitus. R167 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R167's cognition was severely impaired and required maximum/dependent on staff for assistance with ADLs. The care plan dated November 8, 2024 showed R167 needed help with ADLs. The POS for the month of December 2024 Special Instructions: POS *Extensive assistance - one+ person physical assist* On December 16,2024 at 12:40 P.M. R167 was in the dining room on the third floor designated Memory Unit. R167 was eating her lunch. R167 was observed with long chin hair approximately 2 inch long. R167 was also observed with long, jagged fingernails V20, said R167 was a total care for all ADLs. On December 17,2024 at 12:42 P.M., R167 was in the dining room on the third floor designated Memory Unit. R167 was eating her lunch. R167 hygiene and grooming remained unkempt. R167 was touching her food with her bare hands and her fingernails were long, jagged and black substance under nail bed. On December 18, 2024, at 3:46 PM, V2 (Director of Nursing/DON) stated the facility's practice is to ensure that residents are well groomed. Hygiene is provided including nail, facial hair, and incontinence care. Ensure that residents are wearing appropriate, comfortable, and clean clothing. The facility's policies for ADLs were as follows: -Care of Fingernails/Toenails: dated October 2010 shows: Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin -Shaving the Resident: dated October 2010: Purpose The purpose of this procedure is to promote cleanliness and to provide skin care. -Urinary Continence and Incontinence date March 2020: Policy Statement: The staff and practitioner will identify and manage individuals with urinary continence or incontinence. .6. The staff is to assist the resident with his or her toileting needs at least every 2 hours and as needed. Assistance may include but is not limited to checking and changing if incontinent or assisting the resident to the toilet as needed .9. If the individual requires assistance from more than one person to transfer to the toilet, the staff will address his or her mobility problems before attempting a toileting assistance trial. 10. Incontinence care should be individualized at night to maintain comfort and skin integrity and minimize sleep disruption. 11. Prompted voiding is not helpful at night (e.g., between the hours of 10 p.m. and 5 a.m.) and has been shown to disrupt sleep. 12. If the resident is incontinent, provide incontinent care or check and change the resident at least every 2 hours and PRN. 13. If the resident does not respond and does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their name, staff will use a check and change strategy. 14. A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments.

Based on observation, interview, and record review, the facility failed to label and date medication to determine the expiration date once it was opened and failed to ensure narcotic medications were accounted for. This applies to 9 of 11 residents (R4, R11, R18, R36, R38, R89, R90, R134, R136) reviewed for medication storage and labeling in the sample of 35. The findings include: On December 18, 2024, inspections of 6 of the facility's 11 medication carts and 2 of their 3 medication rooms were conducted with each of the assigned staff nurses (V10, V11, V24, V29, V31, V32). The following was observed: 1. On December 18, 2024, at 1:26 PM, there was a Basaglar Kwik Pen (insulin solution) in the 4th floor center 1 medication cart that was unlabeled, opened, and not dated. The pharmacy recommendation shows to discard this medication 28 days after it was opened. R4's Lorazepam (antianxiety) 1 milligram (mg) tablet card/container had a seal broken and taped over for number 30. In addition, there were three water cannister or tumblers stored inside this medication cart. V29 stated that all three belonged to her. 2. On December 18, 2024, at 1:35 PM, the narcotic medications on the 4th floor East medication cart were counted with V10. R136's Lorazepam 0.5 mg tablet showed there were 16 tablets in the bingo card/container. However, it was documented on the narcotic log/sheet that there were 17 tablets remaining. R36's Hydrocodone/APAP (pain medication) 5-325 mg showed 14 tablets, but the documented narcotic sheet showed 15 tablets. R38's Alprazolam (antianxiety) 0.5 mg tablets showed 18 tablets, the documented narcotic sheet showed 20 tablets remaining. R89's Lorazepam 1 mg tablet, showed 10 tablets, the documented narcotic sheet showed 11 tablets remaining. R134's Hydrocodone/APAP 10-325 mg showed 13 tablets, the documented narcotic sheet showed 14 tablets remaining. R18's Hydrocodone/APAP 5-325 mg showed 7 tablets, the documented narcotic sheet showed 8 tablets remaining. On December 18, 2024, at 1:59 PM V28 (Assistant Director of Nursing/ADON) stated the moment the staff administer the narcotic medication to the resident, the staff must sign it out on the narcotic sheet to have accurate count and ensure that it was given. 3. On December 18, 2024, at 2:08 PM, the 3rd floor medication room was inspected with V30 (Nurse). R90's Ozempic 2mg/3 ml was stored in the refrigerator, it was opened and not dated. The pharmacy recommendation shows to discard this medication 56 days after it was opened. 4. On December 18, 2024, at 2:24 PM, the narcotic medications on the 2nd floor [NAME] medication cart were counted with V31. R11's Hydrocodone/APAP 5-325 mg showed 18 tablets, but narcotic sheet/log shows 19 tablets remaining. 5. December 18, 2024, at 2:45 PM, the 2nd floor East medication cart as checked with V11. There was a vial of Insulin Lispro that was unlabeled, opened and not dated. The pharmacy recommendation shows to discard this medication 28 days after it was opened. On December 18, 2024, at 3:40 PM, V2 (Director of Nursing/DON) stated that it is the facility's practice to document on the narcotic sheet/log to ensure accuracy of dispensing and administration of the narcotic medication. V2 added, that it is also the facility's practice to ensure all medications mentioned above are labeled and stored to ensure that potency and expiration date of the medications are monitored. V2 also stated Staff's personal belongings should not be stored in the medication cart. The facility's policy and procedure for Storage of Medication dated March 2020, shows: Policy Statement: The facility shall store all drugs and biologicals safely, securely, and orderly. 6. Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use and shall be stored separately from regular medications. Medications that are in bottles, vials, and pens should be dated when opened and discarded according to the manufacturer's guidelines.

Based on observation, interview, and record review, the facility failed to follow their Water Management Program, failed to follow their policy for PPE (Personal Protective Equipment) during care of a resident in contact isolation, and failed to follow their policy for hand hygiene and glove use during provisions of care. This applies to all 206 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated December 16, 2024, by V1 (Administrator) showed there were 206 residents residing in the facility. On December 17, 2024, at 8:57 AM, V14 (Maintenance Director) said for the facility's Water Management Program for legionella, the facility receives a yearly water report from the village. V14 continued to say a monthly water quality test is performed with a TDS (Total Dissolved Solids) probe. V14 said sometimes while performing the monthly TDS test, he does a chemical test of the water but V14 does not document those test results. V14 said the facility submitted water samples for testing for legionella on December 4, 2024. V14 said the facility does not have documentation to show any legionella testing was performed prior to December 4, 2024. V14 said housekeeping flushes the water in resident rooms on a weekly basis. The instruction manual for the facility's TDS probe showed TDS is short for Total Dissolved Solids. TDS is not a measure of harmful substances or pollutants. It is simply a measure of all substances dissolved in water. Purified water has a TDS of 0 to 1 PPM (Parts Per Million). The ocean has a TDS of over 10,000 PPM. Neither water sources are harmful. TDS is a good tool for monitoring the general quality of a known source of water . 4. TDS and Tap Water: a high TDS of tap water usually indicated a high level of calcium and magnesium (hard water) and other salts. This water is probably corrosive to plumbing fixtures, pipes and appliances, the water may taste bad too. Due to high mineral content, a professional water treatment company will be able to advise you on specific actions to take to correct the situation. The United States Environmental Protection Agency sets the standards for drinking water in the United States. The maximum TDS in drinking water is 500 PPM . The manual does not show the TDS probe can test for chlorine levels. On December 17, 2024, at 2:46 PM, V1 said the facility's Water Management Program's attachment number three cannot be located. V1 continued to say V14 should be following the control measures that are listed in the facility's Water Management Program. The facility's Water Management Program dated 10/18 showed Policy: The facility will implement the Water Management Program to reduce the risk for Legionnaire's disease associated with the building water system and devices, reduce the growth and spread of Legionella bacteria in the facility to identify areas or devices in the facility where Legionella might grow or spread to people so that the facility can reduce that risk . Procedure: 1. The Water Management Program Team: a. The following but not limited to are the members of the Water Management Program Team: i. Owner of the building; ii. Building Manager/Director of Environmental Services; iii. Administrator; iv. Assistant Administrator; v. Medical Director; vi. Infectious Disease Specialist/Physician; vii. Director of Nursing; viii. Assistant Director of Nursing; ix. Interdisciplinary Team of the facility representative; x. Contractors/consultants; xi. State and local health officials; xii. Representative from the Governing Body. b. The following but not limited to are the duties of the Water management team: i. Oversee the program. ii. Identify control locations and control limits. iii. Communicate regularly about the program. iv. Monitor and document the performance of the program. v. Identify and take corrective action as needed . 3. The facility water systems: a. The Director of Environmental Services has to describe the facility's water system using a Flow Diagram and in a Text document. (Attachment number two). b. Once completed, identify areas where legionella could grow and spread. Decide where control measures should be applied and how to monitor them. Establish ways to intervene when control limits are not met. (Attachment number three). 4. Control measures and Corrective actions: .b. With the use of the diagram (Attachment number two), the facility identified and implemented a process in monitoring control measures. Control limit monitoring includes but not limited to checking water temperature weekly and PRN (Pro Re Nata/As Needed) and disinfectant levels weekly and PRN at different areas of the facility. c. The following but not limited to are the areas routinely checked: i. Quality of Water: On a weekly and PRN basis, the quality of the water will be measure throughout the system to ensure that changes that may lead to legionella growth (such as a drop in chlorine levels) are not occurring . v. Unoccupied room or unit closed to public use: if a room or floor will be unoccupied or closed to public use for a longer period of time which could be due to renovations, constructions or just plainly due to low census, this may cause a temporary hazardous condition because the water usage will decrease, which means stagnation is possible, therefore the following course of action should be implemented: a) Daily flushing of the sinks and fixtures with hot and cold water in several rooms including those at the end of the hall, which are farthest from the vertical pipe serving that floor (riser). b) Continued to monitor the water temperature and increase the frequency on monitoring the chlorine levels of the floor/unit/area that is closed from weekly to daily . On December 18, 2024, at 10:58 AM, V32 (Admissions Director) said a resident room on the second floor had been unoccupied since October 18, 2024. V32 continued to say she checked the facility's census from June 1, 2024, to present and the room next door had been unoccupied since before June 1, 2024. The facility does not have documentation to show daily flushing, water temperatures, or chlorine levels were monitored daily for the unoccupied rooms. The facility does not have documentation to show weekly water temperatures or weekly disinfectant levels were monitored. 2. On December 17, 2024, at 9:30 AM V11 (Nurse) prepared and administered medications to R144. There was a sign outside R144's bedroom which showed Contact Precaution. V11 went in and out of R144's bedroom twice, first to administer the intravenous antibiotic medication and then to administer all the oral medications to R144. V11 only used a pair of gloves, however she did not use an isolation gown. When asked about what contact precaution R144 has, V11 was not sure of it. 3. On December 17, 2024, at 4:35 PM, V18 assisted R58 to the bathroom. After R58 used the toilet, V18 wiped R58's perineum, then she pulled the incontinence brief and pants back in place, assisted R58 to transfer from toilet to wheelchair while wearing the same soiled gloves. V18 used one set of gloves all throughout the provision of care. 4. On December 18, 2024, 10:23 AM, V17 (CNA) assisted R24 to the toilet. R24 voided, afterwards V17 assisted R24 to stand up, provided peri-care, pulled the incontinence brief and pants back in place, and assisted R24 to sit down on the wheelchair while wearing same soiled gloves. V17 changed her gloves without performing hand hygiene and continued to assist R24. On December 18, 2024, at 4:02 PM, V2 (Director of Nursing/DON) stated it is the facility's practice to follow standard infection control process such as hand hygiene and donning of complete PPE (Personal Protective Equipment) which include glove and gown for resident on contact isolation. The staff should perform hand hygiene and change gloves in between tasks to prevent spread of infection. R144 is on contact precaution for MRSA (Methicillin-resistant Staphylococcus aureus) of the wound. Facility's Hand Washing/Hygiene Policy with revision date of November 2017 shows: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use and alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: f. Before moving from one contaminated body site to a clean body site during resident care. g. after contact with a resident's skin. j. After removing gloves. 8. The use of gloves does not replace handwashing/hygiene. Facility's Transmission Based Precautions dated June 21, 2023, shows: Contact Precautions: b. Wear a gown and gloves for all interactions with the patient or potentially contaminated areas in the patient's or resident's environment. Donning personal protective equipment (PPE) upon room entry and discarding it before exiting the patient room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide showers twice a week per facility policy. This applies 2 of 5 residents (R3, R6) reviewed for showers in the sample of 7. The findings include: 1. Face sheet, dated 10/30/24, shows R6's diagnoses include Parkinson's disease, cerebral infarction, chronic obstructive pulmonary disease, morbid obesity, depression, difficulty walking, encephalopathy, need for assistance with personal care, reduced mobility, lack of coordination, unsteadiness on feet, and chronic diastolic heart failure. MDS (Minimum Data Sheet), dated 9/20/24, shows R6 was cognitively intact and was dependent on staff for bathing. Care plan, as of 10/28/24, showed R6 was to be provided a sponge bath if she was unable to tolerate a full bath or shower. On 10/29/24 at 1:15 PM, R6 was lying in bed and her hair appeared to have an oily substance throughout. R6 stated stated she was only getting baths once a week because the staff told her they did not have time to provide her baths. On 10/30/24 at 10:42 AM with V2 (Director of Nursing), R6 stated she was not getting scheduled baths on Friday afternoons due to inconsistent staffing on Friday PM shifts. R6 stated she wished to move her scheduled bath times to Friday AM shifts so that she would consistently receive baths on Fridays. R6 stated she never refused her scheduled baths. Review of R6's Bathing record documentation, dated 9/1/24 to 10/28/24, shows R6 was to be offered baths every Tuesday and Friday. The documentation shows R6 was being offered a bath on Tuesdays 9/24/24 and Tuesday 10/22/24. The documentation shows R6's documentation included RR (Refused) or NA (Not Applicable) on Friday 9/6/24, Friday 9/20/24, Friday 9/27/24, Friday 10/18/24, and Friday 10/25/24. On 10/29/24, 3:53 PM, V2 (Director of Nursing) stated documentation of showers/baths which shows residents marked as RR or NA on their scheduled bath days show that the CNA (Certified Nursing Assistant) was documenting the resident refused their shower/bath. V2 stated it was her expectation that if a resident refused a bath/shower, the nurse would be informed, the nurse would speak with the resident, and the nurse would document the conversation with the resident as well as the resident refusal of the shower/bath. Review of R6's nursing progress notes, dated 9/1/24 to 10/28/24, showed no documentation that R6 refused showers. On 10/31/24 at 8:43 AM, V1 (Administrator) stated it was her expectation that all residents were offered a shower/bath twice weekly at the facility. Resident Shower or Bed Bath Policy/Procedure, dated 11/2015, shows If not contra-indicated, shower is to be given to residents at the facility at least twice a week and as needed If the resident refused to have a shower or bed bath, inform the nurse 2. Face sheet, dated 10/30/24, shows R3's diagnoses included osteoarthritis, seizures, anxiety, depression, morbid obesity, idiopathic and hereditary neuropathy, artificial hips, overactive bladder, and hypertension. MDS, dated [DATE], shows R3's cognition was moderately impaired and R3 required substantial/maximal assistance from staff for bathing. Care plan, as of 10/28/24, failed to show R3 had any history of refusing showers/baths on scheduled days. On 10/29/24 at 12:50 PM with R4 (Roommate), R3 stated she felt like she had to fight to get her showers because the staff were too busy. R4 stated she was not receiving her showers/baths on her scheduled bathing days. On 10/30/24 at 10:30 AM, R3 stated she never refused her baths/showers on her scheduled bathing days. R3 stated she always asked for her showers on her scheduled shower days but the staff told R3 they were too busy to provide her with the showers. R4 stated R3 never refused any of her showers on her scheduled shower days. R4 stated, If anyone refuses, it is the staff! R4 stated on R3's scheduled shower days, the staff tell R3 they have no time to provide her scheduled showers or tell R3 it was not her scheduled day to receive a shower. Review of R3's nursing progress notes, dated 9/1/24 to 10/28/24, shows no documentation of R3 refusing offers of baths/showers. Review of R3's bathing documentation, dated 9/1/24 to 10/28/24, shows R3 was documented as refusing showers/baths on the following dates: 9/2/24, 9/5/24, 9/9/24, 9/12/24, 9/23/24, 9/26/24, 9/30/24, 10/24/24, and 10/28/24.

Based on interview and record review, the facility failed to ensure nursing staff remained with a resident until all of the resident's medications were administered per facility policy. This applies to 1 of 6 residents (R2) reviewed for medications left at bedside in a sample of 7. Findings include: Facility Incident report, dated 8/25/24, shows on R1's family observed medications at R2's bedside. The report shows R2 denied that they were her medications and stated she already took her medications. The report shows the medications were removed immediately and the resident was assessed with no concerns. The report shows R2 was monitored for changes in condition on 8/25/24. The incident investigation shows a re-education regarding medication storage and administration was given to facility nursing staff. On 10/29/24 at 10:41 AM with V2 (Director of Nursing), V3 (Infection Peventionist Nurse / Manager on Duty) stated she was the Manager on Duty on 9/25/24 when a nurse supervisor informed her a family found medications inside a resident room. V3 stated she investigated and spoke with the nurse and supervisor on duty at the time the medications were found. V3 stated there were approximately 14 medications and no narcotics. V3 stated the medications included vitamins, supplements, and other typical morning medications. V3 stated when she spoke with the residents in the room, R1 stated she already received and took her morning medications, and R2 stated she also took her medications V3 stated when she further questioned R2, R2 stated she may have forgotten to take her mediations she was provided earlier that mourning by the nurse. V3 stated V5 (Registered Nurse) was on duty and caring for R1 and R2 at the times the medications were found in the residents' room and denied leaving the medications not taken by R2 in R2's room. V3 stated V5 insisted she watched R2 take her medications that morning and stated she did not leave the medication at the bedside. Manager on Duty Statement, dated 8/25/24, shows medications were left on R2's bedside table. The statement shows R2 stated she put the medications on the bedside table intending to take them and forgot to do so. On 10/30/24 at 11:29 AM, V4 (Registered Nurse Supervisor) stated on 8/25/24 she was informed that medications were found at R2's bedside. V4 stated R2 stated the medications were hers and R2 forgot to take the medications. V4 stated she verified that the medications were R2's AM doses of medications and then destroyed the medications. V4 stated the medications should never have been left with the resident and the administering nurse should visualize the residents taking their mediations when medications are administered. MDS (Minimum Data Set), dated 9/6/24, shows R2's cognition was moderately impaired. On 10/29/24 at 1:30 PM, R2 stated on 8/25/24 she forgot to take her morning medications when the nurse handed her the medications. R2 stated she left the medications sitting on the dresser in her room. On 10/30/24 at 1:46 PM, V5 (Registered Nurse) stated she provided R2 with her AM medications on 8/25/24 and watched R2 take her medications that morning. MAR (Medication Administration Record), dated 8/25/24, shows R2's AM medications included cholecalciferol 5000 Units, duloxetine 60 mg (milligrams), glipizide 10 mg, lamotrigine 24 mg, miralax 17 grams, multivitamin 1 tablet, venlafaxine extended release 75 mg, Vitamin E-400, memantine 10 mg, sennosides-docusate sodium 8.6-50 mg, and tramadol 50 mg. Facility document Administering Oral Medications, revised 3/2020, shows, Remain with the resident until all medications have been taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide personal care to dependent residents. This applies to 2 of 4 residents (R2, R3) reviewed for activities of daily living care in a sample of 4. Findings Include: 1. R2 is a [AGE] year-old female with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE] and dependent on staff for personal hygiene. On 5/30/24 at 10:10 AM, R2 was observed with V10 (LPN-Licensed Pratical Nurse) in her room. R2 was noted with a strong urine odor. V10 (Licensed Practical Nurse/LPN) checked on R2, and R2 was observed to be dirty and soaked incontinent brief with urine and discoloration (blackish). On 5/30/24 at 10:10 AM, V10 stated, The CNAs are supposed to change residents every two hours. I don't think R2 was changed today, and I will check with my CNA (Certified Nursing Assistant) to change R2. A review of R2's care plan documents that R2's care is planned for the risk of impaired skin integrity, with interventions including Providing skin care per facility guidelines and as needed (PRN). 2. R3 is a [AGE] year-old female with mild cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R3 is dependent on staff for personal hygiene. On 5/30/24 at 10:30 AM, R3 was in her bed and stated, A lot of time, they don't change me on time. I don't remember anybody changed me today. On 5/30/24 at 10:30 AM, V11 (LPN) checked on R3. R3 was observed with incontinent brief, dirty, and heavily soiled urine that was discolored (blackish inside). A review of R3's care plan documents that R3 is care planned for the risk of impaired skin integrity, with interventions including Providing skin care per facility guidelines and as needed (PRN). On 5/30/24 at 11:00 AM, V2, Director of Nursing (DON) stated, Our residents are supposed to get incontinent care every two hours and as needed. The facility presented the Incontinent-Peri Care Policy (Revised March 2020) document: Incontinent or perineal care must be provided by the nursing staff at least every 2 hours and as needed (PRN) to all residents identified by the staff as incontinent or needing assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure urinary catheter insertion was completed to prevent potential cross contamination. This applies to 1 of 3 residents reviewed for urinary tract infection in a sample of 4. Findings include: R1 is a [AGE] year-old female admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. R1 was admitted with an admitting diagnosis, including spina bifida, chronic idiopathic constipation, bladder dysfunction, and a history of urinary tract infection (UTI). A review of R1's physician order sheet (POS) indicates that R1 has an order to perform a straight urinary catheterization every four hours. V4 (Nurse) was observed on 5/30/2024 at 2:35PM with V5 (CNA-Certified Nursing Assistant) performing a straight catheterization procedure on R1. V4 did not to clean the left and right labia area of R1. V4 was also observed holding the catheter and directing the urine into the collection chamber without using sterile gloves. On 5/30/24 at 2:40 PM, V4 stated, I didn't know I should have used those three cleansing swabs/sticks to cleanse her left and right labia and urethral meatus. On 5/30/24 at 2:50 PM, V2 (Director of Nursing/DON) stated, The staff should follow the straight cath guidelines while performing straight Cath to avoid UTI. The three cleansing swabs/sticks should have been utilized to cleanse R1's left labia, right labia, and urethral meatus. Straight Cath is a sterile procedure, and V5 shouldn't have held the sterile catheter without wearing sterile gloves. The facility provided a Urinary Straight Catheter policy (revised in March 2020) document: For the female: To cleanse the labia, use only one cotton ball for each downward cleansing stroke. Next, cleanse around the urethral meatus. Using a new cotton ball, cleanse directly over the meatus.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Activities of Daily Living assistance was provided for three of three residents (R1, R2, R3) reviewed for requiring extensive assistance with Activities of Daily Living on the sample list of eight. Findings include: 1. R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, heart failure, dermatitis, and malnutrition. R1's MDS (Minimum Data Set) dated February 19, 2024 shows R1 is not cognitively intact, is dependent on staff for toileting hygiene and personal hygiene. R1 is always incontinent of bowel and bladder. R1's Care Plan initiated December 20, 2021 shows R1 requires total assist with personal hygiene and dressing. R1 has bowel and bladder incontinence and to check resident every two hours and assist with toileting as needed. On April 8, 2024 at 9:59 AM, R1 was still laying in bed. There was a notable odor outside of R1's room. At 10:28 AM, V3 CNA provided incontinence care to R1. R1's incontinence brief was saturated with urine from the front of the brief to the back. R1's flat sheet was also wet. V3 said it was the first time she was in R1's room to provide incontinence care. There was a dressing to R1's sacrum that was also saturated. There was a strong urine odor noted. 2. R2's admission Record shows she was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, anxiety disorder, and bipolar disorder. R2's MDS dated [DATE] shows she is dependent on staff for toileting hygiene and showering/bathing herself. R2 is always incontinent of bladder. R2's Care Plan initiated April 8, 2024 shows, The resident has bladder incontinence. Clean peri-area with each incontinence episode. On April 8, 2024 at 9:59 AM, R2 was still laying in bed. At 10:55 AM, V3 CNA provided incontinence care to R2. V3 said this was the first time V3 provided incontinence care to R2. R2's incontinence brief was saturated with urine from the front of the brief to the back of the brief. R2's flat sheet was wet. 3. R3's admission Record shows she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, Alzheimer's disease, dementia, schizophrenia, and major depressive disorder. R3's MDS dated [DATE] shows she is not cognitively intact. R3 is dependent on staff for toileting hygiene and personal hygiene. R3 is always incontinent of bowel and bladder. R3's CNA documentation for response history shows no incontinence care was documented prior to 11:20 AM. R3's Care plan intitiated April 8, 2024 shows she has bowel and bladder incontinence and staff are to check R3 every two hours and assist with toileting as needed. Provide pericare after each incontinent episode. On April 8, 2024 at 11:20 AM, V5 CNA was finishing up providing ADL assistance to R3's roommate. At 11:21 AM, V5 provided incontinence care to R3. R3's incontinence brief was saturated from front to back with dark urine. There was a strong urine odor. R3 did not exhibit any refusal behaviors during these cares. On April 8, 2024 at 2:32 PM, V10 CNA said that incontinence care should be provided at least every two hours or more as needed. The facility's Incontinent-Peri Care policy revised March 2020 shows, The purposes 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. Incontinent or perineal care shall be provided by the nursing staff to all residents identified by the staff to be incontinent or needed assistance. Incontinent care can be provided at least every two hours and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure comfortable temperatures for 3 of 8 residents (R1, R2, and R3), a comfortable bed mattress for 1 of 8 residents (R1), and odorless air for all 93 residents third-floor residents. Findings include: On 03/14/2024, during the investigation, the writer entered the third floor via elevator five different times from 11:00 AM to 3:00 PM. The third-floor entrance from the elevator, dining room, and 300 wing had a strong urine odor. Though the facility's third-floor flooring, residents' rooms, and bathrooms were clean, the mentioned areas had a strong odor of urine. 1. R1's face sheet showed R1 was admitted to the facility on [DATE] with diagnoses including catatonic disorder, schizophrenia, depression, encephalopathy, and urinary retention with acute kidney failure. At 11:28 PM, R1 was in bed, withdrawn, staring at the writer, and did not respond to the writer's interview. R1's bed was sagging in the center, urine odor was present by his door entry, and the room temperature was 85 degrees Fahrenheit. R1 got up and left the room. On 03/14/2024, around 2:00 PM, V14 (R1's volunteer and vice President of United Cerebral Policy (USP) said they provided support to R1 at home, and since 03/10/2024, staff has been volunteering to visit R1 at the facility. V14 said R1's room had a urine odor, and her staff also told her about R1's room and floor's urine odor. V14 said V12 (R1's family member) reported to V5 (Registered Nurse) on 03/10/2024 about his bed since R1 reported to V12 that he had neck pain due to the uncomfortable bed. On 03/14/2024 at 1:45 PM, V6 (Registered Nurse) said she saw in the nursing report that V12 (R1's family member) reported on 03/10/2024 to V5 (Registered Nurse) that R1's bed mattress had issues. V6 said the maintenance staff changed the bed mattress. At 2:42 PM, V5 said V12 (R1's family member) told her the head end of the bed was not rising and was uncomfortable. She endorsed it in the nursing report and was unaware of what happened afterward. On 03/14/2024 at 1:18 PM, V3 (Director of Maintenance) said no one placed the work order for R1's bed concerns and no one reported to him about R1's room's high temperature. V3 said the facility's temperature was checked daily. V3 said the facility runs on a water system, and even shutting off the water system takes a while to cool down the temperature as water pipes remain hot for a while. On 03/14/2024, around 1:30 PM, the writer toured the facility with V3 (Director of Maintenance), checking the temperature of R1-R8 rooms. R1-R3's rooms showed a temperature of 85 degrees Fahrenheit, V3 said the ideal temperature is between 71- and 81-degrees Fahrenheit. V3 checked the bed mattresses of R1-R8. V3 stated that if R1 is uncomfortable in his bed he will talk with V2 (Director of Nursing) and change the mattress. When the writer asked about the urine odor, V3 acknowledged it and said it could be due to the carpet. On 03/15/2024 at 12:46 PM, V4 (Housekeeping Manager) said the facility makes all efforts to keep it clean and odor-free. V4 said her housekeeping staff attends to spills and urination as soon as the staff reports them. V4 said some residents are ambulatory and urinate wherever they want, and it goes unnoticed. So, the management discussed removing it and replacing it with regular flooring. 2. R2's face sheet showed that R2 was admitted to the facility initially on 04/1/2022 with diagnoses including dementia, pulmonary embolism, depression, and under palliative care. R2's room smelled of urine, and the temperature was 85 degrees Fahrenheit. R2 was in bed and not interviewable. On 03/14/2024 at 11:30 AM, V13 (R2's family member) said that the urine smell in the room was due to R2's briefs and bed soaking in urine when she arrived at the facility around 7:00 AM. She changed his briefs and bedding and reported her concerns to the management. V13 said she always feels warm and doesn't know if she feels warm due to room temperature or if that is her. V13 said R3 (R2's roommate) also had the same situation when she came to the facility. 3. R3's face sheet showed [AGE] year-old R3 was admitted to the facility initially on 11/22/2013 with diagnoses including dementia, traumatic brain injury, depression, and schizophrenia. At 12:30 PM, R3 was in the dining room and not interviewable. R3 was sharing the room of R2, where the temperature was 85 degrees Fahrenheit. On 03/14/2024, V7 (student Nursing Assistant) was in the dining room at 12:00 PM, V9 (Certified Nursing Assistant) in the 300 hallway, V10 (Laundry Aide) in the 300 wing at 12:48 PM, and V11 (Dietary Aide) entered the floor via elevator at 1:29 PM acknowledged that the floor had urine odor when the writer asked them. V9 said this odor might be due to carpets. On 03/14/2024, V1 (Assistant Administrator) and V2 (Director of Nursing) said the facility is making all efforts to keep residents safe and happy, and no one reported concerns about temperature and bed mattresses. V1 and V2 said the facility would follow up on all current concerns. A review of the facility policy with a revised date of March 2020, titled Homelike Environment, in part shows residents are provided with a safe, clean, and comfortable homelike environment, including comfortable room temperatures near the range of 71-81-degree Fahrenheit, maintenance of the device, and elimination of odors.

