Based on observation, record review, and interview, the facility failed to provide reasonable accommodation of needs for 4 of 4 randomly observed residents. Bathroom call lights lacked a pull cord. (Residents 15, Resident 90, Resident 13, Resident 83) Findings include: 1. On 8/5/24 at 9:40 a.m., Residents 13 and Resident 83's bathroom was observed. The emergency call light in the bathroom lacked a pull cord. On 8/6/24 at 10:08 a.m., the same was observed. On 8/7/24 at 8:30 a.m., the same was observed. 2. On 8/5/24 at 9:47 a.m., Residents 15 and Resident 90's bathroom was observed. The emergency call light in the bathroom lacked a pull cord. On 8/6/24 at 10:06 a.m., the same was observed. On 8/7/24 at 8:28 a.m., the same was observed. During an interview on 8/7/24 at 8:53 a.m., Unit Manager 2 indicated residents who used the bathroom could use the call light. During an interview 8/7/24 at 9:50 a.m., the DON indicated all residents should have an accessible call light in their bathroom. On 8/7/24 at 9:50 a.m., the DON provided a policy titled Call System, Residents, dated 9/2022, and indicated it was the current policy being used by the facility. A review of the policy indicated, each resident was provided with a means to call staff directly for assistance from the bedroom, toileting/bathing facilities, the floor. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 1 of 1 random observations. A resident's call light was not within reach. (Resident 73) Finding includes: On 8/8/23 at 10:36 a.m., Resident 73 was observed to be calling out for assistance. Resident 73 indicated she needed assistance to the bathroom but did not know where her call light was. At that time, Resident 73's call light was observed to be behind the resident resting on the beside table, out of reach of Resident 73. On 8/9/23 at 10:15 a.m., Resident 73's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) Assessment, dated 7/14/23, indicated Resident 73 had mild cognitive impairment and required extensive assistance of two persons for transfers. On 8/11/23 at 2:50 p.m., the Corporate Nurse Consultant provided the current Resident Call System policy, dated 9/2022. The policy indicated, each resident is provided with means to call staff directly for assistance. 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure the accuracy of resident assessments for 2 of 3 residents reviewed for resident assessment. (Resident 101, Resident 98) Findings include: 1. On 8/9/23 at 11:06 a.m., Resident 101's clinical record was reviewed. A PASRR (Preadmission Screening and Resident Review) Level 2, dated 3/23/22, indicated Resident 101 had a serious mental illness. The Annual MDS (Minimum Data Set) Assessment, dated 3/9/23, indicated Resident 101 did not have a mental illness. On 8/9/23 at 1:12 p.m., the MDS Coordinator, indicated Resident 101's assessment was inaccurate. 2. On 8/9/23 at 11:11 a.m., Resident 98's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) Assessment, dated 7/7/23 indicated Resident 98 received one insulin injection during the assessment period. The Physician's Orders and July 2023 MAR (Medication Administration Record), lacked an order or administration of an insulin. On 8/9/23 at 1:12 p.m., the MDS Coordinator indicated she thought Trulicity (an injectable medication that increases the body's insulin production) was an insulin. On 8/11/23 at 2:50 p.m., the Corporate Nurse Consultant provided the current Certifying Accuracy of the Resident Assessment policy, revised 11/2019. The policy indicated the information captured on the assessment reflects the status of the resident. 3.1-31(d)

Based on observation, interview and record review, the facility failed assess a resident for polyneuropathy and the need for a topical medication treatment. The facility lacked a Physician's Order for a medicated pain cream for the treatment of leg pain and to allow the resident to keep a medicated pain cream at the bedside. The facility failed to prevent a CNA from applying a medicated pain cream to a resident. (Resident 3, CNA 2, CNA 3) Findings include: On 8/10/23 at 10:30 a.m., CNA (Certified Nurse Aide) 2 and CNA 3 were observed providing personal care to Resident 3. Resident 3's legs were observed; and no pain or skin conditions were noted while personal care was being provided. At the conclusion of the personal care, CNA 2 asked CNA 3, Did you put the pain cream on Resident 3? CNA 3's response was No, not yet. At that time, CNA 2 applied Triderma Pain Relief Cream - Maximum Strength (a medicated topical cream for nerve pain) to Resident 3's legs from the hip area to the toes. During an interview at that time, CNA 2 indicated the medicated cream was used to help decrease pain in Resident 3's legs. During an interview at that time, Resident 3 indicated the cream was for her leg pains. During an observation with the DNS (Director of Nursing Services) on 8/10/23 at 10:55 a.m., a Triderma Pain Relief Cream 4 ounce jar was observed in Resident 3's unlocked top drawer of her bedside table. The jar lacked a pharmacy label that indicated the resident's name or the physician's order for the medication. During an interview at that time, Resident 3 indicated she had ordered the cream, kept it in the top drawer of her bedside table, and staff applied the cream to her legs every day. During an interview on 8/10/23 at 11:05 a.m., the Unit Manager indicated she was unaware that Resident 3 had the Triderma Pain Relief Cream in her room. The Unit Manager was also unaware that CNA 2 had applied the cream to Resident 3's legs. CNA 2 should not have applied the cream to Resident 3's legs. During an interview on 8/10/23 at 11:10 a.m., the DNS indicated it was outside of the scope of practice for a CNA to apply or administer any type of medications to a resident. Resident 3 should not have had the cream at her bedside without a Physician's Order. The facility failed to assess Resident 3 to determine if the Resident was appropriate to keep the medication at her bedside. During an interview on 8/11/23 at 2:20 p.m., the CNA Training