Based on observation, interview and record review, the facility failed to provide incontinent care and provide Activities of Daily Living care to residents. This applies to 8 of 8 residents (R3-R10) reviewed for incontinent care and Activity of Daily Living Care on the sample list of 10. Findings include: 1. On 2/28/24 at 10:57 AM, R3 was sitting up in bed in hospital gown watching TV. R3 said she wears an incontinent brief and needed to be changed. R3 said the last time she was changed was at 5:30 AM (over 5 hours earlier) this morning and she does not know which CNA (Certified Nurse Assistant) was assigned to her. At 10:59 AM, R3 pushed her call light and V5 (Restorative Aide) answered the call light at 11:02 AM. V5 said she does not know who R3's CNA (Certified Nurse Aide) was, but will inform her that R3 needed to be changed. At 11:06 AM, V6 (Restorative Aide) came in to change R3. During R3's incontinent care, it was observed that R3's incontinent brief was soaked with urine to the point the incontinent pad that R3 was laying on was also wet. R3's buttocks were noted with redness and R3 complained of soreness to her buttocks. V6 said that R3 was a heavy wetter and does not know the last time R3 was changed since she was not the aide assigned to her. On 2/28/24 at 12:41 PM, V9 (Rehab CNA) said she was the CNA assigned to R3. She said she has not provided incontinent care to R3 since her shift started at 7:00 AM. V9 said that V5 had completed R3's incontinent care. V5 said she did not provide incontinent care to R3 and V6 was the one that provided incontinent care to R3 earlier. R3's EMR (Electronic Medical Record) shows a diagnosis of overactive bladder. R3's MDS (Minimum Data Set) of 2/12/24 shows that R3's cognition is intact and she is dependent on staff for toileting hygiene. R3's care plan (initiated 2/12/23) shows that R3 has an ADL self-care performance deficit. The facility's Incontinent Peri Care policy (revised March 2020) states incontinent or perineal care shall be provided by nursing staff to all residents identified by staff to be incontinent or needing assistance. Incontinent care can be provided at least every 2 hours and as needed. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs and nursing staff were responsible for incontinent care; incontinent care should be done every 2 hours and as needed. V3 also said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 2. On 2/29/24 at 10:31 AM, R9 was observed in bed watching TV. R9 had a hospital gown on with brown stains on it. R9's hair was not combed or brushed, appeared greasy, skin and hair had dry white flakes falling off. R9 said she did not get a shower yesterday (Wednesday) and one was not offerred. She said staff does not want to give her a shower because she is heavy, and they do not wash her hair. R9 is scheduled for showers on Wednesdays and Saturdays. R9's MDS of 12/14/23 shows that her cognition is intact and is dependent on staff for showers and bathing. R9's care plan (initiated on 7/19/21) shows that R9 has an ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 3. On 2/29/24 at 10:20 AM, R8 was observed sitting in the wheelchair in her room. R8 said she did not get a shower yesterday (Wednesday), and it has been a long time since she's had a shower and she really needs one. R8 began to cry and said that she cannot stand up. R8 stated it is hard for her to stand and she feels like staff are scared to give her a shower because she cannot stand. R8 was scheduled to have a shower on Wednesdays and Saturdays. R8's MDS of 2/5/24 shows that her cognition is intact and she is dependent on staff for showers and bathing. R8's care plan (initiated 2/23/22) shows that she has an ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 4. On 2/29/24 at 10:02 AM, R5 was observed sitting in the wheelchair in the hallway. R5 had brownish stains on his sweatshirt and his hair was not combed or brushed. R5 said he did not get a shower yesterday (Wednesday) and he said he would have liked one, but staff did not offer him a shower. R5 is scheduled for showers on Wednesdays and Saturdays. R5's MDS of 11/27/23 shows that R5 needs partial/moderate assistance with showers and bathing. R5's care plain (initiated 1/31/23) shows that R5 has an ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 5. On 2/29/24 at 9:40 AM, R4 was sitting in a chair in his room, R4 had a t-shirt and pants on and both were stained with a whitish gray substance. R4 said he did not get a shower yesterday (Wednesday) and staff told him he would get it later in the day, but they never came back. R4 said he needed staff assistance with showering. R4 is scheduled to have shower on Wednesdays and Saturdays. R4's MDS of 12/19/23 shows that R4 needs partial/moderate assistance with showers and bathing. R4's care plain (initiated 11/16/23) shows that R4 has an ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 6. On 2/28/24 at 2:45 PM, R6 was in bed in his room resting. R6 said he wanted a shower, but he did not get one. On 2/29/24 at 9:50 AM, R6 was in bed; R6 said staff still did not offer him any shower yesterday. R6 showers are scheduled for Wednesdays and Saturdays. R6's MDS of 12/18/23 shows that R6's cognition is intact and is dependent on staff for showers and bathing. R6's care plan (initiated 4/14/22) shows that R6 has and ADL selfcare performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 7. On 2/29/24 at 10:10 AM, R7 was sitting in the wheelchair in the dining room. R7 said she did not get a shower yesterday (Wednesday) and she said she would have liked to have one, but staff did not offer her a shower. R7 was scheduled to have showers on Wednesdays and Saturdays. R7's MDS of 1/19/24 shows that she is dependent on staff for showers and bathing. R7's care plan (initiated 5/12/22) shows that R7 has and ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. 8. On 2/29/24 at 10:35 AM, R10 was sitting in the wheelchair in her room watching TV. R10 said she did not get a shower yesterday (Wednesday) and she would have liked to have a shower. R10's showers are scheduled for Wednesdays and Saturdays. R10's MDS of 1/3/24 shows that her cognition is intact and requires substantial/maximal assistances with showers and bathing. R10's care plan (initiated 11/24/21) shows that R10 has an ADL self-care performance deficit. On 2/28/24 and 2/29/24, V3 (DON/Director of Nursing) said that CNAs were also responsible for showers, and residents get showers 2-3 times a week and as needed. The facility's Shower Bed Bath policy (revised March 2020) states that showers will be given to the resident 2-3 times a week and PRN (as needed). Bed baths can be given 2-3 times a week as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who require extensive assist received assistance with incontinence care and toileting. This applies to 3 of 25 (R124, R41, R76) residents reviewed for activities of daily living in the sample of 35. Findings include: 1. On 11/27/23 at 9:49 AM, R124 was observed lying in bed, a strong foul smelling odor was present. V15 (Certified Nursing Assistant-CNA) provided incontinence care to R124. R124's disposable incontinence brief was heavily saturated with urine and stool. Large amounts of stool soaked through her incontinence pad. R124's buttocks were covered with stool and stool was down her right leg. V15 (CNA) said the facility is short staffed today. She did not have time to change R124 until now and R124 still needs to eat breakfast. It's hard to have this many residents. R124's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, requires extensive assist with toileting and frequently incontinent of urine and stool. 2. On 11/27/23 at 2:03 PM, R41 was observed in her reclining chair in the dining room. She was yelling out in Spanish help me, help me. R41 had a indwelling urinary catheter in place. She said has to use the bathroom to have a bowel movement. V17 (Activity Aide) was verbally notified R41 needs to use the bathroom. V17 said she already told R41's nurse. At 2:08 PM, R41 is yelling out help me, help me and crying she needs to use the bathroom. V17 said R41's nurse is on break, I'm going to get a CNA. V17 said R41 has to use the bathroom, but I can't find anyone to help her. I don't know where her CNA is. At 2:14 PM, R41 continues to yell out and crying she has to use the bathroom. V17 wheeled R41 to her room and told her I'm waiting for someone to take you. V26 (CNA) came to R41's room to assist. V26 said she is working on a different wing and was pulled to assist R41. V26 assisted R41 to the toilet and removed her stool soiled incontinent brief. At 2:25 PM, V16 (CNA) said she is R41's CNA and was on break. V16 said R41 was last toileted in the morning. R41's Minimum Data Set assessment dated [DATE] shows she requires extensive assist with toileting. On 11/29/23 at 9:10 AM, V15 (CNA) said residents should be checked and changed every two hours for incontinence care. There should also be two staff in the dining room, one activity aide and one CNA to assist residents with toileting. 3. On 11/27/23 at 9:00 AM, R76 was sitting in his reclined wheelchair in the dining room. R76 had strong urine odor. At 12:40 PM V6 (Certified Nursing Assistant-CNA) provided incontinence to R76. R76 was saturated with urine. V6 (CNA) said the last time R76 was provided incontinence care was at 7:30 AM, (approximately 5 hours ago). V6 said she was busy and did not get to R76 sooner. R76's Facility assessment dated [DATE] shows R76 is frequently incontinent with urine and needs extensive assist for activities of daily living (ADL's). On 11/29/23 at 9:00 AM, V3 (Assistant Director of Nursing- ADON) said residents should be checked and provided incontinence care every 2 hours and as needed. The facility Policy titled, Incontinent Peri Care, shows, 2. Incontinent or perineal care shall be provided by the nursing staff to all residents identified by the staff to be incontinent or needing assistance. Incontinent care can be provided every 2 hours and as needed.

Based on observation, interview, and record review the facility failed to ensure dressings and pressure relieving interventions were in place for residents with pressure injuries and at risk for pressure injuries. This applies to 3 of 8 (R3, R213, R84) reviewed for pressure in the sample of 35. Findings include: 1. On 11/27/2023 at 9:59 AM, R3 said she did not have a dressing in place on her right side. R3 said she hasn't had a dressing in place for a couple of days. On 11/27/2023 at 10:30 AM, V5 Wound Nurse and V31 Wound Nurse were observed providing wound care to R3. No dressing was observed on R3's pressure injury on her right gluteal fold when R3 was checked by V5 and V31. V31 measured the area and stated it was 8cm (centimeters) x 6cm. V5 said a dressing should be in place. V5 said the order for dressing changes was every 3 days and as needed when soiled or loose. R3's 11/27/2023 Progress Note shows R3 had a deep tissue pressure injury to the right gluteal fold with no signs and symptoms of infection. R3's Order Summary Report Dated 11/28/2023 shows an order for the Right gluteal fold: Cleanse with normal saline, pat dry, apply hydrocolloid every 3 days and prn (as needed) if soiled/loose. R3 Treatment Administration Record (TAR) dated 11/1/2023 to 11/30/2023 shows daily skin checks completed daily from the order start date of 11/9/2023 to 11/27/2023. The facility's Prevention of Pressure Ulcers policy dated 2020 states, provide and administer medications and treatments as ordered by the physician. 2. On 11/27/23 at 10:28 AM, R213's right heel was wrapped in gauze and had a sock over it. R213's right and left heels were flat on the mattress. R213 stated I got a sore on my foot, it's not getting better. They have been doing treatments awhile now. On 11/28/23 at 9:37 AM, R213 was in bed with both heels flat on the mattress. On 11/29/23 at 11:37 AM, V5 Wound Registered Nurse said R213 has a pressure injury to his right heel. V5 said R213's heels should be offloaded off the mattress or he should have heel boots on. R213's Wound Note dated 11/22/23 shows R213 has a Stage IV pressure injury to his right heel. Recommend honey and calcium alginate with dry dressing daily and prn. Offload as tolerated. 3. On 11/27/23 at 10:10 AM, R84 was observed lying in bed with her heels resting on the mattress and not off-loaded. Her heel protector boots were on her chair in her room. V14 (RN) said R84 has no pressure ulcers, but had a history of pressure ulcers on her heels. On 11/28/23 at 9:15 AM, R84 was observed lying in bed with her heels resting on the mattress. Her heel protector boots were on her chair. On 11/29/23 at 11:45 AM, V5 (Wound Nurse) said R84 has unstageable pressure ulcer to her right heel and her heels should be off-loaded or have her heel protector boots on. R84's Physician Progress note dated 11/22/23 documents she has unstageable pressure ulcer to the right heel measuring 5 cm (centimeters) x 7 cm x 0.1 cm and 100% necrotic (non-viable dead tissue). R84's Current Care Plan revised on 11/29/23 documents she has impairment to her skin integrity: right heel unstageable pressure ulcer and scored a 10 on the skin risk scale which categorizes her as having severe risk for skin breakdown with interventions to off load pillow while in bed with heel boots or pillows. The facility's Prevention of Pressure Ulcers Policy dated March 2020, states, The Purpose of this procedure is to provide information regarding the identification of pressure ulcer risk factors and interventions for specific risk factors .33. When in bed, every attempt to should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by the therapist and prescribed by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R68's face sheet shows she is a [AGE] year old female with diagnoses including unspecified dementia with other behavioral disturbance, frontal lobe and executive function deficit following cerebral infarct, bipolar disorder and repeated falls. R68's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, requires partial/moderate assistance with sit to stand transfers and walking assistance. R68's Fall Risk assessment dated [DATE] shows she is a HIGH risk for falls. On 11/27/23 at 11:50 AM, R68 was observed in the dining room in her wheelchair. She has a black left eye with a laceration above her left eyebrow. She was attempting to stand from her wheelchair repeatedly. V14 (RN) assisted R68 back in the wheelchair. V14 said R68 had a recent fall and is high risk for falls. She needs continuous monitoring. On 11/28/23 at 9:18 AM, R68 was observed walking unsteady without staff assistance from the dining room into the hallway. V33 (RN) said she can not walk alone. V17 (Activity Aide) stated, I know I'm only one person. On 11/28/23 at 2:46 PM, V20 (Restorative Nurse) said R68 is a high risk for falls. She a history of falls with most recent she tripped and fell. She used to walk independently but now needs one person extensive assist with a gait belt. She should not be walking without staff assistance. R68's Current Care Plan revised 11/24/23 documents she is at risk for falls related to gait/balance problems actual falls on 8/18/23, 10/17/23, 10/24/23, and 11/24/23 with interventions included downgrade to wheelchair use for ambulation, encourage resident to stay in the atrium after each meal and anticipate and meet the resident needs. The care plan did not include her transfer status or use of a gait belt with ambulation/transfers. 3. R41's face sheet shows she is a [AGE] year old female with diagnoses including unspecified dementia, unspecified fall, urine retention, and obstructive reflux uropathy. R41's Minimum Data Set assessment dated [DATE] shows she requires extensive two person assist with toileting. R41's Fall Risk assessment dated [DATE] shows she is at risk for falls. On 11/27/23 at 2:03 PM, R41 was observed in her reclining chair in the dining room. She was yelling out in Spanish help me, help me. R41 had a indwelling urinary catheter in place. She said has to use the bathroom to have a bowel movement. V17 (Activity Aide) was notified R41 needed to use the bathroom. At 2:08 PM, R41 is yelling out help me, help me and crying she needs to use the bathroom. V17 said R41's nurse is on break, I'm going to get a CNA. At 2:14 PM, R41 continues to yell out and crying she has to the bathroom. V17 wheeled R41 to her room and told her I'm waiting for someone to take you. V26 (CNA) came to R41's room to assist. V26 asked V17 does R41 stand, V17 stated, I don't know. V26 said she is working on a different wing and was pulled to assist R41. V26 transferred R41 from her recliner chair to the toilet without using a gait belt. R41's gait was unsteady and she was unable to stand upright as V26 transferred her. On 11/29/23 at 9:26 AM, V34 (RN) said R41 is alert to self and communicate her needs. She is two person assist for transfers. The facility's Transferring a Resident from one location to another Policy dated March 2020 states, Residents in the facility will be transferred safely from one location to another using the proper transfer technique .transfer the resident; obtain help when necessary, or as identified on care plan/care card . Based on observation, interview and record review the facility failed to safely transfer residents. The facility also failed to supervise a resident who is at a high risk for falls and has history of falls for 3 of 35 residents (R76, R68, R41) reviewed for safety and supervision in the sample of 35. Findings include: 1. R76's electronic medical record accessed on 11/28/23 show R3 has diagnosis of dementia and in need of 2 plus staff for transfer. On 11/27/23 at 12:25 PM, V5 (Wound Nurse) and V6(Certified Nursing Assistant-CNA) were transferring R76 from his wheelchair to bed. V5 (Wound Nurse) applied a gait belt to R76 while V6 (CNA) held onto R76 who was unable to sit up in his wheelchair. R76 was leaning back. During the transfer, R76 was unable to bear weight. R76 was lifted under his arms and transferred to bed. When R76 was being transferred back to his wheelchair, R76 was unable to hold himself up and again kept leaning back. V5 held R76's back for R76 to sit upright. A gait belt was again applied. V5 and V6 transferred R76, held onto the gait belt in R76's waist but lifted R76 under his arms. R76 was unable to bear any weight. V5 said R76 had declined and now unable to bear weight and needs to be assessed for safe transfers. On 11/28/23 at 9:20 AM, V20 (Restorative Nurse) said R76 has poor trunk control and was not safe to transfer via a gait belt, R76 needs to be transferred via a mechanical lift. The facility Transfer Policy dated March 2000, shows Residents in the facility will be transferred safely from one location to another using the proper transfer technique.

Based on observation, interview, and record review the facility failed to ensure a residents urinary catheter tubing and drainage bag was below the level of the bladder for 1 of 8 residents (R380) reviewed for urinary catheter care in the sample of 35. Findings include: R380's Face sheet shows R380 has diagnoses of hyrdonephrosis with ureteropelvic junction obstruction and retention of urine. R380's Care Plan shows R380 has a history of urinary tract infections requiring antibiotic treatment. On 11/27/23 at 10:16 AM, R380 was in bed leaning on her left side. R380's urinary catheter tubing was coming from R380's urethra and draped over R380's upper right leg close to her hip. There was yellow urine in the tubing that was unable to drain into the drainage bag. R380 said she had just returned from the hospital and had problems with the shunt in her kidneys and they put the urinary catheter in. On 11/28/23 at 9:12 AM., R380 was in bed with the urinary catheter drainage bag hanging on bed rail even with mattress. There was yellow urine in tubing all the way to R380's urethra. The tubing was level with drainage bag and at the entrance of the bag the tubing went upward before draining into the bag. The urine was unable to go up the tubing at this point to drain into the collection box attached to the urinary catheter bag. On 11/29/23 at 9:59 AM, V10 Registered Nurse said urinary catheter bags and tubing should be below the level of the bladder so the urine can drain into the bag to prevention urine retention and infection. The facility's Catheter Care Policy dated 3/2020 shows check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. The urinary drainage bag must be held or positioned lower then the bladder at tall times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility to ensure a resident with a diagnosis of dementia that is exhibiting behaviors,, was provided necessary care and services. This applies to 1 of 10 residents (R68) reviewed for dementia care in the sample of 35. Findings include: 1. R68's face sheet shows she is a [AGE] year old female with diagnoses including unspecified dementia with other behavioral disturbance, frontal lobe and executive function deficit following cerebral infarct, bipolar disorder and repeated falls. R68's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, has little interest or pleasure in doing things, trouble concentrating on things, being so fidgety or restless that have been moving around a lot more than usual, being short tempered, easily annoyed, has behaviors of hallucinations, delusion, physical, verbal and other behavioral symptoms not directed towards others, and wandering behaviors daily. On 11/27/23 at 10:51 AM, R68 was observed in the dining room sitting in her wheelchair. She had a large left black eye with laceration above her left eyebrow. Several residents were in the dining room with two activity staff present. Music was playing in the background. R68 was making several attempts to stand up from her wheelchair. V17 (Activity Aide) re-directed her to sit back in her wheelchair. R68 attempted to stand from her wheelchair three times and V17 re-directed back into her wheelchair. After the third attempt V17 wheeled R68 around in her wheelchair then back into the activity room. R68 stood again from her wheelchair. V17 ambulated with R68 then placed her back in her wheelchair. On 11/27/23 at 11:50 AM, V14 (RN) was wheeling R68 in her wheelchair. R68 was making several attempts to stand from her wheelchair. V14 re-directed R168 back into her wheelchair. On /11/27/23 at 2:13 PM, V17 (Activity Aide) said she has battle wounds from R68. R68 scratched her chest and arms. V17's hands and chest with visible scratches and red marks. On 11/28/23 at 9:26 AM, R68 was combative and attempted to hit V19 (Transportation Aide) and then pulled her hair. V19 re-directed R68 back into her wheelchair. R68 remained standing behind R68's wheelchair. R68 attempted to stand up and V19 assisted her back into the wheelchair. At 9:28 AM, V19 said this is my first time with R68, I'm a transportation escort. She said staff did not let her know of R68's behaviors. I'm trying to calm her down, attempting to re-direct her but she keeps on getting up. She's bored and her mind is wandering. She asked another staff in the dining room if thee was something they could give R68. On 11/28/23 at 9:32 AM, V17 (Activity Aide) said R68 is combative and difficult to re-direct. We try to walk with her, wheel in her around in her wheelchair, try to color with her. There is no direction from nursing or how to handle her behaviors, I'm trying to figure things out on my own. I reported to the nurse about her behaviors but nothing happens. I reported to the DON about her behaviors, too. On 11/29/23 at 9:19 AM, V14 (RN) said she's been working at the facility for 14 years. R68 is alert to self, has behaviors of agitation, anxiety, wanders and needs continuous monitoring and direction. We will walk with and try to re-direct her as much as possible. We used to give her as needed medication when she gets anxious but the medication was discontinued. V14 confirmed staff reported R68's behaviors and reported R68 calmed down when her environment was changed. V14 said she did not notify the physician of her increased behaviors. V14 said the facility has a memory care director, but could not recall their name. On 11/29/23 at 10:15 AM, V2 (DON) said we don't have a memory care director. She said there should be someone over seeing the residents on the dementia regarding behavior management. V2 said she was not aware of any recent reports of R68 being combative. V2 said has behaviors of impulsiveness and combative. V2 said she is not sure if staff receive training on how to manage resident behaviors. R68's Psychiatry note dated 10/28/23 documented that R68 was seen in the day room, and that she appeared to be calm but was minimally enraged. No agitation or or aggressive behaviors were noted. R68's Current Care plan initiated on 10/2022 documents R68 has potential to be physically aggressive related to dementia, poor impulse control. She is very confused and has been refusing cares at times and wandering on the unit. She has been physically aggressive towards staff at times. Interventions include to analyze times of day, places and circumstances, triggers and what de-escalate behavior and document. Provide physical and verbal cues to alleviate anxiety, psychiatrist consult as indicated, when the resident becomes agitated; intervene, if response id aggressive towards staff walk away calmly and approach later. The facility's Dementia Care Protocol dated March 2020 states, For individuals with confirmed dementia, the physician will identify a plan to maximize remaining function and quality of life .The physician will order appropriate medications and other interventions to manage behavioral and psychiatric symptoms related to dementia .the physician will help staff adjust interventions and the plan depending on the individuals responses to those interventions .

Based on observation, interview, and record review the facility failed to ensure a resident's narcotic controlled substance record for was in place for 1 of 1 residents (R213) reviewed for controlled substance medications in the sample of 35. Findings include: On 11/28/23 at 09:31 AM, V11 Registered Nurse was reviewing controlled substance medications in the medication cart with this surveyor. R213 had an opened bottle of liquid morphine (narcotic pain reliever) with approximately 25 ml (milliliters) left. There was no controlled substance proof of sheet/form for R213's morphine. V11 stated there is no sheet for this. There should be a sheet to sign off when the medication is given. R213 had a dose once and he did not like it so we don't give it to him. V11 said she did not reconcile/count R213's morphine with the night nurse at shift change. On 11/29/23 at 9:59 AM, V10 RN stated liquid morphine should have a medication reconciliation sheet to sign off when a dose is given and to verify that what's left in bottle matches the amount given. All narcotics are checked shift to shift with the oncoming nurse. R213's Medication Administration Record (MAR) for November 2023 shows an order hydromorphone HCL Solution (narcotic pain reliever) 2 mg (milligrams)/ml Give 1 mg by mouth every 1 hour as needed for pain with a start date of 10/17/23. This same MAR shows R213 received a dose on 11/8/23 at 9:40 AM. The facility's Controlled Substances Policy dated 3/2020 shows an individual resident-controlled substance record must be made for each resident who will be receiving a controlled substance. The nurse has to document the resident's medical record and /or sign out the controlled substances proof of use sheet/form once the medication is administered to the resident. Nursing staff must count controlled medications at the end of each shift.

Based on interview, and record review the facility failed to ensure medication regimen reviews (MRRs) were being completed and documented on a monthly basis. The facility also failed to ensure those recommendations were being followed up on by a physician. This applies to 2 of 5 (R3, R50) reviewed for MRRs in the sample of 35. Findings include: On 11/29/2023 MRRs for the last 6 months was requested for R3 and R50 from V1 Administrator. 1. On 11/29/2023 at 1:15PM, V2 Director of Nursing (DON) attempted to pull up MRR records for R3 for the last 6 months in the computer charting under progress notes and was unsuccessful. V2 said the pharmacist was going to send the records for [R3]. The facility failed to provide copies of monthly medication reviews from individual months for R3. On 11/29/2023 at 12:22PM, V25 Pharmacist said the MRRs are completed monthly and should be visible in the computer charting system under progress notes under pharmacy. V25 said he is unsure why they wouldn't be showing up in the computer charting system. R3's MRRs provided were all dated 11/29/2023. On 11/29/2023 at 1:29PM, V3 Assistant Director of Nursing (ADON) said she was responsible for reviewing the MRRs once a month for the residents on her unit. V3 said the pharmacist provided copies of the MRRs and they noticed they were dated with the same date for [R3]. 2. On 11/29/2023 at 1:15PM, V2 Director of Nursing (DON) said the pharmacist was going to send the records for [R50]. On 11/29/2023 at 12:22PM, V25 Pharmacist said the MRRs are completed monthly and should be visible in the computer charting system under progress notes under pharmacy. V25 said he is unsure why they wouldn't be showing up in the computer charting system. R50's MRR dated 10/26/2023 shows a recommendation for GDR (Gradual Dose Reduction) by V25 Pharmacist to decrease [R50's] Duloxetine (Antidepressant) 120mg (milligrams) daily to 100mg daily. On 11/29/2023 at 1:29PM, V3 Assistant Director of Nursing (ADON) said she was responsible for reviewing the MRRs once a month for the residents on her unit. V3 said R50's MRR dated 10/26/2023 was faxed to the physician on 11/1/2023 and 11/9/2023 but no response. On 11/29/2023 at 3:20PM, V2 Director of Nursing (DON) said there was a response from the physician regarding [R50's] GDR that was identified on the MRR dated 10/26/2023. V2 said the physician had not responded to that request until 11/29/2023. The facility provided two copies of R50's MRR completed on 10/26/2023. One copy showed no response from the physician regarding the GDR request. The second copy of the MRR from 10/26/2023 shows a typed response which was signed by the physician and dated 11/29/2023 addressing the GDR request on the MRR. The facility failed to provide a policy for monthly medication reviews.

Based on interview and record review the failed to implement a pharmacy recommendation of a gradual dose reduction (GDR) for a resident who is receiving a antipsychotic medication. This applies to 1 of 5 residents (R185) reviewed for unnecessary medications in the sample of 35. Findings include: 1. R185's Physician Order Sheets (POS) shows he has diagnoses including unspecified psychosis, unspecified dementia, unspecified severity with other behavioral disturbance and generalized anxiety. The POS shows orders dated 8/3/2023 for Olanzapine (anti-psychotic) 15 mg (milligram) at bedtime for psychotic behavior. The Pharmacy Medication Report dated 11/21/23 shows R185 is due for a GDR and recommends to decrease Olanzapine 15 mg at bed time to Olanzapine 12.5 mg at bedtime. The form is not completed or signed by the physician regarding the recommendation. On 11/29/23 at 1:26 PM, V13 (ADON) said pharmacy sends the recommendation and we fax the form to the physician to review and sign. V13 confirmed R185's GDR was not sent over to the physician until today (11/29/23.) The facility did not provide a policy regarding GDR or for the use of unnecessary medications; upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure insulin administration pens were labeled with an opened date and failed to dispose of expired insulin for 2 of 8 residents (R160, R181) reviewed for medication storage in the sample of 35. Findings include: On [DATE] at 09:31 AM, the 3rd floor medication cart 2 contained R160's lantus insulin pen that was opened and not labeled with an open date or an expiration date. The same cart contained R160's insulin aspart solution bottle that was dated as opened on [DATE], which expired [DATE] and R181's levemir insulin solution bottle with an open date of [DATE] and an expired date of [DATE]. V11 Registered Nurse (RN) said R181's levemir and R160's insulin aspart are expired and should have been thrown out. V11 said R160's lantus insulin solution pen should be dated with the date is was opened. V11 said insulin is good for 28 days once opened. R160's Medication Administration Record (MAR) for [DATE] shows an order for lantus 30 units subcutaneous two times a day for diabetes and insulin aspart inject 10 units subcutaneous two times a day. This same MAR shows both lantus and insulin aspart was administered to R160 on [DATE]. R181's MAR for [DATE] shows an order levemir 50 units subcutaneous at bedtime. This same MAR shows R181 received levemir on [DATE]. On [DATE] at 9:59 AM, V10 RN said insulin should be dated when opened and labeled with the date opened and the expiration date. V10 said insulin is good for 28 days. The facility's Administering Medications Policy dated 3/2020 shows the expiration/beyond-use date on the medications label must be checked before administering. When opening a multi-dose container, the date opened shall be recorded on the container.

Based on observation, interview, and record review the facility failed to ensure food was prepared in a form to meet a residents needs which applies to 5 of 5 residents (R76, R84, R153, R213, R222) reviewed for puree diets in a sample of 35. Findings include: The facility's weekly dietary menu showed the noon meal to be a chicken soft taco, Spanish rice, seasoned corn, and fruit mix on 11/28/23. On 11/28/23 at 10:00 AM, V32 [NAME] stated puree foods should have a smooth consistency like pudding. During the puree prepping, V30 Dietary Manager stated the food processor they have does run at a slower speed so it does take a while to puree the foods. After the puree foods were prepared V32 and V28 Assistant [NAME] did not sample the food items prior to packaging it for serving. On 11/28/23 12:31 PM, A test tray was sampled for the pureed food. The puree chicken was gritty with particulates in it. The puree corn still had parts of the corn kernal shells in it. On 11/28/23 at 1:00 PM, V30 Dietary Manager tried the pureed food, and said the chicken needed to be blended more, and the corn had pieces of husk in it. The Facility's Pureed Diet List printed on 11/29/23 showed R76, R84, R153, R213, and R222 require a puree consistency diet.

Based on observation, interview, and record review the facility failed to ensure the food service areas were sanitized prior to serving food. This failure affects 5 of 5 residents (R84, R124, R153, R213, R380) reviewed for food service in a sample of 35. Findings include: On 11/28/23 at 11:50 AM, V29 Dietary Aide opened the 3rd floor kitchenette where the steam tables are kept for meal serving. There were seven dirty meal trays in the kitchenette. The trays had used, dirty plates, cups, silverware, and paper garbage on them. V29 stated they had no idea why the trays were there. V29 removed the trays from the kitchenette, set up the steam tables, and started serving the noon meal without sanitizing the food serving area. On 11/28/23 at 1:00 PM, V30 Dietary Manager stated the dirty trays should not be stored/left in the kitchenette. They are supposed to be put on the dirty tray carts and brought down stairs to the dishwasher area. The dirty trays could cause cross contamination. The food serving areas should be kept clean. The facilities Kitchen Sanitation Policy dated 12/2015 showed the food service are shall be maintained in a clean and sanitary manner. Equipment, food contact surface, and utensils should be sanitized using hot water and/or chemical sanitizing solutions. R84, R124, R153, R213, and R380 Facesheets showed these residents reside on the third floor of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/27/2023 at 1:39 PM, R134's room door was open. R134's room had signs outside of the room indicating resident was on contact/droplet isolation. On 11/27/2023 at 1:09 PM, R43 was seen outside of his room without a mask on holding his lunch tray. On 11/28/2023 at 8:55 AM, V24 Registered Nurse (RN) was seen exiting a droplet/contact isolation room with her personal protective equipment (PPE) still on. On 11/28/2023 at 9:00 AM, V24 said she had just finished passing medications in a room that COVID-19 positive residents reside in. On 11/29/2023 at 10:46 AM, V4 Infection Control Preventionist (ICP) said staff should not exit isolation rooms with PPE still on. V4 said the doors should be closed for residents on droplet/contact for COVID. V4 said [R134's] door should have been closed. V4 said residents on COVID isolation should not be out in the hallways without a mask and staff should be redirecting them to their rooms. V4 said [R43's] door should have been closed and [R43] should not be in the hallway without a mask. The facility provided list Transmission Based Precaution Report dated 11/23/2023 lists [R134] on contact/droplet isolation with a start date of 11/23/2023 and lists [R43] on contact/droplet isolation with a start date of 11/22/2023. 3. R100's electronic face sheet printed on 11/29/23 showed diagnoses to include but not limited to encounter for attention to gastrostomy, Escherichia coli, and type 2 diabetes mellitus. R100's physician's order sheet printed on 11/29/23 showed enhanced barrier precautions (EBP) related to Gastrointestinal-tube, IV (intravenous) access, specialty female external urinary catheter every shift for infection control. (This was added during the survey process after interviews on 11/27/23.) R100's care plan printed on 11/29/23 and revised on 11/28/23 after interview with surveyor showed enhanced barrier precautions as ordered. R100's Minimum Data Set (MDS) assessment dated [DATE] showed R100 as cognitively intact. On 11/27/23 at 12:57 PM, R100 was sitting up in bed watching television. There was no enhanced barrier precautions signage on the door to R100's room. R100's gastrointestinal tube (g-tube) feeding was running, and a specialty female external urinary catheter machine sat on a bed side table on the far left hand side of the bed. On 11/28/23 at 8:55 AM, there was no enhanced barrier precautions signage on R100's entry door. The resident continued on g-tube feeding, specialty female external urinary catheter and had an IV access site. On 11/28/23 at 8:57 AM, V21 (Nurse Supervisor 2nd floor) said I am not sure if they should be on enhanced barrier precautions when they have a g-tube. I will check with the IP (Infection Preventionist -V4). Technically she should be on EBP. On 11/28/23 at 9:03 AM, V22 (Wound Care nurse) said I was told by IP to wear PPE when I go into her room. She has a specialty female external urinary catheter and a g-tube. On 11/28/23 at 10:20 AM, V4 IP (Infection Preventionist) said for (R100) who has g-tube, uses a specialty female external urinary catheter and has a PICC (peripherally inserted central catheter) (IV) line access, the enhanced barrier precautions sign should be on the door. There is a potential risk for staff or the resident to get an infection. I just got an order for EBP for (R100) this morning. I forgot to put the sign on her door yesterday. Based on observation, interview and record review the facility failed to ensure staff donned and doffed Personal Protective Equipment PPE when entering and leaving rooms with residents who were on isolation due to testing positive for the COVID-19 virus. The facility also failed to ensure doors were kept closed for rooms with COVID-19 positive residents, failed to ensure a COVID-19 positive residents remained isolated in their rooms. The facility also failed to implement enhance barrier precautions. These failures affect 16 of 35 residents (R129, R48, R73, R89, R18, R5, R139, R62, R79, R173, R159, R58, R6, R43, R134 and R100) reviewed for infection control in the sample of 35. Findings include: 1. On 11/27/23 at 9:50 AM, R129, R48, R73's room had a sign on the doorway of droplet contact isolation precaution. V4 (Infection Control Nurse-IP) said the facility was in a COVID-19 outbreak and R129, R48 and R73 were all COVID-19 positive residents that were on isolation. V7 (License Practical Nurse-LPN) entered and exited the isolation room wearing only a surgical mask. V7 said he forgot to apply Personal Protective Equipment (PPE) which was respirator face mask, faceshield, gown and gloves. On 11/27/23 at 10:45 AM, R89, R18 and R5's room had a sign of droplet isolation precaution who were also identified as testing positive for COVID-19 infection by V3 (IP). The door to R89, R18 and R5's room was wide open. V8 (LPN) was inside this room, wearing only a surgical mask. V8's N95 mask was on her neck, talking to another nurse V9 (RN). V9 informed V8 to please close the door. V8 stated I was talking to the other nurse (V9) and if I wear my N95 mask, (V9) would not understand what I was saying. On 11/27/23 at 10:30 AM, R139, R62, R79 and R173's room door was wide open with a sign of droplet isolation precaution. These residents were identified as requiring isolation for testing positive for COVID-19. R139 was out of the room, and was in the doorway of R51's adjacent room who was not on isolation and had tested negative for the COVID-19 virus. There was no staff present at that time to redirect R139. V12 (Housekeeper) was going around looking for staff. V3 (Assistant Director of Nursing ADON) came to the unit15 minutes later and closed the door including another room with COVID-19 positive residents including R159, R58 and R6. V3 said all COVID-19 positive resident rooms should be kept closed to prevent the spread of the COVID-19 virus infection. On 11/27/23 at 11 AM, V4 (Infection Control Nurse-IP) said it has been a challenge to educate staff during this COVID-19 outbreak at the facility. V4 said she has been making rounds and reminding staff about the importance of wearing proper PPE, which includes a respirator face mask, a face shield, gown and gloves, closing doors of rooms with residents who tested positive and on isolation for COVID-19 and redirecting COVID-19 residents to remain in their room. The facility policy entitled Policy on The Core Principles of COVID-19 Infection Prevention dated 5/23 show b. If a resident is suspected or confirmed to have COVID-19 HCP (Healthcare Personnel) must wear a respirator face mask, eye protection gown and gloves. d. In addition, facilities should consider requiring a respirator face mask on all resident care on the affected floor. The Centers for Disease Control (CDC) guidelines dated May 2023 shows, Personal Protective Equipment: HCP (Healthcare Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 (COVID 19) infection should adhere to Standard Precautions and use a NIOSH (National Institute for occupational Safety and health) Approved particulate respirator with special particulate filters or higher, a gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). CDC Patient Placement-Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide personal care to residents requiring assistance with ADL (Activities of Daily Living) needs. This applies to 6 of 9 residents (R4-R9) reviewed for activities of daily living (ADL) from a sample of 9. The Findings include: 1. R4 is an [AGE] year-old female with mild cognitive impairment as per MDS (Minimum Data Set) dated 7/24/23. The MDS also document two-person total dependance with toilet use. On 10/17/23 at 11:00 AM, R4 was in her bed with a urine odor. R4 stated, They haven't changed me yet, and I think I am wet. They changed me last night, and nobody changed me after that. On 10/17/23 at 11:07 AM, V5 (Certified Nursing Assistant / CNA) and V6 (Licensed Practical Nurse / LPN) checked R4 for incontinence. R4 was observed with a double incontinent brief with an inner one with blackish discoloration. Record review on R4's care plan documented that R4 was care planned to prevent UTI with interventions including Checking at least every 2 hours for incontinence, washing, rinsing, and drying soiled areas. 2. R5 is a [AGE] year-old female with severe cognitive impairment as per MDS dated [DATE]. MDS also document that R3 depends on extensive two-person assistance for toilet use. On 10/17/23 at 10:30 AM, R5 was on her bed with a urine odor with three other roommates with her. On 10/17/23 at 10:40 AM, V7 (Certified Nursing Assistant / CNA) stated, I came at 9:00 AM. They called me as they were shorthanded. I didn't change R5 yet. Observed R5 heavily wet, and V7 stated that she would change her now. R5's bladder incontinent care plan document: Check often and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinent episodes. 3. R6 is an [AGE] year-old male with cognition intact as per MDS dated [DATE]. The MDS also document two-person total dependance with toilet use. On 10/17/23 at 11:12 AM, R6 was on his bed with a urine odor and observed urine leaked into the padding (draw sheet) on the bed. R6 stated that he was not changed today. A record review on R6's bladder incontinent care plan document: clean peri-area with each incontinent episode. 4. R7 is a [AGE] year-old female with cognition intact as per MDS dated [DATE]. MDS also document that R3 depends on extensive two-person assistance for toilet use. On 10/17/23 at 11:45 AM, R7 was on her bed with a urine odor and R7 stated, I am not changed yet .I am wet in urine. The CNA doesn't know what she is doing .she doesn't know how to change me . On 10/17/23 at 11:50 AM, V8 (CNA) stated, I didn't change R7 yet. I wish we had more CNAs on the floor . A record review on R7's bladder incontinent care plan document: clean peri-area with each incontinent episode. 5. R8 is a [AGE] year-old male with mild cognitive impairment as per MDS dated [DATE]. MDS also document that R3 depends on extensive two-person assistance for toilet use. On 10/18/23 at 3:00 PM, R8 was on his bed naked, having only a soaked, incontinent brief with urine odor. R8 stated that he had been calling for 45 minutes to change him. On 10/18/23 at 2:55 PM, V9 (CNA) stated, I am not the assigned CNA for R8. I was assigned to the third floor. I came here on the fourth floor to help them out. On 10/18/23 at 3:00 PM, V9 and V10 (CNA) checked on R8 for incontinence and observed R8 with a heavily soiled incontinent brief. V10 stated that she is assigned to the other side of the unit and is not the assigned CNA for R8. 6. R9 is a [AGE] year-old female with mild cognitive impairment as per MDS dated [DATE]. MDS also document that R3 depends on extensive two-person assistance for toilet use. On 10/17/23 at 11:15 AM, R9 stated, They didn't have enough staff to adequately take care of resident needs. They came and checked on me at around 5-6 AM. I was not wet and wasn't changed. After that, I didn't see anybody. I am wet little now. A record review on R9's bladder incontinent care plan document: clean peri-area with each incontinent episode. On 10/17/23 at 1:00 PM V3 (Director of Nursing) stated, Incontinent care should be provided to residents every two hours and as needed. The facility's Incontinent-Peri Care Policy (Revised March 2020) documents 2. Incontinent or Perineal care has to be provided by the nursing staff at least every 2 hours and as needed (PRN) to all residents identified by the staff to be incontinent or needing assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have adequate staff to provide assistant with activities of daily living in a timely manner. This failure has the potential to affect all 248 residents residing in the facility. The Findings include: The facility census sheet dated 10/17/2023 documents 248 residents reside in the facility. On 10/17/23 at 11:25 AM, V14 (Registered Nurse / RN) stated, We have four nurses and six CNAs working on the floor for a census of 101 residents on the fourth floor. Most of the time, we are short of staff. On 10/18/23 at 3:10 PM, V14 added, You come to the weekend to see the accurate staffing picture. We are really short on weekends. On 10/19/23 at 10:20 AM, V12 (Staffing Coordinator) stated, We have low staffing on weekends due to many call-offs and agency staff didn't show up. We tried to replace the call-off staff with restorative aides, but we are short sometimes on weekends. Last Tuesday (10/17/23), I had four CNAs on the third floor, six on the fourth floor, and five on the fourth floor for the morning shift. Last Monday (10/16/23), I had only four CNAs for a resident census of 101 residents due to multiple call-offs. On Sunday, 10/15/23, I had only three CNAs on the second floor, four on the third floor, and four on the fourth floor for the morning shift. On 10/17/23 at 1:00 PM, V3 (Director of Nursing) stated, We should have adequate staffing to provide timely care to our residents. Last-minute call-offs and sometimes the absence of agency staff contribute to a staff shortage. Incontinent care should be provided to residents every two hours and as needed. Record review on the facility-provided staffing sheet indicates multiple call-offs, causing short staff on weekdays and weekends. 1. R2 is a [AGE] year-old female with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R2 has an admitting diagnosis, including spinal bifida, bacteremia, depression, and spinal stenosis. On 10/17/23 at 12:10 PM, R2 was observed on her bed and stated, They lack staff to care for residents, especially on weekends. 2. R4 is an [AGE] year-old female with mild cognitive impairment as per MDS (Minimum Data Set) dated 7/24/23. The MDS also documents two-person total dependence on toilet use. On 10/17/23 at 11:00 AM, R4 was in her bed with a urine odor. R4 stated, They haven't changed me yet, and I think I am wet. They changed me last night, and nobody changed me after that. On 10/17/23 at 11:07 AM, V5 (Certified Nursing Assistant / CNA) and V6 (Licensed Practical Nurse / LPN) checked R4 for incontinence. R4 was observed with a double incontinent brief with an inner one with blackish discoloration. Record review on R4's care plan documented that R4 was care planned to prevent UTI with interventions including Checking at least every 2 hours for incontinence, washing, rinsing, and drying soiled areas. 3. R5 is a [AGE] year-old female with severe cognitive impairment as per MDS dated [DATE]. MDS also documents that R3 depends on extensive two-person assistance for toilet use. On 10/17/23 at 10:30 AM, R5 was on her bed with a urine odor with three other roommates with her. On 10/17/23 at 10:40 AM, V7 (Certified Nursing Assistant / CNA) stated, I came at 9:00 AM. They called me as they were shorthanded. I didn't change R5 yet. Observed R5 heavily wet, and V7 stated that she would change her now. 4. R6 is an [AGE] year-old male with cognition intact as per MDS dated [DATE]. The MDS also documents two-person total dependence on toilet use. On 10/17/23 at 11:12 AM, R6 was on his bed with a urine odor and observed urine leaked into the padding (draw sheet) on the bed. R6 stated that he was not changed today. 5. R7 is a [AGE] year-old female with cognition intact as per MDS dated [DATE]. MDS also documents that R3 depends on extensive two-person assistance for toilet use. On 10/17/23 at 11:45 AM, R7 was on her bed with a urine odor and R7 stated, I am not changed yet .I am wet in urine. The CNA doesn't know what she is doing .she doesn't know how to change me . On 10/17/23 at 11:50 AM, V8 (CNA) stated, I didn't change R7 yet. I wish we had more CNAs on the floor . 6. R8 is a [AGE] year-old male with mild cognitive impairment as per MDS dated [DATE]. MDS also documents that R3 depends on extensive two-person assistance for toilet use. On 10/18/23 at 3:00 PM, R8 was on his bed naked, having only a soaked, incontinent brief with urine odor. R8 stated that he had been calling for 45 minutes to change him. On 10/18/23 at 2:55 PM, V9 (CNA) stated, I am not the assigned CNA for R8. I was assigned to the third floor. I came here on the fourth floor to help them out. On 10/18/23 at 3:00 PM, V9 and V10 (CNA) checked on R8 for incontinence and observed R8 with a heavily soiled incontinent brief. V10 stated that she is assigned to the other side of the unit and is not the assigned CNA for R8. 7. R9 is a [AGE] year-old female with mild cognitive impairment as per MDS dated [DATE]. MDS also documents that R3 depends on extensive two-person assistance for toilet use. On 10/17/23 at 11:15 AM, R9 stated, They didn't have enough staff to take care of resident needs adequately. They came and checked on me at around 5-6 AM. I was not wet and wasn't changed. After that, I didn't see anybody. I am wet little now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the menu items as planned. This failure has the potential to affect all 235 residents consuming food from the kitchen. The Findings include: On 10/19/23 at 1:00 PM, V3 (Director of Nursing) stated, We have 235 residents eating from the Kitchen. Record review on lunch menu dated 10/19/23 document Shepherd's Pie for resident lunch. On 10/19/23 at 11:55 AM, the kitchen tray line contained baked ham that was being served to the residents instead of shepherd's pie as per the menu. On 10/19/23 at 12:00 PM, V16 (Cook) stated, We didn't receive the shipment for [NAME] Pie to serve for resident today (Thursday). We are serving baked ham and au gratin potatoes today instead of [NAME] Pie. On 10/19/23 at 12:15 PM, V17 (Dietary Manager) stated, We are planning menus four weeks ahead and should be followed. The order for ground beef to make Shepherd's Pie was placed for Monday (10/16/23) delivery, and somehow, we didn't receive that. If we put the order on Monday (10/16/23), we will get the delivery on Wednesday (10/18/23). On 10/19/23 at 12:15 PM, V17 added, I was busy with many things happening with the facility and didn't notice Monday's shipping hadn't delivered ground beef to make Shepherd's Pie. The facility presented the Food Preparation Policy (2010) document: The menu spreadsheet will be used in tray service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve hot food to residents at a palatable temperature. This failure has the potential to affect all 235 residents consuming food from the kitchen. The Findings include: On 10/19/23 at 1:00 PM, V3 (Director of Nursing) stated, We have 235 residents eating from the Kitchen. On 10/19/23 at 11:50 AM, the lunch meal tray line was observed, and a test tray was requested. The test tray was the last tray loaded into the food cart to the last serving unit (Third floor). On 10/19/23 at 12:59 PM, V16 (Cook) checked the food temperature from the test tray (on the Third floor) using the facility thermometer. The temperatures were as follows: Au gratin potatoes - 136.2 F Steamed broccoli - 108 F Baked ham - 95F On 10/19/23 at 12:59 PM, V16 stated, The serving temperature for hot food should be a minimum of 135F. We may have to use ceramic food warmer instead of plastic to maintain the food temperature during delivery. R2 is a [AGE] year-old female with mild cognitive impairment per the Minimum Data Set (MDS) dated [DATE]. On 10/17/23 at 12:10 PM, R2 was observed on her bed and stated, The food is cold and not appetizing. The broccoli is overcooked, and it lacks all kinds of vitamins. R4 is an [AGE] year-old female with mild cognitive impairment as per MDS dated [DATE]. On 10/17/23 at 11:00 AM, R4 was in her bed with a urine odor. R4 stated, The food could be better. They always serve cold food, and I don't like eating it. The facility presented Meal Service/Tray Service Policy (dated 2017) documents hot food will be served at 135F or higher.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with incontinence care and toileting, and showers/bed baths. These failures affect 4 of 6 residents (R1, R2, R5, R8) reviewed for Activities of Daily Living in the sample of 8. The findings include: 1. On 9/30/23 at 9:37 AM, V3 and V8 (LPN-Licensed Practical Nurse) went to R2's room. R2 was sleeping in bed. She was wearing a gown and her hair was greasy and not combed. Both V3 and V8 checked (R2)'s brief and she was wet. R2 stated, I think the last time they changed me was at 4 AM. It was still dark outside. Since then, they didn't check me. I fell asleep. They don't check on me every 2 hours. It's like this all the time, I'm always soaked, and they never check on me. Even when I press my call light, I have to wait 8 or 9 hours to be changed. There's not enough staff here, especially on the weekends. It's like there's only one nurse and one CNA for 50 residents, especially on the evening and overnight shifts. They need to hire more staff. The CNA's here don't care about us. I have not had a bed bath for 2 weeks. They never wash my hair. Yes, I would like my hair washed. Last week, V4 (CNA) was rude to me. I think it was late evening or on the evening shift. I pressed my call light because I was wet. I needed to be changed. I was waiting 3 to 4 hours to be changed. No one came. Finally, (V4) came to my room. He yelled at me and said, What do you want? I told him that I was waiting a long time to be changed. He said something about me having a lot of stuff on my bed. He stood there and looked at my bed. Then he walked out. My sister (R1) went in the hallway and saw him laying down on a cot and sleeping for the rest of the shift. R2's face sheet documents the following diagnoses: bilateral primary osteoarthritis of knee, morbid (severe) obesity due to excess calories, pain in right and left knee, low back pain, other symptoms and signs involving the musculoskeletal system, need for assistance with personal care, acute pyelonephritis, urinary tract infection, overactive bladder. R2's MDS (Minimum Data Set) dated 8/30/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates she is cognitively intact. This MDS documents R2 requires extensive assistance with one-person physical assist; R2 requires total dependence with support provided for bathing. This MDS documents R2 is always incontinent of urine and bowel. R2's current care plan documents R2 has an ADL (Activities of Daily Living) self-care deficit performance and bowel incontinence related to disease process. Check resident often and as necessary and assist with toileting as needed. 2. On 9/30/23 at 9:46 AM, R1 was in her room and in her wheelchair. She was observed to have uncombed and greasy hair. R1 stated the following: I have to wait 30 minutes or more to have my call light answered. When I question the CNA's, they say they can't help it because they are short staffed. There are 3 aides for 60 residents. Sometimes, my sister (R2) presses the call light. It takes a couple of hours for them to come, and she's soaked in her urine. I have to call the front desk to call the nursing station to send a staff member here. Or sometimes, I have to wheel myself out of my room and find a staff member. It's ridiculous. Mainly, the night and weekends shifts are short. It's horrible. It's been 3 to 4 weeks since I had my last shower. They said they don't have enough staff to do showers. So, I have to go to the bathroom, take a washcloth and wipe down below and wipe my armpits. They never wash my hair. It's been so many weeks. My hair smells. On 9/30/23, between 9:30 AM and 9:55 AM, the 4th floor hallway where R1 and R2's rooms were located had a pungent and foul urine smell. R1's face sheet documents the following diagnoses: Friedreich ataxia, major depressive disorder, adult failure to thrive, unsteadiness on feet, other symptoms and signs involving the musculoskeletal system, and other lack of coordination. R1's MDS dated [DATE] documents a BIMS score of 14, which indicates she is cognitively intact. For personal hygiene, This MDS documents R1 requires limited physical assistance with one-person for personal hygiene. For bathing, R1 was assessed as 2/2, which means she needs physical help limited to transfer only with support provided. R1 is occasionally incontinent of urine and bowel. R1's care plan documents R1 has an ADL self-care performance deficit. R1 has bowel incontinence and bladder incontinence related to disease process with an intervention to check the resident every 2 hours and assist with toileting as needed. 3. On 9/30/23 at 10:08 AM, R5's call light was on. R5 stated, (V6-LPN) just came in here when I put my call light on. He said he would tell the CNA to clean and change me. But before that I was waiting for 2 hours. I've been wet for 2 hours. You have to wait 3 to 4 hours to be changed in this place. I was last changed at 3 AM. They don't check me every 2 hours. I have not had a shower or bed bath for the past 4 to 5 months. I would love to have a shower. They don't wash my hair. I have sores on my head. Last week, I begged to have my hair washed. The CNA left the shampoo in my hair, and they had to cut my hair. On 9/30/23 at 10:22 AM, V3 (Restorative Nurse) stated, Residents that are incontinent are supposed to be checked every 2 hours. They are either supposed to get a shower or bed bath twice a week. R5's face sheet documents the following diagnoses: rheumatoid arthritis, idiopathic progressive neuropathy, morbid severe obesity due to excess calories, major depressive disorder, low back pain, other specified disorders of bone density and structure, other intervertebral disc degeneration, lumbosacral region, wedge compression fracture of third and fifth lumbar vertebra, and age-related osteoporosis with current pathological fracture. R5's MDS dated [DATE] shows a BIMS score of 12, which indicates she is moderately impaired in cognition. For personal hygiene This MDS documents R5 requires total dependence with one-person physical assist for personal hygiene and total dependence for bathing with support provided. R5 is occasionally incontinent of urine and bowel. R5's care plan has an ADL self-care performance deficit. R5 has bowel incontinence and bladder incontinence related to disease process. This Care Plan documents to check R5 often and as required for incontinence and assist with toileting. 4. On 9/30/23 at 11:31 AM, R8 was observed lying in bed without a gown. R8 stated, It's been quite a while since I got a shower. I can't remember when I last got one. I would like one. There are days when there's not enough staff. That's probably why I don't get my showers. R8's face sheet documents the following diagnoses: muscle wasting and atrophy, unspecified dementia, difficulty in walking, need for assistance with personal care. R8's MDS dated [DATE] shows a BIMs score of 15 which indicates he is cognitively intact. This MDS documents R8 requires extensive assistance with one-person physical assist for personal hygiene, R8 requires physical help in part of bathing activity and support provided. R8 is occasionally incontinent with urine and bowel. R8's care plan has an ADL self-care performance deficit. R8 has bowel incontinence and bladder incontinence related to disease process. This care plan documents to check R8 often and as required for incontinence and assist with toileting. The facility's policy titled Personal Hygiene dated March 2020 documents: Procedure: 1. Daily as needed the resident will be assisted to improve personal hygiene. 2. The following but not limited to are the areas that need to be taken care of: a.) Hair care c) Dressing/grooming d.) Bathing/shower g.) incontinent care. Facility's policy titled Incontinent-Peri Care (2020) documents: 2. Incontinent or perineal care shall be provided by the nursing staff to all residents identified by the staff to be incontinent or needing assistance. Incontinent care can be provided at least every 2 hours and as needed. Facility's policy titled Shower-Bed Bath (March 2020) documents: The shower will be given to the resident 2-3 times a week and prn. Bed baths can be given 2-3 times a week as needed and or as requested by the resident.