Coordinator indicated the CNA staff were not supposed to administer or apply any type of medications to the residents. During an interview on 08/14/23 at 8:41 a.m., Resident 3 indicated she has used the cream for about 5 years. Resident 3 indicated a while ago she had notified the therapy department and a nurse about using the cream. The CNAs applied the cream twice a day to elevate the leg pain. During an interview on 8/14/23 at 10:12 a.m., LPN (Licensed Practical Nurse) 4 indicated it was outside the scope of practice for a CNA to apply medicated creams or ointments to any residents. During an interview on 8/14/23 at 10:14 a.m., CNA 5 indicated CNAs were not supposed to apply any medicated creams to residents. During an interview on 8/14/23 at 10:14 a.m., CNA 8 indicated CNAs were not allowed to apply any medicated creams to residents. On 8/09/23 at 2:11 p.m., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, pain, polyneuropathy (nerve damage affecting many nerves in different parts of the body), and osteoarthritis. A Physician's Order and a nursing measure, effective 2/4/22 with no end date, indicated nursing staff were to assess and record Resident 3's pain level every shift. A review of the August Medication Administration Record (MAR) report indicated Resident 3 was without any pain during that time frame. A Physician's Order and a nursing measure, effective 2/4/22 with no end date, indicated nursing staff were to assess and record Resident 3's skin condition weekly. A review of the August MAR report indicated Resident 3 was without any skin conditions during that time frame. The Quarterly MDS (Minimum Data Set) Assessment, dated 6/21/23, indicated Resident 3 was cognitively intact. The clinical record lacked a Physician's Order for Triderma Pain Relief Cream - Maximum Strength (cream). The clinical record lacked an assessment for Triderma Pain Relief Cream - Maximum Strength (cream) to be kept at Resident 3's bedside. On 8/11/23 at 9:08 a.m., the Corporate Nurse Consultant provided a copy of CNA 2's Job Description. A review of the document indicated, .The Nurses Aide assists the licensed nursing staff by performing routine nursing duties and activities of daily living .assists residents with dressing, grooming, eating, bathing, positioning, turning, toileting, and exercising .Successful completion of a State approved geriatric nursing assistant training program .I understand the information contained in the Job Description . The document was signed by CNA 2 on 6/27/23. On 8/11/23 at 9:08 a.m., the Corporate Nurse Consultant provided a copy of CNA 3's Job Description. A review of the document indicated, .Nurse Aides assist the licensed nursing staff by performing routine nursing duties and activities of daily living .assists residents with dressing, grooming, eating, bathing, positioning, turning, toileting, and exercising .Successful completion of a State approved geriatric nursing assistant training program .I understand the information contained in the Job Description . The document was signed by CNA 3 on 1/15/19. On 8/10/23 at 11:44 a.m., the DNS provided a copy of the Administering Medications policy, dated December 2022, and indicated it was the current policy in use by the facility. A review of the policy indicated, .only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so .Medications must be administered in accordance with the orders .topical medications used in treatments must be recorded on the resident's treatment record .shall reevaluate .examine the individual .determine if there is a clinical reason for .the medication . On 8/10/23 at 11:44 a.m., the DNS provided a copy of the Administering Topical Medications policy, dated October 2010, and indicated it was the current policy in use by the facility. A review of the policy indicated, .this procedure is to provide guidelines for the safe administration of topical medications .verify that there is a physician's medication order .follow the medication administration guidelines in the policy entitled Administering Medications .assess the area for broken skin, drainage, debris, rashes, allergic reaction or signs of infection . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide care in a dignified manner for 1 of 1 meal observations. Residents sitting at the same table were not served at the same time and residents were not assisted immediately after their meal was served. (Resident 53, Resident 86, Resident 41, Resident 89, Resident 9, Resident 100, Resident 94) Finding includes: During the noon meal the following was observed. On 8/7/23 at 11:55 a.m., Resident 53's food was sitting in front of him covered. Staff were not observed to be assisting Resident 53 with the food. Resident 86 was seated directly beside Resident 53. Resident 86 was observed to be eating the noon meal. At 12:04 p.m., Qualified Medication Aide (QMA) 6 was observed to assist Resident 53 with his noon meal. Resident 41 was observed to be sitting at the same table. Resident 41 was not served the noon meal until 12:06 p.m. Resident 89 was observed to be sitting at the same table. Resident 89 was not served the noon meal until 12:07 p.m. Resident 89's noon meal was observed to remain covered. Resident 9 was observed to be sitting at the same table. Resident 9 was not served the noon meal until 12:11 p.m. Resident 100 was observed to be sitting at the same table. Resident 100 was not served the noon meal until 12:12 p.m. Resident 94 was observed to be sitting at the same table. Resident 94 was not served the noon meal until 12:13 p.m. At 12:17 p.m., QMA 7 was observed to assist Resident 89 with the noon meal. On 8/9/23 at 1:09 p.m., Licensed Practical Nurse (LPN) 75 indicated during meals residents sitting at the same table should be served at the same time. On 8/11/23 at 2:50 p.m., the Corporate Nurse Consultant provided the current Assistance with Meals policy, revised 3/2022. The policy included, but was not limited to, Resident's who cannot feed themselves will be fed with attention to safety, comfort, and dignity. 3.1-3(a)