Based on observation, interview, and record review, the facility failed to provide adequate staffing in order to: answer call lights timely, provide incontinent care, and provide showers/bed baths. This failure has the potential to affect all 245 residents who reside in the facility. The findings include: On 9/30/23 at 10:31 AM, V2 (DON-Director of Nursing) stated, We are okay with staffing. Some days we are short. We are using 2 agencies. We are especially short on the weekends. We ask staff to stay over. We do have call offs and no show no calls. On the 2nd floor, in the morning shift (7am to 3pm), there should be 3 nurses in the morning and 3 nurses in the evening (3pm to 11pm). In the overnight shift (11pm to 7am), there should be 2 nurses. In the morning, there should be 4 CNA's (Certified Nursing Assistants) in the morning and evening. In the night shift, there should be 3 CNA's. On the 3rd floor, there should be 4 nurses in the morning and 4 nurses in the evening. In the night shift, there should be 2 nurses. In the morning and evening, there should be 6 to 7 CNA's. On the night shift, there should be 4 to 5 CNA's. On the 4th floor, there should be 4 nurses in the morning and 4 nurses in the evening. In the night shift, there should be 2 nurses. In the morning and evening, there should be 6 to 7 CNA's and on the night shift, there should be 4 to 5 CNA's. On 9/30/23, the facility's 3 units with residents were observed with V3 (Restorative Nurse/Manager on Duty). At 10:02 AM, there were only 5 CNA's on the third floor, which has 98 residents. At 10:21 AM, there were only 3 CNA's on the 2nd floor which only had 50 residents. As per V2, there should have been at 6 to 7 CNA's on the 3rd floor and at least 4 CNA's on the second floor. On 9/30/23 at 2:18 PM, surveyor reviewed the 1 month staffing schedule with V2. The following was noted: On Saturday 9/2/23 for the evening shift, on the second floor, there were only 3 CNA's. As per V2, there should have been 4 CNA's. On the 3rd floor, there were only 5 CNA's. As per V2, there should have been 6 to 7 CNA's. On the 4th floor, there were only 3 nurses. As per V2, there should have been 4 nurses. On Sunday 9/10/23, on the 3rd floor, there were only 3 CNA's working in the night shift. As per V2, there should have been 4 to 5 CNA's working. On the 4th floor, there were 3 CNA's working in the night shift. As per V2, there should have been 4 to 5 CNA's working. On Saturday 9/16/23 in the morning shift, on the second floor there were only 3 CNA's. As per V2, there should have been one more CNA to equal 4 CNA's. V2 put a rehab aide up on the unit. On the 3rd floor, there were only 5 CNA's with one rehab aide. As per V2, there should have been between 6 to 7 CNA's. On the 4th floor, there were 4 CNA's and one rehab aide. As per V2, there should have been between 6 to 7 CNA's. On Sunday 9/23/23 in the evening shift, on the second floor there were only 3 CNA's. As per V2, there should have been 4 CNA's. On the third floor, there were 4 CNA's. As per V2, there should have been 6 to 7 CNA's. On the 4th floor, there were 3 nurses and 5 CNA's. As per V2, there should have been 4 nurses and 6 to 7 CNA's. Review of the nursing staff sheets for days listed above show that no one from management or a department head stayed over to help. On 9/30/23 at 12:09 PM, R6 was lying in bed and stated, There could be more staff on the weekends and in the evenings. He said it takes a longer time for his call light to be answered on those shifts. On 9/30/23 at 11:16 AM, surveyor asked V6 (LPN-Licensed Practical Nurse) if he was short staffed. V6 stated, It varies. Sometimes, I work on the 2nd and 4th floors. They have a different census. I usually get 23 to 25 residents. Most of the time, I can handle this. Today everyone (the residents) is okay. But sometimes, we need another nurse. As far as CNA's go-yes, we are sometimes short staffed. This may cause them to be behind more on their tasks. I think with the nurses we are all good. But we need more CNA's. Facility's policy on staffing (March 2020) documents: 1. The facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. The facility's Facility Data Sheet dated 9/30/23 documents 245 residents reside in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to provide hygiene and grooming for residents who require extensive assistance to total dependence from staff for activities of daily living (ADL) care. This applies to 4 of 4 residents (R1, R2, R3, R4) reviewed for ADL care in the sample of 5 residents. The findings include: 1. R1 is 71 years-old who has multiple medical diagnoses such as need for assistance for personal care, and morbid obesity, low back pain, urinary tract infection, history of pyonephrosis, history of acute pyelonephritis, and history severe sepsis with septic shock. Minimum Data Sheet (MDS) dated [DATE] shows that R1 is alert and oriented, and requires extensive assistance for grooming and hygiene, and totally dependent on toileting assistance from staff. On 7/24/23 at 2:10 PM, R1 was resting in bed, unkempt and not wearing clothes except for the bedsheet that cover her. There was a strong body and urine odor coming from R1. R1 stated that she had not been changed since the previous shift and that staff only give her bed bathes. R1 added that she did not get a bed bath often. On 7/24/23 at 2:33 PM, V9 (Certified Nursing Assistant/CNA) rendered incontinence care to R1 who was heavily saturated with urine which overflowed to the pad, the flat sheet, and mattress. R1 also had a bowel movement, her feces were dry and pasty which adhered to the skin. R1's shower/bathing records in the past 6 months showed that she received bed bath on 1/19/23 and 6/16/23. 2. R2 is 78 years-old who has multiple medical diagnoses such as complete lesion of L4 of lumbar spinal cord, intervertebral disc degeneration of lumbar region, hydronephrosis of renal and ureteral calculous obstruction, history of bacteremia, and history of pyelonephritis. MDS dated [DATE] shows that R2 is alert and oriented. The same MDS indicates that R2 is totally dependent for bed mobility and toileting and requires extensive assistance for grooming and hygiene. On 7/25/23 at 7:00 AM, R2 was resting in bed awake, anxious, and upset. R2 stated I need help. No one came to change me this shift (night shift). I was changed last night. There were 3 people who came and said that they are going to come back but they never did. I'm in pain my bun has been wet for quite a while and it's very uncomfortable. R2 was unkempt and disheveled, wearing a gown, hair unkept, and nails long and uneven. R2 was noted with a strong urine and body odor. On 7/25/23 at 7:05 AM, V10 (CNA) came in and provided incontinence care to R2 who was heavily saturated with urine and had a huge bowel movement that extended to her frontal perineum, covering her labia. The urine overflowed to her incontinence pad and bedsheet. There was redness on her skin in the buttocks which was blanchable. A strong body, urine, and fecal odor emanated from R2. On 7/25/23 at 10:34 AM, R2 in bed, she remained unkempt and disheveled with hair uncombed and has strong body odor. R2 stated that the last time she had a shower was last year and bed bath was several months ago. R2 also said I need my hair washed, it's so oily and messy. My armpit stinks. I put tissue on my armpit to absorb the smell, but I could still smell it. I always ask the staff, and they would say they don't have time, or I will come back but they don't. Since you're here can you do something about it, for me to have a shower. R2 also showed her long uneven nails and said, I have been asking for a nail clipper because they don't have time to clip it, I told them I will do it myself. R2's active care plan shows that R2 has bladder and bowel incontinence related to disease process. The same care plan shows multiple interventions which include providing peri-care and cleaning R2's peri-area with each incontinence episode. The facility was unable to present documentation of when R2 received shower or bed bath in the past 6 months. 3. R3 is 76 years-old who has multiple medical diagnoses such as morbid (severe) obesity, chronic kidney disease, adult failure to thrive, and need for assistance for personal care. MDS dated [DATE] indicates that R2 is alert and oriented. The same MDS shows that she is totally dependent on staff for bed mobility, toileting, and grooming/hygiene care. On 7/25/23 at 7:10 AM, R3 was awake and resting in bed. R3 stated she has not been changed on the night shift. R3 also said that she's very uncomfortable. R3 showed her incontinence brief, which was heavily soaked with urine, which overflowed to her incontinence pad. There was formation of brown ring stain at the edges of the pad. The was body and urine odor coming from R3. On 7/25/23 at 10:00 AM, V10 (CNA) was in R3's bedroom and stated that she just completed R3's incontinence care. R3 resting on her bed, and when asked if she had a shower or a bed bath, R3 stated she has not had a shower or a bed bath in a very long time, her fingernails were long and dirty with unidentified substance underneath. R3 showed the thick accumulation of dandruff on her scalp, she also showed her teeth which has thick substances at the line between her teeth and gums (dental plaques). She said she has not brushed her teeth in a long time. She verbalized I would like to shower and brush my teeth. R3's active care plan shows that R3 has urinary incontinence due to decrease mobility, decrease bladder capacity related to morbid obesity and diabetes. The same care plan shows multiple interventions which include: To check R3 often and as required for incontinence. The facility was unable to present documentation of when R3 received shower or bed bath in the past 6 months. 4. R4 is 62 years-old who had multiple medical diagnoses to include multiple sclerosis (MS) and neuromuscular dysfunction of the bladder. MDS dated [DATE] shows that R4 is alert and oriented. The same MDS shows that R4 requires extensive assistance for bed mobility and personal hygiene and grooming and is totally dependent from staff for toileting care. On 7/25/23 at 7:15 AM, R4 resting in bed, awake and oriented. R4 stated that she hasn't been change the whole shift. V5 (Nurse) assisted R4 to position on her right side. R4's incontinence brief was heavily saturated with urine, which overflowed to her incontinence pad and sheet with formation of brown ring stain at the edge of the pad. There was a strong body, urine, and fecal odor coming from R4. On 7/25/23 at 10:05 AM, R4 stated, I haven't had a bed bath nor a shower in a long time. I forgot when I had it last because it's been a long time. Yes, they brushed my teeth. The last time they did it was last week. I would like to have shower and a bed bath because I wanted to be clean. R4 remained with body odor and heavily saturated with urine. On 7/25/23 at 10:10 AM, V10 (CNA) handed a wet washcloth to R4. R4 wiped her face and arm pit, then V10 proceeded to provide incontinence care R4 who was heavily saturated with urine and had a bowel movement. R4 stated that she didn't know she had a bowel movement. The feces were dry and pasty which adhered to the skin. There was a dark black/brown line underneath her right breast. V10 was asked to check the brown discoloration underneath R4's right breast. V10 wiped it repeatedly and it lightened. It showed that it was some dead skin that already turned dark brown. R4 stated I told you I haven't had a shower and bed bath in a long time and the solution to take it off is just plain soap and water. R4's active care plan indicates that R4 has bowel and bladder incontinence related to MS. The same care plan indicates multiple interventions to include to assist R4 to the toilet every 2 hours and as needed if still with some control of her bowel function and provide peri care after each incontinent episode. R4's shower/bathing records in the past 6 months showed that she received bed bath on 3/1/23. 7/25/23 at 2:49 PM, V2 (Director of Nursing/DON) stated that the staff must check and change a resident's incontinence brief every 2 hours and as needed, to keep the resident clean, promote comfort, prevent skin breakdown and infection. V2 also stated that residents are supposed to received shower or bed bath twice a week. Part of the hygiene and grooming is to comb the resident's hair, trimmed, clipped, and clean the fingernails, facial shaving, and application of deodorant. As human being they need to feel comfortable, and they feel that by being clean. For comfort and dignity. Facility's Shower or Bed Bath policy and procedure dated 11/2015 indicates: Policy: If not contra-indicates, shower is to be given to resident at the facility at least twice a week and as needed. Bed bath is to be given to the resident daily and as needed. Facility's Policy and Procedure for Peri-Care with revised date of October 2016 indicates: Purpose: The purposes of this facility are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Procedure: 2. Incontinent care must be provided by the nursing staff at least every 2 hours and as needed to all residents identified by the staff to be incontinent. 4. Perineal care is to be provided during the bath. It is also done whenever the peri-area is soiled with urine and feces.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure that there are enough Certified Nursing Assistants (CNA) and Nurses to provide timely care for residents who require extensive assistance for all activities of daily living (ADL) care and other nursing care. This applies to 4 of 5 residents (R1, R2, R3, R4) reviewed for staffing in the sample of 5. The findings include: 1. R1 is 71 years-old who has multiple medical diagnoses such as need for assistance for personal care, and morbid obesity, low back pain, urinary tract infection, history of pyonephrosis, history of acute pyelonephritis, and history severe sepsis with septic shock. Minimum Data Sheet (MDS) dated [DATE] shows that R1 is alert and oriented, and requires extensive assistance for grooming and hygiene, and totally dependent on toileting assistance from staff. On 7/24/23 at 2:10 PM, R1 was resting in bed, unkempt and not wearing clothes except for the bed sheet that cover her. There was a strong body and urine odor coming from R1. R1 stated that she has not been changed since the night before and that the staff doesn't provide showers but only give bed bathes. R1 stated that she recently had a bed bath which was not often. R1 verbalized that the facility is bad because they don't have enough staff to provide timely care. On 7/24/23 at 2:33 PM, V9 (Certified Nursing Assistant/CNA) provided care to R1 who was heavily saturated with urine which overflowed to the pad, the flat sheet, and mattress. R1 also had a bowel movement, her feces were dry and pasty which adhered to the skin. R1's shower/bathing records in the past 6 months showed that she received bed bath on 1/19/23 and 6/16/23. 2. R2 is 78 years-old who has multiple medical diagnoses such as complete lesion of L4 of lumbar spinal cord, intervertebral disc degeneration of lumbar region, hydronephrosis of renal and ureteral calculous obstruction, history of bacteremia, and history of pyelonephritis. MDS dated [DATE] shows that R2 is alert and oriented. The same MDS indicates that R2 is totally dependent for bed mobility and toileting by 2 staff and requires extensive assistance for grooming and hygiene. On 7/25/23 at 7:00 AM, R2 was resting in bed awake, anxious, and upset. R2 stated I need help. No one came to change me this shift (night shift). I was changed last night. There were 3 people who came and said that they are going to come back but they never did. I'm in pain my bun has been wet for quite a while and it's very uncomfortable. R2 was unkempt and disheveled, wearing a gown, hair unkept, and nails long and uneven. There was body and urine odor coming from her. On 7/25/23 at 7:05 AM, V10 (CNA) came in and provided incontinence care to R2 who was heavily saturated with urine and had a huge bowel movement that extended to her frontal perineum, covering her labia. The urine overflowed to her incontinence pad and bed sheet. There was redness on her skin in the buttocks which was blanchable. A strong body, urine, and fecal odor emanated from R2. V10 was the only one who assisted R2 for incontinence care and repositioning. On 7/25/23 at 10:34 AM, R2 in bed, she remained unkempt and disheveled with hair uncombed and has strong body odor. R2 stated that the last time she had a shower was last year and bed bath was several months ago. R2 also said I need my hair washed, it's so oily and messy. My armpit stinks. I put tissue on my armpit to absorb the smell, but I could still smell it. I always ask the staff, and they would say they don't have time, or I will come back but they don't. Since you're here can you do something about it, for me to have a shower. R2 also showed her long uneven nails and said, I have been asking for a nail clipper because they don't have time to clip it, I told them I will do it myself. They don't have enough staff over here. It's so hard to get help from staff. I want to leave this place. The facility was unable to present documentation of when R2 received shower or bed bath in the past 6 months. 3. R3 is 76 years-old who has multiple medical diagnoses such as morbid (severe) obesity, chronic kidney disease, adult failure to thrive, and need for assistance for personal care. MDS dated [DATE] indicates that R2 is alert and oriented. The same MDS shows that she is totally dependent on staff for bed mobility, toileting, and grooming/hygiene care. On 7/25/23 at 7:10 AM, R3 was awake and resting in bed. R3 stated she has not been changed on the night shift. Nobody checked her the night shift. The staff don't do regular rounds in the night shift to check and change her incontinence brief. They don't have enough staff. R3 also said that she's very uncomfortable. R3 showed her incontinence brief, which was heavily soaked with urine, which overflowed to her incontinence pad. There was formation of brown ring stain at the edges of the pad. The was body and urine odor coming from R3. On 7/25/23 at 10:00 AM, V10 (CNA) was in R3's bedroom and stated that she just completed R3's incontinence care and that she was the only staff who cleaned R3. R3 was resting on her bed, and when asked if she had a shower or a bed bath, R3 stated she has not had a shower or a bed bath in a very long time, her fingernails were long and dirty with unidentified substance underneath. R3 showed the thick accumulation of dandruff on her scalp, she also showed her teeth which has thick substances at the line between her teeth and gums (dental plaques). She said she has not brushed her teeth in a long time. She verbalized I would like to shower and brush my teeth. The facility was unable to present documentation of when R3 received shower or bed bath in the past 6 months. 4. R4 is 62 years-old who had multiple medical diagnoses to include multiple sclerosis (MS) and neuromuscular dysfunction of the bladder. MDS dated [DATE] shows that R4 is alert and oriented. The same MDS shows that R4 requires extensive assistance for bed mobility and personal hygiene and grooming and is totally dependent from staff for toileting care. On 7/25/23 at 7:15 AM, R4 resting in bed, awake and oriented. R4 stated that she hasn't been change the whole shift. V5 (Nurse) assisted R4 to position on her right side. R4's incontinence brief was heavily saturated with urine, which overflowed to her incontinence pad and sheet with formation of brown ring stain at the edge of the pad. There was a strong body, urine, and fecal odor coming from R4. On 7/25/23 at 10:05 AM, R4 stated I haven't had a bed bath nor a shower in a long time. I forgot when I had it last because it's been a long time. Yes, they brushed my teeth. The last time they did it was last week. I would like to have shower and a bed bath because I wanted to be clean. R4 remained with body odor and heavily saturated with urine. On 7/25/23 at 10:10 AM, V10 (CNA) handed a wet washcloth to R4. R4 wiped her face and arm pit, then V10 proceeded to provide incontinence care R4 who was heavily saturated with urine and had a bowel movement. V10 was struggling to change and reposition R4. While R4 was holding to the side rails tightly and said that it was uncomfortable, but she needed to be clean and change (for incontinence brief). R4, she didn't know that she had a bowel movement. The feces were dry and pasty which adhered to the skin. There was a dark black/brown line underneath her right breast. R4 stated I told you I haven't had a shower and bed bath in a long time. On 7/25/23 at 7:15 AM, when R4 was asked if there's enough staff in the facility R4 responded Heck no! they don't have enough staff here. When I push the call light to ask for help it takes forever for them to respond. On 7/25/23 at 10:30 AM, V10 stated that R2, R3, and R4 needs 2 staff assistance for bed mobility and incontinence care. However, they don't have enough staff to help her because the other staff are also busy with their own residents. Majority of the time she (V10) does the incontinence care and repositioning by herself. If she waits for other staff's help, the longer the care is delayed. V10 added, she couldn't do the bed bath and the toothbrush for residents because she's doing what the night shift was not able to do. 5. On 7/24/23 at 2:15 PM, the 4th floor has pervasive urine odor. V12 (Nurse) stated that there were 3 nurses and 5 CNA who were working in the morning shift. V11, V12, V26 (All Nurses) and V13 (CNA) were on the floor. The rest of the CNA staff (V9, V27, V28, V29) were not working on the floor. V12 stated that V9, V27, V28, V29 all went on break without telling them (Nurses), leaving the residents without care. 6. On 7/25/23 at 6:45 AM, during unit observation there were 5 staff listed on the schedule of the night shift, V5 and V6 (Both Nurses) and V23, V24, and V25 (All CNA). Only V5, V6, and V25 were on the 4th floor. V23 and V24 were not on the unit. V5 looked for them (V23 and V24) and was unable to find them. V23 and V24 left the facility without telling the nurses and before the morning shift staff arrived. 7. On 7/25/23 at 10:40 AM, V8 and V11 (Both Nurses) were observed still passing morning (9:00 AM) medications. At 11:05 AM, V11 stated she finished passing her morning medications at around 10:45 AM, while V8 stated that she finished passing morning medications at 11:00 AM. From 7/24/23 through 7/25/23 multiple nurses and certified nursing assistants (CNA) were interviewed with regards to staffing: On 7/24/23 at V12 (Nurse) stated that they are understaffed. There were always 3 nurses on the morning and evening shifts and 4-5 CNA staff for the whole 4th floor which is too much. V12 stated she has 30 or more residents to pass medications to on the day shift. V12 stated it is impossible to pass all these medications on time to all her assigned residents. V12 add that there is never enough CNA and there's not enough nurses and CNAs especially during weekend. On 7/24/23 at 2:30 PM, V13 (CNA) stated that they don't have enough staff. On 7/24/23 at 3:18 PM, V14 (Nurse) stated that they don't have enough staff. There are times that he couldn't get a break. Often, acuity is very high. In as much as he wanted to listen to all the residents needs, he couldn't. V14 had to prioritized because there's not enough staff. On 7/24/23 at 3:55 PM, V15 (CNA) stated that she moves around all throughout the facility. It is hard to keep up on the 4th floor due to the acuity of the residents. V15 said, she cares about her residents but at the end of the day they still need extra help because they don't have enough staff. On 7/24/23 at 4:07 PM, V16 (CNA) stated that they need more CNA staff to be able to do their job the way they should. They are always short of staff. The residents are not getting the proper care. This is not occasionally; this is all the time. It's unfair to all nursing staff and residents. They are all overworked, and he felt bad for the residents. They couldn't give the quality care that residents deserve because they are always understaffed and overworked. On 7/24/23 at 4:35 PM, V18 (CNA) stated that they don't have enough staff. The acuity is heavy. He doesn't feel like they were able to give quality care to the residents, not when they have over 30 residents especially on weekends. Weekend is horrible. There are times when they look at the schedule and it looks like there are plenty of staff. However, some of those staff listed on the schedule doesn't show up. It's a ghost schedule. There are also few nurses scheduled which is also bad. They (staff) kept complaining to the administration, but it seems like they're not listening. On 7/24/23 at 4:51 PM, V19 (CNA) stated that they don't have enough staff in the facility. There were only 3 of them on 7/23/23. They had 97 residents, and they divided the residents among the 3 CNA staff. V19 tries her best to do as much as she could. However, she couldn't do it the way it supposed to be done. They have very heavy care residents. They have two residents on the 4th floor who are combative. These two residents require 3 staff to assist them. There's not enough staff and the pay is not enough. V19 also said that she loves this facility, she has been working to this facility for 25 years and had taken care of lot of the resident for many years, that's why she stayed even when it's understaffed. On 7/24/23 at 5:04 PM, V20 (Nurse) stated this was the second time her agency assigned her in this facility. This facility has a very heavy acuity. This has been the heaviest facility she has been assigned to. The scheduler always says there are 4 nurses but in reality, there were only 3 nurses on the schedule. V20 is doing her best, but within the legal time of the nursing care. V20 also said she doesn't feel that they were able to give quality care to the residents. On 7/24/23 at 5:09 PM, V21 (Nurse) stated that they don't have enough staff. V21 tries her best with what she could do on her given time. It's impossible to give timely nursing care to residents when acuity is heavy. She not going lie, the work in this facility is hard. Even when they help each other it's not enough the acuity is heavy. They have 35 residents each on the 4th floor. That's a lot. They had to check vital signs on all residents, administer medications, provide mental health care, help the CNA when needed, etc. V21 has been working in this facility for 3 years. It takes her 1 hour to get in this place. She stayed in this facility because she loves the residents. It hurts that there's only 3 nurses assigned for morning and evening shift, and they are unable to give quality care because of the heavy acuity. On 7/24/23 at 5:18 PM, V4 (Nurse) stated that there is not enough staff in the facility. She was unable to say about quality care except that it's not there. The main problem is that they don't have enough nurses placed on the schedule. On 7/25/23 at 6:50 AM, V5 and V6 (Both Nurses on the night shift) stated that they don't have enough staff in the facility. They have 97 residents and almost 50 residents to take care of, in each of them. On 7/25/23 at 9:50 AM, V22 (CNA) stated that they don't have enough staff in the unit (4th floor). On 7/25/23 at 10:40 AM, V8 (Nurse) stated that they don't have enough staff. V8 added that when they are late passing the medications, the residents yell, and curses at them. They couldn't pass all the medications on time because there are so many residents and few nurses scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide personal care to residents requiring assistance with ADL (Activities of Daily Living) needs. This applies to 4 of 8 residents (R2, R3, R4, and R5) reviewed for activities of daily living (ADL) from a sample of 8. The Findings include: 1. R2 is [AGE] year-old male with severely impaired cognition as per MDS (Minimum Data Set) assessment dated [DATE]. The MDS also document two-person extensive assist with toilet use. On 7/15/23 at 10:15 AM, R2 was observed in his low bed with a heavily soaked incontinent brief. V10 (Certified Nursing Assistant/CNA) stated on 7/15/2023 at 10:15AM, that V10 was not R2's nurse aide, but confirmed that R2's incontinent brief was heavily soaked. At 10:22AM, V10 opened the incontinent brief, and it was noted to be heavily soaked. Record review on R2's incontinent care plan document: Check resident every two hours and assist with toileting as needed. 2. R3 is an [AGE] year-old female with mild cognitive impairment as per MDS dated [DATE]. MDS also document that R3 depends on extensive two-person assistance for toilet use. On 7/15/23 at 10:40 AM, R3 was observed on her bed with soiled linen and heavily soaked incontinent brief. On 7/15/23 at 10:43 AM, V11 (Certified Nursing Assistant/CNA) stated, I am not the assigned CNA for R3. I worked on the other side and heard they had only one CNA on the whole floor for last night. I don't think R3 has been changed. Record review on R3's bowel and bladder incontinent care plan document: Check resident every two hours and as required for incontinence. 3. R4 is a [AGE] year-old female with mild cognitive impairment as per MDS dated [DATE]. MDS also documents that R4 is dependent on extensive two-person assistance for toilet use. On 7/15/23 at 10:55 AM, R4 was on her bed and stated, I don't think I ever changed today. I think they are shorthanded since I haven't been changed yet. At 10:58 AM, V12 (CNA) checked on R4 for incontinence and observed that R4's incontinence brief was heavily soiled with black stool like substance inside. V12 stated at 11:00AM that she started work at 7:00AM that day and had not check on R4 until 10:58AM, four hours into the shift. Record review on R4's bowel and bladder incontinent care plan document: Check resident every two hours and assist with toileting as needed. 4. R5 is a [AGE] year-old female with mild cognitive impairment per MDS dated [DATE]. MDS also documents that R4 depends on extensive two-person assistance for toilet use. On 7/15/23 at 10:35 AM, V13 (Registered Nurse/RN) checked on R5 for incontinence and observed a black-colored, heavily soaked incontinent brief. V13 stated that she had been looking for R5's CNA and did not know where he was. Record review on R5's bladder incontinent care plan document: Check and change resident every two hours. On 7/15/23 at 11:40 AM, V4 (ADON) stated that his staff is supposed to check the resident and provide incontinent care every two hours and as needed. The facility presented Incontinent-Peri Care Policy (Revised October 2016) document: 2. Incontinent or Perineal care has to be provided by the nursing staff at least every 2 hours and as needed (PRN) to all residents identified by the staff to be incontinent or needing assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve foods to residents at a palatable temperature. This has the potential to affect all 230 residents consuming food from the kitchen. The Findings include: On 7/15/23 at 1:00 PM, V17 (Dietary Director) stated, We have 230 residents eating from the Kitchen. On 7/15/23 at 11:40 AM, the lunch meal tray line was observed, and a test tray was requested. The test tray was the last tray loaded into the food cart to the last serving unit (Fourth-floor cart#4). On 7/15/23 at 12:20 PM, V16 (Cook) stated that he took the temperatures of all food items, and the temperature was above 170F. V16 added that he didn't enter it into the log because he was waiting for the surveyor to come, as he was told to wait for the surveyor from previous surveys. On 7/15/23 at 12:37 PM, V16 checked the food temperature from the test tray (on fourth-floor cart#4) using the facility thermometer. The temperatures were as follows: Puree Meat - 116F Mechanical Soft Meat - 123F Beef Patties - 128.6F Mechanical Soft Carrots - 115F Mashed Potatoes - 120F Carrots - 119F On 7/15/23 at 12:45 PM, V17 (Dietary Director) stated that the food serving temp should be at least 135F. V17 added that he should order a new food cart and eliminate the serving delay once the food arrives in units. R1 was a [AGE] year-old male admitted on [DATE] with moderate cognitive impairment as per Minimum Data Set (MDS) dated [DATE]. On 7/15/23 at 2:30 PM, R1 stated, The food was too cold, and I complained to the dietary manager. He wasn't doing anything. R3 is an [AGE] year-old female with mild cognitive impairment as per MDS dated [DATE]. On 7/15/23 at 10:43 AM, R3 stated that the food was too cold, the morning breakfast eggs were cold, and she felt like throwing up. R7 is a [AGE] year-old male with cognition intact as per MDS dated [DATE]. On 7/15/23 at 3:35 PM, R7 stated, Food is not tasty and is cold most of the time. The facility presented Meal Service/Tray Service Policy (revised 2010) document: Hot food will be served at 135For higher and cold foods will be served at 41F or lower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy for providing communication devices and initiating a communication care plan for identified non-English speaking residents. This applies to 3 of 3 residents (R1, R7, and R8) reviewed for resident's rights in the area of translation in the sample of 10. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including: dementia and stroke. R1's MDS (Minimum Data Set) dated March 13, 2023, showed R1 had severely impaired cognitive skills for daily living. The MDS continued to show R1's preferred language was Bulgarian and needed an interpreter to communicate with healthcare staff. The MDS showed R1 was dependent on facility staff for transfers between surfaces and required extensive assistance from facility for all other ADLs (Activities of Daily Living). R1's language care plan dated October 5, 2021, showed the resident has a communication problem related to language barrier. The care plan goal dated October 7, 2021, showed, The resident will maintain current level of communication function with what assistance i.e., making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, writing messages through the next review date. The care plan continued to show multiple interventions dated October 5, 2021, including, Resident prefers to communicate in Bulgarian language whenever possible. On April 17, 2023, at 4:31 PM, V9 (LPN/Licensed Practical Nurse) said R1 does not speak English. V9 continued to say he would communicate with R1 by using hand gestures and body language. On April 18, 2023, at 12:38 PM, V15 (CNA/Certified Nursing Assistant) spoke to R1 in English and explained she will be repositioning R1. V15 and V16 (both CNAs) repositioned R1 in bed and R1 cried out. V15 asked R1, What's wrong? R1 responded to V15 in another language. V15 said she did not understand what R1 said to V15. On April 18, 2023, at 3:47 PM, V11 (LPN/Licensed Practical Nurse) said she has a Bulgarian language book to use with R1. V11 continued to say she does not use the communication book with R1. On April 18, 2023, at 3:15 PM, V5 (Social Services Director) said staff should be using communication boards when interacting with non-English speaking residents. 2. R8's EMR showed R8 was admitted to the facility on [DATE], with multiple diagnoses including: dementia, kidney failure, peripheral vascular disease, and diabetes. R8's MDS dated [DATE], showed R8 had modified independence of cognitive skills for daily decision making. The MDS continued to show R8's preferred language was Serbian and needed an interpreter to communicate with healthcare staff. The MDS showed R8 required extensive assistance from facility staff for ADLs. R8's care plans do not show a care plan for communication. On April 17, 2023, at 4:40 PM, V10 (Activities) said R8 speaks Bulgarian (not Serbian). V10 continued to say there is not a Bulgarian communication board she can use to communicate with R8. On April 18, 2023, at 3:39 PM, V18 (RN/Registered Nurse) said R8 does not speak English. V18 said she does not know what language R8 speaks. V18 said she does not use a communication board to communicate with R8. On April 19, 2023, at 4:45 PM, V2 (DON/Director of Nursing) said she does not know what language R8 speaks. V2 continued to say she asked the nurse, and she also did not know what language R8 spoke. 3. R7's EMR showed R7 was admitted to the facility on [DATE], with multiple diagnoses including: stroke, dementia, aphasia, chronic obstructive pulmonary disease, and deaf. R7's MDS dated [DATE], showed R7 had severe cognitive impairment and was totally dependent on facility staff for ADLs. The MDS continued to show R7's preferred language was Cambodian, and R7 needed an interpreter to communicate with healthcare staff. R7's communication care plan dated January 19, 2022, showed, The resident has a communication problem related to language barrier. The care plan continued to show multiple interventions dated January 19, 2022, including Resident requires assistance with communication, can utilize communication board as needed. On April 18, 2023, at 3:34 PM, V17 (CNA/Certified Nursing Assistant)) said R7 does not speak English. V17 continued to say there is not a communication board to use when communicating with R7. The facility's policy titled, Translation and/or Interpretation of Facility Services, revised November 2015, showed, Policy Statement: This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. Policy Interpretation and Implementation: . 2. When encountering LEP individuals, staff members should identify the language spoken by the resident id not able to speak English. 3. Any staff can provide translation services free of charge to any resident or resident's all LEP. The person shall receive information a communication board to be able to communicate to any staff in the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide shower, incontinence care, nail hygiene, grooming, assistance for bed mobility and feeding to residents that required staff assistance for ADLs (Activities of Daily Living). This applies to 27 of 27 residents (R1 through R27) reviewed for ADLs in a sample of 29. The findings include: On February 15, 2023, from the hours of 10:30 A.M. through 3:00 P.M. at intermittent observations, together with V3 (Wound Care Nurse Specialist/Licensed Practical Nurse/LPN) the following residents (R1 through R27) were observed: 1. R1 was observed lying in his bed. R1 was alert and oriented and able to verbalize needs. R1 said that he needs to be repositioned, incontinence brief needed changed and asked for water to drink. It was noted that his water container was empty. When asked when was the last time R1 was provided incontinence care, R1 said that it was around 9:00 A.M. During this observation, it was around 12:20 P.M. V4's (Certified Nurse Assistant/CNA) and V5's (LPN) attention were called. They both said that they were trying hard to provide care of residents, however, they cannot provide them care according to acceptable standard practice like checking on residents every 2 hours because the facility needs more help with staffing. V4 said, I last change his brief maybe 9:00 A.M. I know it has been almost 4 hours I did not get to him. When V4 and V5 unfastened R1's brief, the incontinence brief was heavily soaked with urine. R1 also requested to be repositioned for comfort since he has been lying in same position (supine for almost 4 hours). R1 said Can I have water please to drink? My cup has been emptied for a while now. After the incontinence care and repositioning was provided to R1, V4 provided a refill of water to drink. R1 took a big sip and was able to hold the cup. R1 said that he just needs the staff to refill his cup of water to drink. R1 was also observed with unkempt, matted beard, and moustache. R1's hair appeared oily and uncombed. 2. R2 was observed sitting in his wheelchair. R2 was in the third-floor dining room. V6 (R2's son) was next to R2. They both said that R2 goes out 2-3 times a week for an outside therapy service. R2 was noted with long sharp edged fingernails. The fingernails were embedded with a black substance. R2 said that he has been at the facility for a year. R2 and V6 said that R2 was never given a shower but a bed bath at times. R2 said I guess they do not give me a shower because I use the total lift device and they need more people to transfer me. V3 (LPN) checked the shower schedule binder, and it showed random documentation of shower sheets. R2 was provided a bed bath 2-3 times but not a shower for an undetermined length of time. Months of the shower schedule were kept in the shower binder. V7 (CNA) said We don't rely on that shower book because most of the time there were no available shower sheets to be filled in. It is okay, I will give him a shower tomorrow. 3. R3 was observed sitting in his wheelchair. R3 was in the second-floor dining room. R3 was noted to have multiple wound dressings around left lower left leg. There were multiple surgical pin sites sticking out from the left ankle surgical site. R3 also had a below knee right amputee. R3 said I want to go home, and I will be going home Friday. I cannot wait to go home. I do not like this place. It takes time for everything if you need help. R3 said he needed assistance with his ADLs due to his functional limitation. R3 was noted with unkempt, uncombed oily hair and long knotted beard. When asked if he wanted to be shaved, R3 replied It would be nice if someone would help me shave so I look decent, especially since I'm going home. I don't want my girlfriend see me like this. 4. R4 was observed lying in bed. R4 was on an air loss mattress. V8 (R4's daughter) was at R4's bedside. V8 said that she comes everyday around 12:00 noon so she can provide care to R4. V8 said They need more staff here. I filed a grievance because (R4) was not timely changed with his incontinence brief. Just like today when I came in at 12:00 noon, my father was soaking wet. I changed his brief; here look at it. Here is also his sweatpants and white shirt that was soaked with his urine when I changed his brief at noon. It was around 12:45 when R4 was observed. The soiled brief was at the garbage bin next to R4. R4's sweatpants were in his hamper. The sweatpants were gray in color, smelled of urine and the crotch area was wet. The shirt was white in color, and the waist part was also wet and smelled like urine. R4's wheelchair was next to his bed. The wheelchair had a cushion with a pillowcase used to cover the cushion. The pillowcase was also wet and made a ring mark due to the leaked urine. 5. R5 was observed lying in bed. R5 was lying supine and looked very uncomfortable. R5 was lying in between the edge of her bed mattress and the upper part of the bed siderail. R5 appeared trapped between the bed and the bed rail. R5 said that only once a CNA came in R5's room and changed her brief. R5 said, That was early this morning. I think she is from agency. Now I'm wet and need to be change and put in the middle of my bed. When V3 (LPN)unfastened R5's incontinence brief, it was soaked with urine. There were multiple incontinence pads (2 cloth and 1 disposable pads) under R5's soiled brief. Observations continued to the second floor with V3 (LPN): 6. R6 was observed lying in bed. R6's incontinence brief was heavily soaked with urine when it was unfastened by V3 (LPN). R6 said she was changed at 9:00 A.M. During the observation, it was 2:30 P.M. 7. R7 was observed sitting in her wheelchair in the second-floor dining room. R7 said I am the birthday queen today. R7 was very proud of her crown and her attire. R7 was noted with long nails with jagged edges and nails were heavily embedded with black substance. R7 was asked about her nails. R7 responded It would have been nice if someone would trim my nails so I would look clean and feel good. 8. R8 was observed sitting in her wheelchair in the second-floor dining room. R8's fingernails were long, jagged and heavily embedded with black substance under the nail's beds. R8, a female resident, also was observed with long facial hair including the chin area. R8 was uncombed and an accumulation of a white flaky substance that look like dandruff was all over her shirt around her neck, shoulder areas. 9. R10 was observed lying in bed. R10's incontinence brief was heavily soaked with urine when it was unfastened by V3 (LPN). R10 said she was changed around 9:00 A.M. During the observation, it was around 2:00 P.M. Observations continued to the third floor with V3 (LPN): 10. R11 was sitting in her wheelchair in the third-floor dining room. V9 (R11's husband) was visiting and was sitting next to R11. R11 was confused and not able to verbalize needs. R11, a female resident, was noted with facial hair around the chin area, crusty eyes and uncombed hair. R11's fingernails were long, jagged and had black substance under the nails. V9 said that R11 needed help with her hygiene. 11. R12 was sitting in her wheelchair in the third-floor dining room. R12 was confused and not able to be verbalized needs. R12, a female resident, was noted with facial hair around the chin area and unkempt oily hair. R12's fingernails were long, jagged and had a black substance under the nails. 12. R13 was sitting in her wheelchair in the third-floor dining room. R13 was confused. R13, a female resident, was noted with facial hair around the chin area and unkempt oily hair. R13's fingernails were long, jagged and had a black substance under the nails. 13. R14, a female resident, was seen sitting in her wheelchair in the third-floor dining room. R14 said in a loud tone of voice I need help; help, need to go to the bathroom. No staff came immediately and R15, a male resident who was ambulatory, started to propel R14's wheelchair out of the dining room and attempting to help R15's bathroom needs. Surveyor prompted a staff for R14's toilet needs. V10 (Registered Nurse/RN) came to assist R14. 14. R15 was observed sitting on the couch in the third-floor dining area. R15 had difficulty expressing self and said he needed help in shaving his long beard/moustache. R15 also had long fingernails that were jagged in edges and had a black substance under the nails. 15. R16 was observed sitting in her wheelchair in the third-floor dining area. R16 had long fingernails that were jagged in edges and had a black substance under the nails. 16. R17 was observed sitting in his wheelchair in the third-floor dining area. R17 was noted with his long unkempt beard/moustache. R17 also had long fingernails that were jagged in edges and had a black substance under the nails. 17. R18 was observed sitting in her wheelchair in the third-floor dining area. R18 had long fingernails that were jagged in edges and had a black substance under the nails. 18. R19 was observed lying in bed in her room. R19 had long fingernails that were jagged in edges and had a black substance under the nails. 19. R20 was observed sitting in her wheelchair in the third-floor dining area. R20 had long fingernails that were jagged in edges and had a black substance under the nails. 20. R21 was lying in her bed. R21 had long fingernails that were jagged in edges and had a black substance under the nails. V7 (CNA) unfastened R21's incontinence brief. R21's brief was heavily soaked with urine and the urine had leaked through R21's incontinence cloth pad and bed sheet. 21. R22, a female resident, was sitting in her wheelchair in the third-floor dining area. R22 had facial hair around her chin area. R22 had long fingernails that were jagged in edges and had a black substance under the nails 22. R23 was observed sitting in his wheelchair in the third-floor dining area. R23 was noted with a long unkempt beard/moustache. R23 also had long fingernails that were jagged in edges and had a black substance under the nails. 23. R24 was observed lying in bed in her room. R24, a female resident, was observed with unkempt hair and had long hair sticking out from her ears. R24 also was noted with long fingernails that were jagged in edges and had a black substance under the nails. V7 (CNA) had unfastened R24's incontinence brief. R24 was heavily soaked with urine. V7 said it was around 10:00 A.M. when she changed R24's brief. At this time of observation, it was 2:10 P.M. Observations on the 4th floor continued with V3 (LPN): 24. R25 was lying supine in bed. R25's knees were in flexed position pointing outward. R25 was noted with an indwelling urinary catheter. The catheter tubing was tied to a cloth tape and the tape was wrapped around R25's right mid-thigh area. The cloth tape was smeared with fecal material. The cloth tape was also stretching the urinary catheter from R24's penile area. This observation was pointed to V3 (LPN)and V5 (LPN). V5 said that she will place an appropriate device to secure the indwelling catheter to prevent tugging the catheter away from R24's penile area. R24 was also noted with long fingernails that were jagged in edges and had a black substance under the nails 25. R26 was observed sitting in her wheelchair in the lounge area. R26 was noted with long fingernails that were jagged in edges and had a black substance under the nails. 26. R27 was observed lying in bed in her room. R26 was noted with long fingernails that were jagged in edges and had a black substance under the nails. V3 (LPN) had unfastened R27's incontinence brief. R27 was moderately soaked with concentrated urine, dark amber color. R27 asked for water to drink. R27's water cup was noted empty and needed refilled. Together with V3 (LPN), another intermittent observation was made on February 16, 2023 from 10:00 A.M. through 12:00 P.M. At 10:00 A.M., R2 was lying in bed. R2 was happy and smiling. R2 stated I finally got my shower early this morning. It took 4 people to give me shower. I guess they do not have enough people here; that why I never got a shower for all this time for a year. I feel so clean. They give me a bed bath, but it is so refreshing to have a shower. I go to my therapy 3 times a week at an outside facility and sometimes I am not comfortable in case I might have a body odor. Around 10:30 A.M., R1 was observed lying in bed. R1 said I need my incontinence brief changed. When V4 (CNA) had unfastened R1's incontinence brief, R1 was heavily saturated with urine and soft stool. At 12:30 P.M. R5, was lying in bed. R5 was lying supine and looked very uncomfortable. R5 was lying in between the edge of her bed mattress and the upper part bed siderail. R5 appeared trapped between the bed and the bed rail. R5 was served a pureed lunch of sweet potatoes, mashed potatoes and mechanical texture of meat. The lunch tray was noted with a meal ticket that showed R5 requires feeding assistance. R5 was observed holding a spoon with her left hand and trying to reach her food that was placed on top her overbed tray table. The tray table was next to her bed and was perpendicular to her bed. On 2/15 and 16 of 2023 during the observations, interviews were also held with direct care staff (nurses and CNAs) and they all said that the residents observed require extensive to total assistance for ADLs. Record review shows that R1 through R27's EMR (Electronic Medical Records) show that they need staff assistance for their ADLs including incontinence care, grooming and hygiene and turning and repositioning. The EMR (Electronic Medical Record) of shows the following: 1. R1, a [AGE] year-old admitted to the facility on [DATE]. Review of record shows that R1 was presented from hospital prior to admission to the facility after he tripped and fell at home. R1 used to be heavy substance abuse user but has been clean in the past 5 years. He is also on disability after multiple bypass surgeries. An X-ray of the shoulder showed displaced proximal humerus fracture as well as distal humerus displaced fracture. Reduction was done in the ED (Emergency Department). Orthopedic was on consult. S/P (status post) open reduction with intramedullary nail fixation. R1 was transferred to the facility for rehabilitation. The record shows other pertinent diagnoses such as Bipolar 1 disorder, cocaine abuse, depression, diabetes mellitus, type II, hyperlipidemia, hypertension, myocardial infarction with cardiac surgery. The EMR also shows a Special Instructions for R1 to be assisted as Total dependence with 2 plus person assistance. 2. R2's care plan dated 12/19/2022 shows that R2 has an ADL self-care performance deficit related to hypertension, dementia, left hip fracture status post ORIF (open reduction internal fixation), cervical and lumbar degenerative joint disease, polyarthritis and anemia. The face sheet of the EMR shows Special Instruction: total dependence with 2 plus person assistance with use of mechanical lift transfer device. The MDS (Minimum Data Set) dated 12/19/2022 shows that R2 is cognitively intact with BIMS score (Brief Interview for Mental Status) of 15/15; and functional mobility assessed as 4/3 (total dependence with 2 plus person assistance) for bed mobility, transfer, toilet use and bathing. 3. The MDS dated [DATE] shows R3's BIMS score of 15/15 indicating cognitively intact; functional mobility 3/3 (extensive assistance with 2 plus person assist) for bathing, transfer, toilet. The face sheet of the EMR shows special instructions for R3 to be handled with extensive assistance with 2 plus person assistance. The care plan 2/4/2023 shows that R3 has an ADL self-care performance deficit due to activity intolerance related to acute osteomyelitis left ankle and foot, hypertension, diabetes mellitus, benign prostate hyperplasia, acquired absence of the right below the knee, presence of coronary angioplasty, Charcot's joint, left ankle and foot. R2, a [AGE] year-old and was admitted to the facility on [DATE]. 4. R4, an [AGE] year-old with diagnoses of Parkinson's Disease, dementia, AHSD (atherosclerotic heart disease), with original admission to the facility on 8/3/2022 and readmitted on [DATE]. The special instructions written on the Face Sheet shows R4 requiring extensive assistance with 2 plus person assistance, The MDS dated [DATE] shows R4's BIMS score of 2/15 (severely impaired with cognition) and functional mobility of 4/3 (total assistance with 2 plus person assistance) for bed mobility, transfers and toilet use. 5. R5, an [AGE] year-old with diagnoses of polyarthritis, anxiety disorder, and major depressive disorder. R5 was originally admitted to the facility on [DATE] and readmission on [DATE]. The special instruction written on the face sheet shows that R5 requires extensive assistance with 2 plus person assist with ADLs. The MDS dated [DATE] shows that R5's memory was okay. R5's functional assessment per MDS shows extensive assistance with 2 plus person assist for bed mobility, transfers, toilet use and limited assistance with 1 person assist for feeding. 6. R6 though R27 require staff assistance from extensive to total assistance with ADLs. The facility's ADL policy, dated January 2022, shows Resident will receive assistance with Activities of Daily Living (ADLs) every shift .ADLs include bathing, grooming, dressing, ambulation and toilet needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient nursing and CNA (Certified Nursing Assistant) staff to accommodate and provide required ADL (Activity of Daily Living) care to residents that needed assistance. This has the potential to affect all 244 residents residing at the facility. The findings include: The Facility Data Sheet dated February 15, 2023 showed the facility census was 244. On Wednesday, February 15,2023 during the initial tour of the facility, three CNAs (V14 through V16) were assigned to the first floor residents which had a resident census was 65 (20-21 residents per CNA). There were five CNAs (V14 through V18) assigned to the third floor which had a resident census of 84 (16-17 residents per CNA). There were 4 CNAs (V5, V22 through V25) assigned to the fourth floor which had a resident census of 95 (23-24 residents per CNA). The February 16, 2023 schedule showed that resident census for third floor was 84 with 4 CNAs (20-21 per CNA) and 4th floor resident census was 95 with 4 CNAs assigned (22/24/27/ residents per CNA). The facility Resident/Family Complaint Log shows residents/families for the week (2/14/2023) had expressed concerns regarding lack of ADL care and increased fall incidents. On 2/15 and 16, of 2023, confidential interviews were held with direct care staff that included nurses, CNAs and managerial nursing position. The interviews show a unanimous statement that facility does not have enough staff to accommodate residents' needs, and care that is considered acceptable nursing practice cannot be provided. The staff also said that it is impossible to provide residents required needs such as turning and repositioning every 2 hours, checking and providing incontinence care every 2 hours, 2 meals and feeding assistance for day shift (breakfast and lunch), showers to be given, and toileting needs and whatever needs in between. They also said that their residents require extensive to total assistance with ADLs. On 2/16/2021 at 12:45 P.M., V26 (Staffing Scheduler) said that she tries her best to schedule sufficient nursing staff for residents' care but it does not happen and ends up lack of staffing issues. Together with V3 (License Practical Nurse/LPN/Wound Care Treatment Nurse), observations held at random times on 2/15 and 16, 2023 to multiple residents (R1 through R27). There were multiple concerns regarding lack of ADL care, hygiene and grooming which were not maintained to R1 through R27. V3 said that R1 though R27 require extensive to total assistance from staff. The observations were as follows: 1. R1 was lying in his bed. R1 was alert and oriented and able to verbalize needs. R1 said that he needed to be repositioned, incontinence brief needed to be changed and also asked for water to drink. It was noted that his water container was empty. When asked when was the last time R1 was provided incontinence care, R1 said that it was around 9:00 A.M. During this observation, it was around 12:20 P.M. V4's (CNA) and V5's (LPN) attention were called. They both said that they were trying hard to provide care of residents, however, they cannot provide them care as acceptable standard practice like checking on residents every 2 hours because the facility needs more help with staffing. V4 said I last changed his brief maybe 9:00 A.M. I know it has been almost 4 hours I did not get to him. When V4 and V5 unfastened R1's brief, the incontinence brief was heavily soaked with urine. R1 also requested to be repositioned for comfort since he had been lying in the same position (supine) for almost 4 hours. R1 said Can I please have water to drink? My cup has been emptied for a while now. After the incontinence care and repositioning was provided to R1, V4 provided a refill of water to drink. R1 took a big sip and was able to hold the cup. R1 said that he just needs the staff to refill his cup of water to drink. R1 was also observed with unkempt, matted beard, and moustache. R1's hair appeared oily and uncombed. 2. R2 was observed sitting in his wheelchair. R2 was in the third-floor dining room. V6 (R2's son) was next to R2. They both said that R2 goes out 2-3 times a week for an outside therapy service. R2 was noted with long sharp edged fingernails. The fingernails were embedded with a black substance. R2 said that he has been at the facility for a year. R2 and V6 said that R2 was never given a shower but a bed bath at times. R2 said I guess they do not give me a shower because I use the total lift device and they need more people to transfer me. V3 (LPN) checked the shower schedule binder and it showed random documentations of shower sheets. R2 was given 2-3 bed baths but not a shower for the length of time (months) shower sheets were kept in the shower schedule binder. V7 (CNA) said they do not rely on that shower binder schedule because most of the time there were no available shower sheets to be filled in. V7 said, It is okay. I will give him shower tomorrow. 3. R3 was observed sitting in his wheelchair. R3 was in the second-floor dining room. R3 was noted to have multiple wound dressings around left lower left leg. There were multiple surgical pin sites sticking out from the left ankle surgical site. R3 also had below knee right amputee. R3 said I want to go home, and I will be going home Friday. I cannot wait to go home. I do not like this place. It takes time for everything if you need help. R3 said he needed assistance for his ADLs due to his functional limitation. R3 was noted with unkempt, uncombed oily hair and long knotted beard. When asked if he wanted to be shaved, R3 replied It would be nice if someone would help me shave so I look decent when I'm going home. I don't want my girlfriend see me like this. 4. R4 was observed lying in bed. R4 was on an air loss mattress. V8 (R4's daughter) was at R4's bedside. V8 said that she comes everyday around 12:00 noon so she can provide care to R4. V8 said They need staff here. I filed a grievance because (R4) was not timely changed with his incontinence brief. Just like today when I came in at 12:00 noon. My father was soaking wet. I changed his brief; here look at it. Here is his sweatpants and white shirt that were soaked with urine when I changed his brief at noon. It was around 12:45 when R4 was observed. The soiled brief was in the garbage bin next to R4. R4's sweatpants were in his hamper. The sweatpants were gray in color, smelled of urine and the crotch area was wet. The shirt was white, and the waist part was also wet and smell like urine. R4's wheelchair was next to his bed. The wheelchair had a cushion with a pillowcase used to cover the cushion. The case was also wet and made a ring due to soaked leaked urine. 5. R5 was lying in bed. R5 was lying supine and looked very uncomfortable. R5 was lying in between the edge of her bed mattress and the upper part of the bed siderail. R5 appeared trapped between the bed and the bed rail. R5 said that it was only once that a CNA came in here and changed her brief. R5 said That was early this morning. I think she is from an agency. Now I'm wet and need to be changed and put back on the middle of my bed. When V3 (LPN) unfastened R5's incontinence brief, it was soaked with urine. There were multiple incontinence pads (2 cloth and 1 disposable pads) under R5's soiled brief. Observations continue to the second floor with V3 (LPN). 6. R6 was observed lying in bed. R6 was heavily soaked with urine when R6's incontinence brief was unfastened by V3. R6 said she was changed at 9:00 A.M. During the observation, it was 2:30 P.M. 7. R7 was sitting in her wheelchair in the second-floor dining room. R7 said I am the birthday queen today. R7 was very proud of her crown and her attire. R7 was noted with long nails, jagged edges and nails were heavily embedded with a black substance. R7 was asked about her nails. R7 responded It would have been nice if someone would trim my nails so I would look clean and feel good. 8. R8 was sitting in her wheelchair in the second-floor dining room. R8's fingernails were long, jagged and heavily embedded with a black substance under the nail's beds. R8, a female resident, also had long facial hair including the chin area. R8's hair was uncombed and had an accumulation of white flakey substance that look like dandruff all over her shirt around her neck, shoulder areas. 9. R10 was lying in bed. R10 was heavily soaked with urine when incontinence brief was unfastened by V3 (LPN). R10 said she was changed around 9:00 A.M. During the observation, it was around 2:00 P.M. Observations continue on the third floor with V3 (LPN). 10. R11 was sitting in her wheelchair in the third-floor dining room. V9 (R11's husband) was visiting and was sitting next to R11. R11 was confused and not able to verbalize needs. R11, a female resident, was noted with facial hair around the chin area, crusty eyes and uncombed hair. R11's fingernails were long, jagged and had a black substance under the nails. V9 said that R11 needed help with her hygiene. 11. R12 was sitting in her wheelchair in the third-floor dining room. R12 was confused and not able to verbalize needs. R12, a female resident, was noted with facial hair around the chin area and unkempt oily hair. R12's fingernails were long, jagged and had a black substance under the nails. 12. R13 was sitting in her wheelchair in the third-floor dining room. R13 was confused. R13, a female resident, was noted with facial hair around the chin area and unkempt oily hair. R13's fingernails were long, jagged and had a black substance under the nails. 13. R14, a female resident, was seen sitting in her wheelchair in the third-floor dining room. R14 said in a loud tone of voice I need help; help, need to go to the bathroom. No staff came immediately and R15, a male resident who was ambulatory, started to propel R14's wheelchair out of the dining room and attempted to help with R14's bathroom needs. Surveyor prompted a staff for R14's toilet needs. V10 (RN/Registered Nurse) came to assisted R14. 14. R15 was observed sitting on the couch in the third-floor dining area. R15 had difficulty expressing self and said he needed help in shaving his long beard/moustache. R15 also had long fingernails that were jagged in edges and had a black substance under the nails. 15. R16 was observed sitting in her wheelchair in the third-floor dining area. R16 had long fingernails that were jagged in edges and had a black substance under the nails. 16. R17 was observed sitting in his wheelchair in the third-floor dining area. R17 was noted with a long unkempt beard/moustache. R17 also had long fingernails that were jagged in edges and had a black substance under the nails. 17. R18 was observed sitting in her wheelchair in the third-floor dining area. R18 had long fingernails that were jagged in edges and had a black substance under the nails 18. R19 was observed lying in bed in her room. R19 had long fingernails that were jagged in edges and had a black substance under the nails. 19. R20 was observed sitting in her wheelchair in the third-floor dining area. R20 had long fingernails that were jagged in edges and had a black substance under the nails. 20. R21 was lying in her bed. R21 had long fingernails that were jagged in edges and had a black substance under the nails. V7 (CNA) unfastened R21's incontinence brief. R21's brief was heavily soaked with urine and the urine had leaked through R21's incontinence cloth pad and bed sheet. 21. R22, a female resident, was sitting in her wheelchair in the third-floor dining area. R22 had facial hair around her chin area. R22 had long fingernails that were jagged in edges and had a black substance under the nails 22. R23 was observed sitting in his wheelchair in the third-floor dining area. R23 was noted with a long unkempt beard/moustache. R23 also had long fingernails that were jagged in edges and had a black substance under the nails. 23. R24 was observed lying in bed in her room. R24, a female resident, was observed with unkempt hair and had long hair sticking out from her ears. R24 also was noted with long fingernails that were jagged in edges and had a black substance under the nails. V7 (CNA) had unfastened R24's incontinence brief. R24 was heavily soaked with urine. V7 said it was around 10:00 A.M. when she changed R24's brief. At this time of observation, it was 2:10 P.M. Observations on the 4th floor continued with V3 (LPN): 24. R25 was lying supine in bed. R25's knees were in flexed position pointing outward. R25 was noted with an indwelling urinary catheter. The catheter tubing was tied to a cloth tape and the tape was wrapped around R25's right mid-thigh area. The cloth tape was smeared with fecal material. The cloth tape was also stretching the urinary catheter from R24's penile area. This observation was pointed to V3 (LPN) and V5 (LPN). V5 said that she will place an appropriate device to secure the indwelling catheter to prevent tugging the catheter away from R24's penile area. R24 was also noted with long fingernails that were jagged in edges and had a black substance under the nails 25. R26 was observed sitting in her wheelchair in the lounge area. R26 was noted with long fingernails that were jagged in edges and had a black substance under the nails. 26. R27 was observed lying in bed in her room. R26 was noted with long fingernails that were jagged in edges and had a black substance under the nails. V3 (LPN) had unfastened R27's incontinence brief. R27 was moderately soaked with concentrated urine, dark amber color. R27 asked for water to drink. R27's was noted with an empty cup of water and needed refilled. Together with V3 (LPN) another intermittent observation was made on February 16/2023 from 10:00 A.M. through 12:00 P.M. At 10:00 A.M., R2 was lying in bed. R2 was happy and smiling. R2 stated I finally got my shower early this morning. It took 4 people to give me a shower. I guess they do not have enough people here; that why I never got a shower for all this time for a year. I feel so clean. They give me a bed bath, but it is so refreshing to have a shower. I go to my therapy 3 times a week at an outside facility and sometimes I am not comfortable in case I might have a body odor. At around 10:30 A.M., R1 was observed lying in bed. R1 said I need my incontinence brief changed. When V4 (CNA) had unfastened R1's incontinence brief, R1 was heavily saturated with urine and soft stool. At 12:30 P.M. R5 was lying in bed. R5 was lying supine and looked very uncomfortable. R5 was lying in between the edge of her bed mattress and the upper part bed siderail. R5 appeared trapped between the bed and the bed rail. R5 was served a pureed lunch of sweet potatoes, mashed potatoes and mechanical texture of meat. The lunch tray was noted with a meal ticket that showed R5 requires feeding assistance. R5 was observed holding a spoon with her left hand and trying to reach her food that was placed on top her overbed tray table. The tray table was next to her bed and was perpendicular to her bed. On 2/15 and 16 of 2023 during the observations, interviews were also held with direct care staff (nurses and CNAs) and they all said that the residents observed require extensive to total assistance for ADLs. Record review shows that R1 through R27's EMR (Electronic Medical Records) document they need staff assistance for their ADLs including incontinence care, grooming and hygiene and turning and repositioning. The EMR (Electronic Medical Record) shows the following: 1. R1, a [AGE] year-old admitted to the facility on [DATE]. Record review showed that R1 was presented from hospital prior to admission to the facility after he tripped and fell at home. R1 used to be heavy substance abuse user but has been clean in the past 5 years. He is also on disability after multiple bypass surgeries. A shoulder X-ray showed displaced proximal humerus fracture as well as distal humerus displaced fracture. Reduction was done in the ED (Emergency Department); Orthopedic was on consult. S/P (status post) open reduction with intramedullary nail fixation. R1 was transferred to the facility for rehabilitation. The record shows other pertinent diagnoses such as Bipolar 1 disorder, cocaine abuse, depression, diabetes mellitus, type II, hyperlipidemia, hypertension, myocardial infarction with cardiac surgery. The EMR also shows a Special Instructions for R1 to be assisted as Total dependence with 2 plus person assistance. 2. R2's care plan dated 12/19/2022 showed that R2 has an ADL self-care performance deficit related to hypertension, dementia, left hip fracture status post ORIF (open reduction internal fixation), cervical and lumbar degenerative joint disease, polyarthritis and anemia. The face sheet of the EMR shows Special Instruction: total dependence with 2 plus person assistance with use of mechanical lift transfer device. The MDS (Minimum Data Set) dated 12/19/2022 showed that R2 is cognitively intact with BIMS score (Brief Interview for Mental Status) of 15/15; and functional mobility assessed as 4/3 (total dependence with 2 plus person assistance) for bed mobility, transfer, toilet use and bathing. 3. The MDS dated [DATE] showed R3's BIMS score of 15/15 indicating cognitively intact; functional mobility 3/3 (extensive assistance with 2 plus person assist) for bathing, transfer, toilet. The face sheet of the EMR showed special instructions for R3 to be handled with extensive assistance with 2 plus person assistance. The care plan 2/4/2023 showed that R3 has an ADL self-care performance deficit due to activity intolerance related to acute osteomyelitis left ankle and foot, hypertension, diabetes mellitus, benign prostate hyperplasia, acquired absence of the right below the knee, presence of coronary angioplasty, Charcot's joint, left ankle and foot. R2 is a [AGE] year-old and was admitted to the facility on [DATE]. 4. R4 is an [AGE] year-old with diagnoses of Parkinson's Disease, dementia, AHSD (atherosclerotic heart disease), with original admission to the facility on 8/3/2022 and readmitted on [DATE]. The special instructions written on the Face Sheet showed R4 requiring extensive assistance with 2 plus person assistance. The MDS dated [DATE] showed R4's BIMS score of 2/15 (severely impaired with cognition) and functional mobility of 4/3 (total assistance with 2 plus person assistance) for bed mobility, transfers and toilet use. 5. R5 is an [AGE] year-old with diagnoses of polyarthritis, anxiety disorder, and major depressive disorder. R5 was originally admitted to the facility on [DATE] and readmission on [DATE]. The special instruction written on the face sheet showed that R5 requires extensive assistance with 2 plus person assist with ADLs. The MDS dated [DATE] showed that R5's memory was intact. R5's functional assessment per MDS showed extensive assistance with 2 plus person assist for bed mobility, transfers, toilet use and limited assistance with 1 person assist for feeding. 6. R6 though R27 require staff assistance from extensive to total assistance with ADLs. The facility's Activities of Daily Living policy, dated January 2022, showed Resident will receive assistance with Activities of Daily Living (ADLs) every shift . ADLs include bathing, grooming, dressing, ambulation and toilet needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide incontinence care in a dignified manner for 2 of 2 residents (R139, R65) reviewed for dignity in the sample of 35. The findings include: 1. On 1/25/23 at 10:40 AM, V21 (Agency Certified Nursing Assistant/CNA) was providing incontinence care to R139. R139 was on her back with her vaginal and rectal areas exposed. R71 (R139's roommate) was sitting in her wheelchair at the foot of the bed watching R139's care. V21 did not intervene. R71 watched the remainder of the incontinence care from the foot of R139's bed. R139's Face Sheet printed 1/25/23 showed diagnoses to include, but not limited to: chronic non-pressure ulcer to the right foot, diabetes, contractures of bilateral lower extremities, COPD (Chronic Obstructive Pulmonary Disease), Stage 3 CKD (Chronic Kidney Disease), dementia, depression, and personal history of strokes. On 1/26/23 at 9:31 AM, V3 (Director of Nursing/DON) stated, Residents are supposed to be provided privacy during all care. It's a dignity issue. R71 should not have been watching R139's care. The facility's Resident Rights, Privacy, and Dignity Policy (revised 11/17) showed, Employees shall treat all residents with kindness, respect, dignity and uphold the residents' rights. Policy Interpretation and Implementation: 2 . d. The resident has the right to privacy and confidentiality . 3. The facility must promote and protect the rights of the residents . 26. Provide privacy when providing ADLs (Activities of Daily Living) from the staff in the bedroom, bathroom or bathing room . 29. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity .2. R65's admission Record, printed by the facility on 1/25/23, showed she had diagnoses including bipolar disorder, anxiety disorder and schizoaffective disorder. The same sheet showed a diagnosis of ileostomy status (a surgical opening constructed by bringing the end or loop of the small intestine out onto the surface of the skin where intestinal waste is collected). R65's facility assessment dated [DATE] showed she is dependent on staff for toileting and requires extensive assist of one staff member for hygiene. The assessment showed R65 requires assistance from two staff members for bed mobility. The assessment also shows R65 has an ileostomy and is always incontinent of urine. On 1/24/23 at 10:54 AM, V16 (Registered Nurse/RN) was standing at the medication cart. This surveyor stopped to ask V16 a question. V16 asked if we could talk after he got everything settled for a resident who was being discharged . This surveyor agreed and walked over to R65's room, that she shared with two other residents. R65's curtain was pulled on her section of the room. At 10:56 AM, V16 (RN) entered R65's room carrying a sheet. V16 walked over to the third bed (R65's) and placed the sheet on top of R65, who was naked and exposed. V16 said he had been changing R65's colostomy bag. V16 exited R65's room. At 10:57 AM, V32 (CNA) came into R65's room and removed the sheet to provide personal care for R65. V32 removed the soiled fitted sheet from under R65, then went out of the room and came back with a clean fitted sheet. V32 left R65 uncovered when she went out of the room to get the sheet. On 1/25/23 at 9:45 AM, R65 said she felt uncomfortable when they left her uncovered and naked the previous day. R65 said she felt like she should not be left like that. On 1/25/23 at 2:49 PM, V16 said he had just changed R65's colostomy bag and It was an overlook. V16 said he should have covered R65 up before leaving the room. V16 said it is important not to leave residents exposed and naked for their dignity. R65's care plan titled Restorative: Bed Mobility Program showed R65 has decreased or limited ability to move to and from a lying position, and a decreased or limited ability to turn from side to side in bed. The facility's policy and procedure titled Resident Rights, Privacy and Dignity, with a revision date of November 2017, showed Employees shall treat all residents with kindness, respect, dignity and uphold the resident's rights. The policy showed 2. p. The resident has the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. q. The resident has the right to be treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure there were no discrepancies with resident advanced directives for 3 of 3 residents (R193, R439, R177) reviewed for Advanced Directives in the sample of 35. The findings include: 1. R193's face sheet showed a [AGE] year-old female with admitted to the facility on [DATE]. R193's diagnoses included hemiplegia and hemiparesis following cerebral infarction, gastrostomy, and seizures. On [DATE] at 9:50 AM, R193 was in her room and in bed. R193 was alert and oriented to person, place, time, and situation. On [DATE] at 09:26 AM, V3 (Director of Nursing/DON) said, There shouldn't be a discrepancy between a resident's POLST (Physician Order for Life Sustaining Treatment) and other information in the medical record. The POLST is a legal document, and we need to honor the resident's wishes. There shouldn't be any discrepancies. The correct information should be readily available in the resident's record. R193's medical record showed a [DATE] POLST form signed by a physician. This POLST form showed R193 elected Do Not Resuscitate (DNR) status. R193's Physician Order Sheet showed an order for a full code (full resuscitation). R193's Electronic Medical Record banner showed full code status. R193's medical record did not show any documentation of changes or revocation of the DNR. R193's face sheet showed R193 was her own financial representative. The facility's 8/2011 Do Not Resuscitate Order Policy showed the facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate (DNR) order. A DNR order must be signed on the physician order sheet. Maintained in the resident's medical record. DNR orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. The facility's 8/2011 Advance Directives Policy showed Advance directives will be respected in accordance with state law and facility policy. Prior to or upon admission to the facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to formulate advance directives. Prior to or upon admission the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record. The facility has defined advance directives as preferences regarding treatment options and include but are not limited to: Do Not Resuscitate-indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment and care plan. The Director of Nursing Services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. 2. R439's face sheet showed an [AGE] year-old male admitted to the facility on [DATE]. R439's hospital record (1/5-[DATE]) showed his code status was confirmed as DNR/Do Not Intubate (DNI). This record showed a [DATE] order for No CPR/DNI from admission on ward. R439's electronic record banner does not show a code status. R439's Physician Order Sheet did not show an order for code status.3. The admission record for R177 documents she was admitted to the facility on [DATE] following a cerebral infarction affecting her left side. She has additional diagnoses including osteoarthritis, hypertension, anxiety and has a gastrostomy (feeding) tube. The same record shows her advanced directives to include a full code status. A review of the record shows a signed DNR (Do Not Resuscitate)/Practitioner Orders for Life-Sustaining Treatment form (POLST). The POLST form signed by R177 on [DATE] indicates she wishes to be a DNR. The form was scanned into the record on [DATE], the day of her admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to supervise residents with swallow precautions while eating for 2 of 6 residents (R3, R95) reviewed for safety in the sample of 35. The findings include: 1. R3's face sheet dated 1/25/23 showed diagnoses including but not limited to schizophrenia, depression, anxiety, and dementia. R3's facility assessment dated [DATE] showed severe cognitive impairment and staff assistance of one person for eating. R3's physician orders showed an order start dated 7/17/22 for Mechanical soft texture diet. On 1/24/23 at 11:00 AM, R3 was in bed and her breakfast tray was still in front of her on the bedside table. R3 stated she eats her meals alone in her room. R3's diet ticket showed Aspiration Precautions/Mechanical Soft. The ticket listed interventions of tray set up, cut up solids, fully upright, slow rate, and small bites/sips. On 1/26/23 at 9:50 AM, V27 (Speech Therapist) stated she (R3) needs a mechanical soft texture diet to prevent aspiration. V27 stated, R3 pockets foods and residual is left in her mouth. She is also missing multiple teeth. A one assist for eating means one staff member is present and providing feeding assistance. V27 said R3 needs staff present in the room while eating for safety. The staff member ensures the interventions on the diet ticket are happening. V27 said R3 has the potential to choke if she doesn't follow them. On 1/26/23 at 9:25 AM, V3 (Director of Nurses) stated residents need supervision during meals if they are not fully alert and oriented. They need to be able to make their needs know or it is a safety issue. Residents on aspiration precautions need staff supervision to prevent choking or aspirating food. The facility's Feeding Program policy, revision dated 9/2022, states: 2. The dining room assistant will sit with residents according to their special needs, such as sociability and mental capacity. 4. Residents with special problems (social or physical) are assigned a designated feeder who is not counted into the staffing pattern to assist with lunch and dinner meals. 2. R95's face sheet dated 1/25/23 showed diagnoses including but not limited to dementia, psychotic disturbance, mood disturbance, and anxiety. R95's facility assessment dated [DATE] showed severe cognitive impairment and staff assistance of one person for eating. R95's physician orders showed an order start dated 5/28/22 for Pureed texture diet. On 1/24/23 at 12:50 PM, R95 was in bed and eating alone. R95 had a pureed texture food tray in front of her and was spooning the foods into her mouth. R95 was able to speak but was clearly confused. R95's diet ticket showed a puree diet for meals. At 1:11 PM, V14 (Certified Nurse Aide/CNA) removed R95's tray and stated R95 eats all meals in a puree texture. At 1:15 PM, V17 (CNA) stated she needs pureed food because she doesn't have any teeth and can't chew well. On 1/25/23 at 9:36 AM, R95 was in bed and again eating alone in her room for breakfast. On 1/26/23 at 9:57 AM, V27 (Speech Therapist) stated she (R95) needs a pureed diet due to her dementia, lack of teeth and reduced safety with intake. V27 stated R95 needs staff assistance at all meals to ensure she is not eating too fast or taking big bits of food. R95 needs to alternate liquids and solids. Staff are needed to provide cues and instructions to her. R95 is at risk for choking and/or aspiration if eating alone.

Based on observation, interview and record review the facility failed to ensure a midline intravenous dressing was changed for 1 of 3 residents (R177) reviewed for intravenous fluids and dressings in the sample of 35. The findings include: On 1/24/23 at 10:15 AM, R177 was observed lying in bed wearing a hospital gown. She had IV (Intravenous) access to the right antecubital area. The IV site had a small circular pad at the entry point of the catheter, and a clear dressing over the site. The clear dressing was coming off at the edges and rolled up at the corners. The dressing was only covering half of the IV site, and the dressing was not dated. On 1/24/23 at 10:18 AM, R177 said she has had antibiotics through the IV but not for a while. She said the nurses have not done anything with it, such as change the dressing or flush the line. R177's progress notes show on 12/14/22 a midline single catheter was placed to the right brachial vein. The December 2022 nursing progress notes show R177 was receiving IV antibiotics for an upper respiratory infection. R177's December 2022 and January 2023 MAR (Medication Administration Record) and TAR (Treatment Administration Record) were reviewed and show no orders for flushing or changing the dressing. The nursing progress notes for R177 show no documented dressing changes. On 1/24/23 at 11:41 AM, V36 (Nursing Supervisor) said the midline dressing is changed weekly, by the RN (Registered Nurse). She said the dressing change orders should be on the MAR or the TAR. V36 said the midline dressing should be dated and signed off on the order sheet. The nurse should be reinforcing the dressing if it is coming off at the edges. The facility's 9/1/2016 policy for Guidelines for preventing intravenous catheter related infections documents, Surveillance: 6. Any time that dressing is not intact or end caps are missing, the catheter has potential for contamination. Catheter site dressing regimens: 4. Change TSM (transparent, semi permeable membrane) dressings every 5 to 7 days or PRN (as needed) if damp, loosened, or visibly soiled. This does not require a physician's order.

Based on observation, interview, and record review the facility failed to ensure medications were administered in a manner to meet professional standards for 1 of 5 residents (R112) reviewed during medication administration. The findings include: On 1/25/23 at 8:54 AM, V10 (Licensed Practical Nurse/LPN) began preparing R112's medications at the medication cart in the hallway. V10 had 10 pills in a medication up and one liquid medication prepared. V10 stated, I need to check his vital signs before I give the metoprolol (heart medication). V10 turned her back to the medication cart (leaving the pills and liquid medication) and walking into R112's room. R112 was located in the bed farthest from the door and his privacy curtain was pulled. V10 positioned herself near R112's bed so her back was to the privacy curtain and doorway. R112's medications were not under direct visualization while she checked R112's vital signs. R112's Face Sheet dated 1/25/23 showed diagnoses to include, but not limited to pneumonia, thrombocytosis, acute posthemorrhagic anemia, gastrointestinal bleed, CHF (congestive heart failure), diabetes, peripheral vascular disease, depression, dysphagia, and left above the knee amputation. R112's January 2022 Medication Administration Record (MAR) showed the following medications were to be given at 0900 on 1/15/23: aspirin, ezetimibe (for cholesterol), finasteride (for urine flow), loratadine (allergy medication), senna, flomax (for urine flow), metoprolol succinate ER (heart medication), Vitamin C, ferrous gluconate, lactulose solution (medication for the liver), pantoprazole (anti-reflux medication), sucralfate (for gastric ulcers), On 1/26/23 at 9:36 AM, V3 (Director of Nursing) stated, The medications should be under the nurses' direct supervision at all times. They should not be left on the cart. It's a safety issue. Anyone could walk past the med cart and take the medications. The facility's Administration of Medications Policy (dated 10/15) showed, Policy: All medications shall be administered as prescribed by the physician or licensed independent practitioner in accordance with the standard nursing practice and current regulations . Procedure: 1. During Medication Pass, the following but not limited to should be followed by the nurse: .g. The medication/treatment cart should be kept in visual control. If unable to maintain control, the cart must be locked. If leaving the cart to administer medications, only one resident's medication may be taken. No medications are kept on top of the cart .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a system in place to offer, track, monitor, record and re-offer immunizations for influenza and pneumonia for 3 (R220, R22, R99) of 5 residents reviewed for immunizations in the sample of 35. The findings include: 1. R220's face sheet showed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included COVID-19, malignant neoplasm of the left breast, need for assistance with personal care, malignant neoplasm of the bone, erosive osteoarthritis, fracture of the sacrum, pathological fractures of the right femur and pelvis. On 1/26/23 at 12:07 PM, V4 (facility identified Infection Preventionist) said R220 was not offered the pneumonia vaccine that she was aware of. V4 said there were no immunization refusals documented and she does not know if R220 was offered the influenza vaccine this season. V4 said there was no pneumonia vaccine history documented for R220 and it was not offered that she knew of. V4 said, If residents aren't offered and given immunizations, they can get sicker than they need to. Documenting and tracking immunizations are important so we know how to prevent and treat going forward. The absence of this data may result in fatalities. V4 said she couldn't say if the facility was following the CDC recommendations for any of the recommended immunizations. V4 said the facility does not have a system in place to track, monitor and ensure residents receive or are offered recommended immunizations per Centers for Disease Control and Prevention (CDC) guidance and recommendations. The facility's immunization flow sheet showed there was no information for R220's pneumovax (pneumonia vaccine) or influenza (flu) history. The CDC adult immunization schedule showed the influenza vaccine should be administered annually to people over the age of 65. This schedule showed one dose of a pneumonia (PCV15) should be administered followed by pneumonia (PPSV23) or one dose of PCV20 for adults over the age of 65. The facility's 2/1/22 Influenza Vaccine policy showed all residents who have no contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents in the facility, unless the vaccine is medically contraindicated or the resident has already been immunized. Residents admitted between October 1st and March 31st shall be offered the vaccine. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. The Director of Nursing or designee will maintain surveillance data on influenza vaccine coverage and reported rates of influenza among residents. Administration of the influenza vaccine will be made in accordance with current Centers for Disease Control and Prevention recommendations at the time of the vaccination. The facility's 11/17 Pneumococcal Vaccine Policy showed residents in the facility will be offered pneumococcal vaccine to aid in preventing pneumococcal infections (e.g., pneumonia). Residents in the facility will be offered the vaccine unless medically contraindicated or the resident has already been vaccinated. If refused, appropriate entries will be documented in each resident's medical record indicating the refusal of the pneumococcal vaccination. Administration of the pneumococcal vaccine or re-vaccinations will be made in accordance with current Centers for Disease Control and Prevention recommendations at the time of the vaccination. 2. R22's electronic medical record had no documentation under the immunization tab regarding the administration of the influenza and pneumonia vaccines. The facility provided immunization log shows R22's influenza and pneumonia columns are left blank. 3. The admission record for R99 documents she was admitted to the facility on [DATE] with congestive heart failure, heart disease, and hypertension. R99 is a full code. A review of R99's record shows she was not offered the flu vaccine or pneumonia vaccines. The record does not indicate it was offered and accepted or offered and declined. The facility immunization log shows blank space for pneumovax and flu vaccine, and no record for a history of COVID-19 vaccines. On 1/26/23 V4 stated she was unaware if R99 had been offered any vaccines. V4 said R99's daughter was initially the power of attorney, but is no longer, and unsure who to contact for consent for any treatments or vaccines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/24/23 at 11:19 AM, R45 was lying on his back in bed. R45 was slow to respond to questions and his speech was slow and deliberate. R45 had tube feeding running and had an NPO (nothing by mouth) sign about the head of his bed. R45's lips, mouth, and oral mucous membranes were dry, cracked, and scaling. There was dry, loose skin crusted to his lips and inside his mouth. R45's breath had a foul odor that could be smelled through the surveyor's N95 mask. On 1/25/23 at 2:52 PM, V5 (Wound Care Coordinator) and V16 (Wound Care Nurse) provided wound care to R45. R45's mouth and lips continued to be dry, with crusted skin present. There were no toothettes or oral care kits observed at R45's bed side. R45's Face Sheet dated 1/25/23 showed diagnoses to include but not limited to: acute respiratory failure; aspiration pneumonia; sepsis; diabetes; unspecified convulsions; iron deficiency anemia; schizoaffective disorder; dementia; reduced mobility; need for personal assistance with personal care; severe protein-calorie malnutrition; muscle wasting and atrophy; dysphagia; gastrostomy tube (G-tube); stroke; compression fracture of first lumbar vertebrae; and left toe amputation. R45's Personal Hygiene Task printed 1/25/23 showed, Personal hygiene: Self-performance - how the resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) . This document showed R45 required extensive assistance from staff to perform personal hygiene. This documented showed that R45 had not received personal hygiene 5 out of the last 14 days. This document showed the last time R45 received personal hygiene was 1/23/23. On 1/26/23 at 10:28 AM, V18 (CNA) said R45 is confined to the bed. V18 stated, He had a decline over the last 3 months. Oral care should be provided daily. I usually provide oral care in the morning, when I'm getting the residents up for the day. A resident's lips and inside of their mouth should not have dried up, crusty skin. That means someone isn't taking care of his mouth. He is NPO, so he needs extra oral care to keep his mouth moist. The staffing is always short around here and sometimes oral care and shaving don't get done. We just don't have time to get to everything. 4. On 1/24/23 at 10:20 AM, R85 was lying diagonally across an air bed. R85's head was against the left side rail of the bed and her feet were hanging off the right edge of the bed at her ankles. R85 had white zinc paste on her left cheek and a red smear on her right cheek. R85's had a lot of debris noted on her dentures. R85's breath was foul-smelling and was noted through the surveyor's N95 mask. R85 said she couldn't remember the last time they helped her brush her teeth. R85 stated, I don't even have a toothbrush. And if I did, I couldn't reach it. R85 lifted her arm up toward her nightstand, but she was 1-2 feet away from being able to reach anything on the nightstand. There were no oral care supplies noted on R85's nightstand. R85 said she has had a rash to her face since she's been in the facility. R85 stated, The doctors were just here, they don't do anything for it. So I tried putting some of that butt paste on there. It didn't really help. My face just itches like crazy and feels like sandpaper. It's really dry. R85's legs were uncovered from her knees down. R85's legs were dry and appeared to have a brown bark appearance with areas of purple discoloration. R85's bed was full of pieces of the dried skin and scabbing. R85 said her legs hurt and it feels like there is always something on them. R85 stated, I have lymphedema in both my legs. R85's toenails were long, thick, and yellow with debris caked under the nailbeds. R85 said the purple discolorations were from the last time the podiatrist saw here. R85 stated, I think that was a few months ago. They never soak my feet or legs here. My legs feel so dry, but they never put lotion on me. I can't do it myself. Also, I have a diaper on and yesterday they only changed it twice. It was soaking wet, and my bed was soaked too. I have a diaper rash and it hurts when I sit in urine like that. I've only been changed once today and that was early this morning, around 6 AM. They haven't been back yet, but I need to be changed. Thank you for listening to me; it's nice to know that someone cares. At 11:30 AM, R85 was still in the same position in bed and had not been provided incontinence care. There was a strong odor of urine in R85's room. On 1/26/23 at 10:21 AM, R85's door was closed. R85 stated, You know they didn't change me until 6 PM on Tuesday night. I knew I needed to be changed because my skin was hurting. They did put the cream on my diaper rash and that seems to help. I'd really like my hair washed! It's been ages since it's been washed. R85's hair appeared greasy, and the back of her head had an area of matted hair that was tangled. R85's Face Sheet dated 1/25/23 showed diagnoses to include but not limited to: CHF (congestive heart failure), PVD (Peripheral Vascular Disease), morbid obesity, major depressive disorder, polyosteoarthritis, chronic venous insufficiency, and lymphedema. R85's facility assessment dated [DATE] showed R85 had moderate cognitive impairment; did not reject care; required extensive assistance of staff for bed mobility, toilet use, and personal hygiene; and was always incontinent of bowel and bladder. R85's Bladder Elimination Task showed on 1/24/23 that she was only provided incontinence care at 7:28 AM. R85's last Podiatry Visit was dated 8/26/22. R85's Care Plan (initiated 7/19/21) showed, R85 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness secondary to dx (diagnosis) of obstructive uropathy, hypertension, HL, GERD, depression, PVD, uterine cancer, breast cancer, respiratory failure . Interventions: .Bed mobility is total dependence on two person physical assist . Toileting at total dependence on two person physical assist . Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report changes to the nurse . Oral Care Routine: (AM, PC (after meals), and HS (at bedtime)): brush teeth, rinse dentures, clean gums with toothettes, rinse mouth with wash . Reposition as necessary to avoid injury . Skin Inspection: The resident requires SKIN inspection q shift/PRN. Observe redness, open areas, scratches, cuts, bruises, and report changes to the nurse. Toilet Use: The resident requires extensive assistance by 2 staff for toileting needs/check and change at least Q2H/PRN (every 2 hours and as needed) . R85's Care Plan (initiated 7/26/21) showed, Risk for Impaired Skin Integrity . Interventions: Keep skin clean and well lubricated. Monitor skin for moisture, apply barrier product as needed . On 1/26/23 at 9:40 AM, V3 (Director of Nursing/DON) said the CNA should round on each resident at least every 2 hours and the nurse should round every 4 hours, essentially rounding on each resident approximately hourly. An incontinent resident should be checked regularly and changes ASAP. It's not good to have urine and/or stool sitting on their skin. It can be caustic to the skin. And they should be provided oral care regularly. V3 stated, It's a dignity issue. If I laid in bed with a wet brief all day, I would feel powerless and angry. On 1/26/23 at 11:41 AM, V19 (Licensed Practical Nurse/LPN) said R85 has dryness on her legs, but the facility has cream for her legs. V19 stated, She's had that dryness on her face for a long time. Sometimes I catch her putting that zinc cream on her face. It is really dry and I'm sure it itches. I don't think we have anything ordered for her face. R85 will turn on the call light if she needs something. By the time she usually turns on the call light, she's already soaked. I don't look at her peri-area often. I would have to ask my CNA if she has a rash. 5. R220's Face Sheet showed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of the left breast, need for assistance with personal care, malignant neoplasm of the bone, erosive osteoarthritis, fracture of the sacrum, and pathological fractures of the right femur and pelvis. On 1/24/23 at 10:55 AM, R220 said, V28 (CNA) was going to get me into bed and got called away. I called the receptionist desk on my cellphone to get someone to help me get into bed. I told them I was all wet. I called the reception desk a second time to tell them I was still waiting. When I got help, I couldn't slide on the board to get into bed because I was all wet. My niece is getting hospice because I need additional care. I had to wait two hours in 'pee and poo'. It made me feel discouraged, disgusted, terrible. It makes me want to cry. I can't do stuff for myself. They're very short handed. For each CNA, they have 19 people to take care of. I was in tears when I spoke to V36 (Nursing Supervisor) about it. R220's 12/7/22 facility assessment showed total dependence of two plus persons physically assist for transfers, bed mobility, toilet use, and bathing. This assessment showed R220 was cognitively intact. Based on observation, interview and record review, the facility failed to ensure the residents, who are dependent on staff, received assistance with basic ADLs (Activities of Daily Living), such as feeding, toileting, oral hygiene and changing of adult garments in a timely manner. This applies to 5 of 8 resident (R345, R343, R45, R85 and R220) in the sample of 35. The finding include: 1. R345's Face Sheet shows his admission date was on 1/18/23, and his diagnoses include cerebral palsy, pressure ulcer (admitted with), Parkinson's disease, and a need for assistance with personal care. On 01/25/23 at 1:02 PM, R345's breakfast tray was placed on a dresser beyond R345's ability to reach (R345's lunch tray had not yet arrived). R345's breakfast tray was untouched, including his liquids. R345 was alert and made eye contact with this surveyor and gestured to his tray, then to his mouth. When this surveyor pointed to his tray, R345 nodded his head 'yes.' R345 indicated he did not speak English. On 1/25/23 at 1:30 PM, V30 (Spanish Interpreter for the facility) helped translate for R345. Through V30, R345 said no one has come into his room to offer assistance with breakfast. On 01/25/23 at 3:46 PM, V22 (Registered Nurse/RN/Restorative) said R345 is a resident who is totally dependent on staff for food and hydration. R345's 1/19/23 Restorative Assessment Checklist and Baseline Care plan show he is totally dependent on all ADLs, including eating. R345's 1/19/23 POS (Physician Order Sheet) shows R345 is total care for nutrition. The Revised (9/2022) Policy and Procedure on the Feeding Program documents the CNAs (Certified Nursing Assistants) will be assigned daily to feed residents .and to monitor a resident's intake at each meal, and residents with special problems are assigned to a designated feeder who is not counted into the staff pattern to assist with lunch and dinner. The undated ADL Policy and Procedure shows under the category Policies: All residents will be assessed .for their abilities to perform ADLs. A program will be developed based on the residents' needs .and will be systematically and consistently carried out by staff. 10. The ADL program will be carried out daily, 7 days a week. If the plan involves eating/feeding abilities, the plan will be carried out at all meals, 7 days a week. 2. R343's Face Sheet shows his admission date was on 1/18/23, and his diagnoses include alcoholic cirrhosis of the liver, heart failure, pancreatitis, inflammatory arthritis, with gout, type 2 diabetes mellitus, and pain in his legs. On 01/24/23 at 10:58 AM, R343's room smelled of stool. R343 said he 'pooped' and no one has come to change him. R343 said he is still sitting in his own stool. R343 said he pressed his call light at 9:30 AM, and someone came in and said, I'll be back, and never came back. V28 (CNA) said she didn't know (343) used his call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 1/24/23 at 11:19 AM, R45 was laying on his back in an air bed. R45 was frail and appeared chronically ill. R45's air mattress was set at 400 pounds and his heels were resting on the bed. R45 did not have his heels offloaded. On 1/25/23 at 2:52 PM, V5 (Wound Care Coordinator) and V15 (Wound Care Nurse) provided wound care to R85. R85 was laying on his back, wearing bilateral heel boots. R85 had a golf-ball sized open area to his sacrum. V15 measured the sacral wound to be 5.5 cm x 5 cm. R85's buttocks were deep red/purple in color with several areas of old healed pressure noted. V5 said R45 can hold himself over during cares but needs assist to turn and reposition. R45 had 2 cm x 2 cm area of eschar to his right heel. V5 said R45's heel boots were to offload the pressure from R45's heel and he should wear them as much as possible. V5 said the air beds should be set slightly higher than the resident's current weight and adjusted monthly (with the weights). V5 replied, No, R45's mattress should not have been set at 400 if he only weighs 140 pounds. It could be too firm and would interfere with the purpose of the air mattress. The purpose of the air mattress is to prevent development of pressure wounds and assist with healing of current pressure wounds. I would expect any wound prevention interventions that are recommended to be in place. R45's Face Sheet printed 1/25/23 showed diagnoses to include, but not limited to: acute respiratory failure, aspiration pneumonia, sepsis, diabetes, unspecified convulsions, iron deficiency anemia, schizoaffective disorder, dementia, reduce mobility, need for assistance with personal care, severe protein-calorie malnutrition, osteoarthritis, dysphagia, stroke, and muscle wasting and atrophy. R45's facility assessment dated [DATE] showed he had moderate cognitive impairment; was totally dependent on staff for bed mobility, transfers, toilet use, and personal hygiene; was always incontinent of bowel and bladder; and pressure ulcers. R45's Weight and Vitals Summary printed 1/25/23 showed on 1/17/23 R45 weighed 140 pounds. R45's Braden Scale for Predicting Pressure Sore Risk dated 1/13/23 showed R45 was at High Risk, with a score of 11. R45's COMS - Skin Only Evaluation dated 1/18/23 showed R45 had an unstageable, deep tissue pressure injury to his right heel that measured 1.5 cm x 1.5 cm. The wound bed was necrotic and the peri-wound skin was fragile. This document showed R45 had a Stage IV: Full thickness tissue loss, pressure injury to his sacral area. This wound measured 5 cm x 5 cm x 0.1 cm. The wound bed was necrotic . 5. On 1/24/23 at 11:09 AM, R26 was lying on his back in bed. R26 was on an air mattress with his heels resting on the bed. R26's heels were not offloaded. On 1/25/23 at 2:39 PM, V5 (Wound Care Coordinator) and V13 (Wound Care Nurse) were providing wound care to R26. R26 was lying in bed with bilateral heel boots in place. V5 said R26 only has the sacral wound at this time, but he used to have wounds to his feet. The heel boots are to prevent him from developing wounds again. he should have them on at all times, but they can be removed for care. R26's Face Sheet dated 1/26/23 showed diagnoses to include, but not limited to: stroke; unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder; CHF; diabetes; dementia; dysphagia; need for assistance with personal care; unqualified visual loss of both eyes; microcephaly; reduced mobility; and unspecified intellectual disabilities. R26's facility assessment dated [DATE] showed he had short-term and long-term memory problems; required extensive assistance from staff for bed mobility, transfers, and personal hygiene; had an indwelling catheter; and was always incontinent of bowel. R26's Care Plan (revised 1/6/23) showed, Risk for impaired skin integrity . Interventions: Keep skin clean and well lubricated . Position resident to reduce causes of frictions and shear . Utilize pillows or foam wedges to avoid direct contact with bony prominences. Utilize pressure relieving devices on appropriate surfaces. 6. On 1/24/23 at 10:44 AM, R68 was lying on her back in bed with a gauze roll in her left hand. R68 was frail with bony prominences visible from the doorway. R68 was on a low air bed with bolsters in place. R68's air mattress was set at 200 pounds and her heels were in direct contact with the bed. The facility's undated Wound list showed R68 had a Stage IV pressure ulcer, extending from her left buttock into the sacrum. R68's Face Sheet dated 1/25/23 showed diagnoses to include, but not limited to: Alzheimer's Disease, dementia, peripheral vascular disease, hypertension, dysphagia, and insomnia. R68's facility assessment dated [DATE] showed she had short-term and long-term memory problems; was totally dependent on staff for ADLs; was frequently incontinent of urine; always incontinent of bowel; and had a Stage IV pressure ulcer. R68's Care Plan (initiated 4/27/22) showed, The resident has potential/actual impairment to skin integrity. Resident has the following skin issues: Left buttock extending to sacral area - Stage IV PI (pressure injury). Left lower leg trauma wound - closed 11/23/22. Resident scored 9 on the Braden scale which categorizes her as having very high risk for skin breakdown . Interventions . Low air loss/alternating pressure mattress . The resident needs pressure relieving/reducing mattress, pillows to protect the skin while in bed. Based on observation, interview, and record review, failed to ensure residents' air mattresses were inflated according to their weight; failed to ensure residents' pressure relieving interventions were implemented; and failed to identify a resident at risk for pressure injury for 6 of 15 residents (R124, R220, R224, R45, R26, R68) in the sample of 35. The findings include: 1. R124's face sheet showed a [AGE] year-old male with diagnoses including sepsis, malignant neoplasm of anus and rectum, severe protein calorie malnutrition, gastrostomy, colostomy and human immunodeficiency virus (HIV). On 01/24/23 at 01:29 PM, R124 said, The state lady said I should have an air mattress on my bed. I wish I did. I can't lay on my back because it's too painful. I've had buttock wound for about two years from the cancer. On 01/26/23 at 09:26 AM, V3 (Director of Nursing/DON) said, Residents should be checked and changed every hour. We do rounds to check on them. It's important to do this to ensure they're clean, dry, reposition them and make sure they're ok. If they're laying in urine and stool for hours, skin breakdown occurs and can affect their skin integrity. If this is not done, it could make them (residents) feel powerless, because they can't get up and do it themselves, angry and could cause urinary tract infections (UTIs). I wouldn't set an air mattress much higher than their current weight. It can affect the patient. Skin breakdown can happen can cause pressure. R124's weight record showed a 12/2/22 weight of 103 pounds and a height of 5 foot 10 inches. R124's nutritional care plan showed a 12/22 weight of 103 pounds, a significant weight loss and a body mass index (BMI) of 14.8 (underweight). R124's bed mobility program care plan showed a decreased or limited ability to move to and from a lying position, decreased or limited ability to move from side to side, and decreased or limited ability to position self while in bed. R124 did not have a potential or actual risk of impairment in skin integrity care plan. R124 had a colostomy, significant weight loss, BMI of 14.8, history of sepsis, cancer, current open cancerous wound, and impaired mobility. R124's 1/15/23 pressure sore risk assessment (signed 1/26/23) showed R124 was at risk. R124's 1/6/23 facility assessment showed he required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The facility's 2/22 Pressure Ulcer Definition Policy showed pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The facility's 1/2018 Wound Prevention Program documents Residents whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers are being assessed and identified and implement preventative measures and or provide appropriate treatment modalities for ulcers according to standard of care. Regardless of the resident's pressure injury risk score, each risk factor and potential cause(s) should be reviewed individually. Develop a care plan and implement intervention according to the resident risk factors identified. Prevention of skin breakdown: daily skin hygiene, inspect skin every shift with care for signs and symptoms of breakdown, keep local areas of skin clean, dry and free of body wastes, perspiration and wound drainage. Activity, Mobility, and Positioning Interventions: Establish an individualized turning and repositioning schedule if the resident is immobile. While in bed or in wheelchair, resident should be turned/repositioned at least every two hours and as needed, unless contraindicated due to resident's medical condition. If the resident is on bed, position the resident body on bed with pillows or other support devices to protect bony prominence susceptible to pressure. Keep the linens dry and wrinkle free. Skin protection Intervention: Assess and treat incontinence. Provide low air loss mattress and or wheelchair cushion if indicated. Nutrition: Observe for clinical signs of malnutrition, significant unintentional weight loss, and hydration deficits. If inadequate, assess labs and obtain dietary consult. Notify dietitian of residents who has a pressure ulcer. Obtain order for nutritional supplements and use protein supplements as indicated. Encourage fluid intake. The facility's 10/2010 Pressure Ulcer Risk Assessment Policy (provided to the survey team) documents Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Multiple factors, including pressure intensity, pressure duration, and tissue tolerance, significantly affect the potential for the development and healing of pressure ulcers. An individual may also have various intrinsic risks due to aging, for example: decreased subcutaneous tissue and lean muscle mass, decreased skin elasticity . The facility's 11/2015 Pressure Ulcer Risk Assessment Policy documents Identifying residents at risk: Extrinsic risk factors for pressure ulcers include: pressure- the resident is not capable of moving without assistance, is confined to bed, and/or requires a regular schedule of turning. Maceration-the resident is persistently wet. Intrinsic risk factors for pressure ulcers include immobility, altered mental status, incontinence, poor nutrition. Diagnosis and conditions that increase risk for pressure ulcers: urinary incontinence, sepsis, paraplegia/quadriplegia, terminal cancer, diabetes, dementia, hemiplegia/hemiparesis, cerebrovascular accident, steroid therapy, radiation therapy, and chemotherapy. The facility's 11/2015 Low Air Loss Mattress Policy documents Low air loss mattress will be provided to residents for the following purposes but not limited to: be able to maintain or promote adequate circulation for residents that are high risk for skin breakdown, to those residents that spends most of the time on bed due to medical condition, relieve pressure on bony areas, aid in healing of stage 3 or 4 pressure ulcers and to prevent the development of pressure ulcer. Ensure the air mattress is inflated according to the manufacturer's guidelines. Periodically, check the air mattress to ensure that it is inflated properly. 2. R220's face sheet showed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of the left breast, need for assistance with personal care, malignant neoplasm of the bone, erosive osteoarthritis, fracture of the sacrum, and pathological fracture in neoplastic disease of the right femur and pelvis. On 1/24/23 at 10:55 AM, R220 was in bed. Her low air loss mattress was set at 350-1,000 pounds (lbs.). R220 did not have heel offloading boots on as she laid in bed. R220 said, I can't do stuff for myself. I sat for two hours soiled in urine and stool. When asked about a history of pressure wounds, R220 said she had one on her butt (now resolved). R220's 12/7/22 facility assessment showed total dependence of two plus persons physical assist for transfers, bed mobility, toilet use, and bathing. This assessment showed R220 was cognitively intact. R220's 12/2/22 admission skin assessment showed a Stage 3 pressure injury to the sacrum. R220's wound center note showed a Stage 3 pressure injury to the sacrum and due to her multiple comorbidities, she was at high risk for developing new and worsening wounds. She should be provided heel offloading boots which are to be worn at all times while in bed. R220's care plan showed a history of a Stage 3 pressure injury and potential for impairment of skin integrity. Keep skin clean and dry. Heel offloading boots were not included in her interventions. 3. R224's face sheet showed a [AGE] year old male with diagnoses of pressure ulcer to the sacrum, cerebral infarction, sepsis, spinal stenosis, diabetes, hypertension, seizures, dysphagia, myocardial infarction, and gastrostomy. On 1/24/23 at 11:34 AM and 1:16 PM, R224 was flat on his back in bed. His air mattress was set at 320 pounds. R224 was unable to speak. On 1/25/23 at 9:58 AM, R224 was flat on his back in bed. R224 was unable to speak. R224's Physician Order Sheet showed current treatment orders for an unstageable pressure injury to the right hip. There were also orders to be up in a chair three days a week for two hours at a time. R224's 11/29/22 pressure risk assessment score showed a very high risk. R224's 1/9/23 facility assessment showed he was totally dependent for bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. This assessment showed two unstageable pressure ulcers. R224's skin integrity care plan had no repositioning interventions. R224's weight record showed a height of 6 foot and a 1/6/23 weight of 150 pounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received their range of motion programs for 1 of 1 resident (R43) reviewed for range of motion in the sample of 35, and for 3 residents (R59, R55 and R90) outside of the sample. The findings include: 1. R43's admission Record, printed by the facility on 1/26/23, showed he had diagnoses including cerebral palsy and age-related osteoporosis. R43's facility assessment dated [DATE] showed he was cognitively intact. The assessment showed he was dependent on staff for transfers and bathing. The assessment showed R43 required extensive assist of staff for dressing, toileting and personal hygiene. R43's care plan titled Restorative: AROM (Active Range of Motion) Program showed he requires AROM to all of his extremities daily related to decreased mobility, decreased muscle strength and endurance. R43's restorative program documents, provided by V22 (Restorative Nurse) on 1/26/23, showed he was at risk for impaired range of motion related to weakness and staff should provide AROM on his bilateral upper and lower extremities, 15-20 reps (repetitions) to each extremity x 3 sets or as tolerated. On 1/24/23 at 10:21 AM, R43 was in bed sitting in the upright position. R43's right hand appeared to be contracted. R43 was asked if he could open his right hand. R43 was able to partially extend his fingers and thumb on his right hand. R43 said staff do not exercise or perform any range of motion (ROM) with him. 2. R59's admission Record, printed by the facility on 1/26/23, showed she had diagnoses including Guillain-Barre Syndrome and hypertension. R59's facility assessment dated [DATE] showed she was cognitively intact. The assessment showed R59 required extensive assist of staff for transfers, bathing and toileting. The assessment showed R59 required limited assist of staff for dressing and personal hygiene. R59's Restorative care plans, initiated on 10/13/22, showed she is on a dressing program and an AROM (Active Range of Motion) program. The AROM program showed she requires active range of motion to all extremities daily related to decreased mobility, decreased muscle strength, endurance, and related to her diagnoses of Guillain-Barre Syndrome. R59's restorative program documents, provided by V22 (Restorative Nurse) on 1/26/23, showed she should be provided AROM on both of her upper and lower extremities. 15-20 reps each extremity x 3 sets or as tolerated. R59's dressing/grooming restorative program, provided by V22 on 1/26/23, showed Cue and assist to thread both legs into pants. Decrease assist as able. On 1/24/23 at 10:38 AM, R59 said They (staff) used to do range of motion but they stopped at least a year ago. I can't walk. I transfer myself with my upper body. 3. R90's admission Record, provided by the facility on 1/26/23, showed he had diagnoses including Parkinson's disease, primary osteoarthritis of his right and left hand, and acquired absence of right and left leg, below the knees. R90's facility assessment dated [DATE] showed he had moderate cognitive impairment (Brief Interview for Mental Status/BIMS score of 10) and required extensive assist of staff for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. R90's Restorative care plans, initiated on 9/13/22 showed he was on a prosthesis program, an AROM program, a bed mobility program and a walking program. R90's restorative program documents, provided by V22 on 1/26/23, showed R90 was at risk for impaired range of motion related to weakness and staff should provide AROM on bilateral upper and lower extremities. 15-20 reps each extremity x 3 sets or as tolerated. R90's Walking program showed Resident with impaired mobility as evidenced by inability to ambulate independently and requires assistance of one person related to weakness. Resident will be able to ambulate 200 feet with use of rolling walker with extensive assist of one person. Resident currently on walking program with use of rolling walker, gait belt and wheelchair to follow with staff assistance. Current goal is 150 feet. Resident able to ambulate 100 feet. On 1/24/23 at 10:33 AM, R90 said They (staff) used to do exercises with me; haven't for about a year now. 4. R55's admission Record, printed by the facility on 1/26/23, showed she had diagnoses including atherosclerotic heart disease, peripheral vascular disease, gout, acquired absence of right leg above the knee, idiopathic progressive neuropathy (damage of the peripheral nerves-causing numbness, tingling, prickling in hands and feet), and absence of left toe(s). R55's facility assessment dated [DATE], showed she was cognitively intact and required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. R55's Restorative care plans, initiated on 9/23/22, showed she was on a dressing program, a bed mobility program and an AROM program. The AROM program showed R55 required active range of motion to all extremities daily related to decreased mobility, decreased muscle strength and endurance. R55's Restorative program documents, provided by V22 on 1/26/23, showed she is at risk for impaired range of motion related to weakness and staff should provide AROM on bilateral upper extremities 15-20 reps each extremity x 3 sets or as tolerated. On 1/24/23 at 10:47 AM, R55 was sitting in a wheelchair in her room. R55 said staff maybe come in a couple of times a week, adding, They come in and move your legs or something. On 1/26/23 at 10:57 AM, V35 (Certified Nursing Assistant/CNA) said he had 17 residents to take care of. V35 said the Rehab aides do the range of motion for the residents. At 10:58 AM, V34 (CNA) said she had 16 residents. V34 said the restorative aides do the range of motion. V34 said there are no restorative aides today (1/26/23) because they got pulled to the floor. V34 said It happens often, and we do not have time to do the ROM (range of motion). On 1/26/23 at 10:59 AM, R43 was sitting in upright position in bed. His right hand was in the same clenched position and angled to the side as was seen during the initial tour. On 1/26/23 at 11:13 AM, V22 and V23 (Registered Nurses/Restorative Nurses) said there were 6 restorative aides (RAs) for the facility, 2 full time and 4 part-time. V22 said The restorative aides get pulled to the floor so the restorative programs may not be getting done, especially on Mondays and Tuesdays. V22 said R43, R59, R55 and R90 were all on restorative programs. V22 said R43 was on an AROM and mobility program and staff should exercise his upper and lower extremities 15 reps (repetitions). V22 said there was nothing specifically for R43's right hand. V22 said R59 was on an AROM and dressing program. R55 was on an AROM and mobility program, and R90 was on an AROM and walking program with his prostheses. V22 said it is because the restorative aides are pulled to work the floor most of the time that the residents are not getting their restorative programs. V22 stated, It is important to make sure the programs are done to prevent decline and contractures. The facility's Rehabilitative/Restorative Nursing Care policy and procedure, with a revision date of April 2007, showed Rehabilitative nursing care is provided for the resident if needed .2. Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan. 3. the facility's rehabilitative/restorative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. 4. Rehabilitative nursing care is performed according to plan of care for those residents who require such services . The facility's undated Restorative Services Activities of Daily Living policy showed All residents will be assessed on admission and quarterly, or more often as change of condition warrants, for their abilities to perform activities of daily living. A program will be developed based on the resident's needs and involving formalized therapy and/or restorative nursing, as applicable. This program will be reflected in the interdisciplinary care plan and be systematically and consistently carried out by staff.

Based on observation, interview and record review the facility failed to ensure bedtime snacks were distributed to 4 of 4 residents (R220, R343, R350, and R228) reviewed for bedtime snacks in a sample of 35. The findings include: The facility's Resident Census and Conditions of Residents (Form CMS-672), dated 1/25/23, documents there are 239 residents residing in the facility. 1. On 1/25/23 at 2:20 PM, R220 was alert and oriented to person and place. R220 said she has never been offered a snack in the evening. R220's Face Sheet shows her diagnoses to include fracture of the right pelvis, femur, and sacrum. 2. On 1/25/23 at 2:25 PM, R343 was alert and oriented to person, place and time. R343 said he has never been offered a snack in the evening. On 1/26/23 at 9:03 AM, R343 said he was not offered a nighttime snack last night. R343's shows, his diagnoses to include Type 2 diabetes mellitus. 3. On 1/26/23 9:01 AM, R350 was alert and oriented to person, and time. R350 said she has never been offered a nighttime snack. R350 said she asked for a milk the evening of 1/25/23 and was told they were out of milk. R350's Face Sheet shows her diagnoses to include depression, anxiety, and the need for assistance with personal care. 4. On 1/25/23 at 2:17 PM, R228 was alert and oriented to person, place and time. R228 said she was never offered a snack at night since she's been at the facility. R228's Face Sheet shows her diagnoses to include multiple healing fractures from a motor vehicle accident. On 1/25/23 at 2:30 PM, V29 (Dietary Manager) said the nighttime snacks are made in the kitchen and taken up to the different floors to their refrigerators and distributed by the CNAs (Certified Nursing Assistants) to the resident's door to door. On 1/26/23 at 9:06 AM, V31 (Restorative CNA) said, When the nighttime snacks come to the nurses' station the nurse should go door to door to offer the residents a snack. It's important because there is so much time in between dinner and breakfast. On 1/26/23 at 12:00 PM, V3 (Director of Nursing) said the CNAs should be distributing nighttime snacks to all residents to bridge the time gap between dinner and breakfast. The revised (10/2020) Bedtime Snacks Policy and Procedure shows, 1. Evening snacks will be offered to the residents. 2. Place the snacks on the overbed table or serving area. Arrange the supplies so that they can be easily reached by the resident. 3. Assist the resident to a nearly upright position. 4. Arrange the snack so it can be easily reached by the resident.

Based on observation, interview and record review the facility failed to have sufficient nursing staff to provide care and services for all residents in the facility. The findings include: The CMS 672 Resident census and conditions of residents report dated 1/25/23 shows the facility has 239 residents. The report shows 191 residents are occasionally or frequently incontinent of bladder and 150 are incontinent of bowel. The report also shows the facility has 19 facility acquired pressure injuries. The CMS staffing data report for the 3rd quarter of 2022 documents the facility triggered for excessively low weekend staffing. On 1/26/23 at 8:07 AM, V38 (Ward Clerk/Scheduler) said normally there are 4 aides on 2nd floor, and 6 for both the 3rd and 4th floors, that is minimal staffing. V38 said on the weekends she tries to over staff, but there are call offs. The 2nd floor has less residents, so an aide is moved to cover another floor with more residents. Currently the facility uses only one agency to fill the shortage of staff. V38 said there are a lot of call offs on the weekends, which leaves the facility short. She said to cover the call offs the supervisor will call staff to come in and cover, sometimes the staff will stay over but not all the time. V38 said they also call the next shift to see if they can come in early. The agency will open the shift on the portal for anyone to pick it up. On 01/26/23 at 10:22 AM V2 (Assistant Administrator) said the facility has used several staffing agencies. V2 said, There are 2 staff that do the schedule. We pull restorative and clinical nursing staff to come in and assist. The call offs are reported back to the agency, and they will make efforts to find a replacement. We offer incentives and bonuses to cover shifts, and booster rates for agency to pick up more shifts. V2 said, The staff will stay over or come in early to help cover the shifts. Restorative staff will schedule and make sure the showers are getting done and help out. We will adjust staffing, we try to schedule as many as possible and try to cover for call offs. The resident list report shows the first floor of the facility to have 60 residents. The third floor had 91 residents, and the fourth floor had 95 residents. On 1/25/23 at 10:51 AM, R47 said she had not had a bed bath or shower in over a month, her hair is greasy, and cannot get her face washed or teeth brushed in the morning. She said the staff are nice people, but they are short staffed. She said after physical therapy she is not getting any range of motion and cannot go home until she can get rid of her incontinence brief and get moving. She said she has the brief on because she cannot get up and has had 3 urinary tract infections since her admission. On 1/24/23 at 10:38 AM, R80 said Sometimes the staffing is shorthanded, and they have a lot of residents. and it is overwhelming to them. No certain shift or day of the week they are short, it is just overall. On 1/24/23 at 10:47 AM, R55 said only a couple times a week does she get range of motion, sometimes there is not enough staff. On 1/26/23 at 10:58 AM, V34 (Certified Nursing Assistant) said she had 26 residents, and the restorative aides are pulled to the floor, and no one has time to the restorative programs or range of motion. On 1/26/23 at 11:13 AM, V22 and V23 (Restorative Nurses) said the restorative aides get pulled to work the floor so the restorative programs may not be getting done, and the monthly weights are not getting completed. V23 said, No monthly weights were completed for September, October and December. There are 6 restorative aides and they get pulled at least twice a week at least to work on the floor. If there are only 1 or 2 restorative aides, we work with the residents with the highest priority; not everyone is getting completed. V22 said the restorative aides are here on the weekend but they get pulled to work on the floor. V22 said weekends are shorter than the week. On 1/25/23 at 9:48 AM, V37 (CNA) said the night shift and weekends are really short staffed. Today she had 15-17 residents and can hardly get done with all of her duties and cannot imagine how they get done on night shift. On 1/24/23 at 1:15 PM V14 (CNA) said residents are supposed to get checked and changed every 2 hours but has no time to go back to check on them. V14 said she had last checked on R95 at 9:30 AM this morning and now it is after lunch and has no time to check on her because she is too busy with other things. On 1/26/23 at 11:47 AM, V3 (Director of Nursing) said staffing on the units should include 4 aides on the 2nd floor, and 6 aides on the 3rd and 4th floors. She said that is the minimum amount of staff that should be working. She said additional staffing would depend on the acuity of the residents. She said there is enough staff to assist residents with all ADLs (Activities of Daily Living). V3 said all of the tasks on the floor can be broken up among the staff, and not all residents get a shower every day. The daily staffing schedules were reviewed and show the weekends to have fewer staff, and numerous call offs by the agency staff. Staffing at times for the 2nd floor includes 3 staff, the 3rd floor and 4th floor each had 5 staff for weekends. The April 2022 Facility assessment shows an average census of 198 residents. The services offered include ADLs (bathing, showers, oral care), bowel and bladder toileting programs, incontinence prevention and care, pressure injury prevention and care, infection control, therapy, and providing person-centered care. During the course of this annual survey, noncompliance was identified in multiple care areas including resident dignity and privacy, ADL care not being completed, pressure injuries, ROM (range of motion) programs incomplete, bowel and bladder incontinence, weight loss and weights not done as ordered, and bedtime snacks not being offered.

Based on observation, interview and record review, the facility failed to have an Infection Preventionist who completed the specialized training in Infection Prevention and Control. This has the potential to affect all of the residents in the facility. The findings include: The Resident Census and Conditions of Residents form (form CMS-672) dated 1/25/23, showed 239 residents resided in the facility. On 1/24/23 at 9:56 AM, V2 (Assistant Administrator) identified V4 as the facility's Infection Preventionist. V2 said V4 was on vacation and would return on 1/25/23 or 1/26/23. On 1/25/23 the document titled Resident Vaccination Status as of 1/18/23 was reviewed. The document had 74 residents that had no record of having a COVID-19 vaccine. On 1/26/23 at 9:45 AM, V4 (Infection Preventionist) said she just started working for the facility 2 months ago. V4 said she received no training for the job, adding I have had no guidance or direction on what I am supposed to do. V4 said Today is my last day at the facility. I gave them at least a 2 week notice, and they do not have anyone hired yet that I know of to do the Infection Preventionist job. I have not trained anyone for the job. I cannot do the Infection Preventionist training and the job at the same time; it is too much. At 10:01 AM, V4 said she had not completed the specialized Infection Preventionist training, and she was in the process of completing the training. V4 said she started the training the week of December 5, 2022. V4 said the facility has had three Directors of Nursing in the last 60 days. The facility's COVID-19 Testing Plan and Response Strategy, with a revision date of 12/2022, showed 5. Required Personnel, Training and Experience Required to Execute the Testing Plan: The facility will contact IDPH (Illinois Department of Public Health) and the Local Health Department for training the Infection Preventionist and additional staff to initiate testing of resident and staff at the facility. The facility's undated policy and procedure titled Infection Control showed 3. The QAPI (Quality Assurance and Performance Improvement) committee, through the designated Infection Preventionist shall oversee implementation of infection control policies and practices, and help department heads and managers ensure that they are implemented and followed.

Based on observation, interview and record review, the facility failed to obtain vaccination status for residents. This has the potential to affect all of the residents in the facility. The findings include: The Resident Census and Conditions of Residents form (form CMS-672) dated 1/25/23, showed 239 residents resided in the facility. On 1/24/23, the facility provided a list titled Resident Vaccination Status (as of 1/18/23). The list showed 74 residents that had no record of vaccination status in their medical record. The list showed 7 residents showing only dose one in their medical record and 41 residents with no information regarding boosters in their medical record. The NHSN (National Health Safety Network) website data for the facility, for the week ending 1/8/23, showed the residents with their primary vaccination was 84%. On 1/26/23 at 9:45 AM, V4 (Infection Preventionist) said on 1/17/23 she swept all of the residents' charts for vaccination status. V4 said all of the residents that show no record on the list that was provided do not have any information regarding their vaccination status in their medical record. V4 said she did not have anything from the previous IP person showing a list of resident vaccinations. V4 said she was going on vacation, so she gave the list to the Assistant Director of Nursing (ADON) and to the 3:00-11:00 PM Supervisor and asked them to divide the list among the nurses to see if the residents have already received the vaccines, and if they have not had the vaccines, to get consent to receive the vaccines or get the resident's refusal for the vaccine. V4 said, They should have already had this completed. Either offered the residents the vaccines or have them sign a refusal after education was provided regarding the benefits and risks of the vaccine. It is probably going to be 114 residents that we have no information regarding their vaccine status on, or that have no information regarding a second dose or booster. V4 said she knows some of the residents have had the vaccines, however it is not documented in their medical record. V4 said at this time, the facility is not aware of the vaccination status of these residents. V4 said she just started working for the facility 2 months ago and has not received any training for the job. V4 said, I have had no guidance or direction on what I am supposed to do. V4 said the facility has had three different Directors of Nursing in the last 60 days. V4 said she is in the process of doing the specialized Infection Preventionist training but has not completed the training yet. The facility's COVID-19 Testing Plan and Response Strategy showed Infection Prevention and Control Interventions .C. Vaccination remains critically important in reducing hospitalization and death for COVID-19. Facilities should encourage residents, staff and families to remain up-to-date with COVID-19 vaccination, including all eligible booster doses.

Based on the interview and record review the facility failed to follow the physician's order and provide intermittent catheterization (Straight Cath) to R1. This applies to 1 of 3 residents (R1) reviewed for catheterization. Findings include: R1 was interviewed on December 3, 2022, at 10:40AM and stated that on November 28, 2022, that the night nurse stayed over and gave R1 her 9:00AM medications but did not provide the catheterization (straight cath). R1 continued and stated that V3 (Nurse) gave her noon medications late. R1 stated that she asked V3 to provide the catheterization, but V3 told R1 she needed a nurse aide to help. R1 added that she needs this catheterization to prevent urinary infections. R1 stated she was not catharized as ordered at 10:00AM and 2:00PM on November 28, 2022. V3 (Nurse) was interviewed on December 3, 2022, at 1:45PM and confirmed that she did not administer the catheterization to R1. V4 (Infection Control Nurse) was interviewed December 3, 2022, at 12:15 PM. V4 stated that on that day there was no nurse for R1's side of the unit. According to V4, the other three nurses spilt the residents and caused R1's catheterization to be missed. V4 also stated that R1 was getting a urinary infection, and that's why her Urologist wanted to do a straight Cath every four hours. V4 confirmed during the interview that R1 should have been catheterized every four hours as ordered by the physician. R1's Physician Order Sheet (POS) documents the order (entered on 8/8/22) to straight Cath R1 every four hours (six times a day). Record review of the MAR (Medication Administration Record) shows no documentation for catheterization for R1 for 10:00AM and 2:00PM.