**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, resident and staff interviews, and policy review the facility failed to carry out therapy recommendations and provide restorative exercises for 1 of 3 residents reviewed for rehabilitation services and/or limited range of motion (Resident #17). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had diagnoses of cerebrovascular accident (CVA) (stroke), lymphedema and a chronic non-pressure ulcer on his buttock. The MDS recorded the resident had a Brief Interview for Mental Status score of 15, indicating cognition intact. The MDS documented the resident had impaired range of motion (ROM) on one side of his body. The resident required substantial to maximum assistance for toileting, and partial to moderate assistance for transfers and ambulating 10 feet. The MDS recorded the resident had physical therapy (PT) services 7/21/23 to 8/18/23, and no days of restorative nursing program (RNP) during the 7 day look-back period. The MDS assessment dated [DATE] revealed the resident required substantial to maximum assistance for transfers, toileting, and ambulating 10 feet. The resident had dependence for ambulating 50 and 150 feet. The MDS recorded the resident had zero (0) minutes of physical therapy, and no days of RNP during the 7 day look-back period. The Care Plan revised on 12/16/24 revealed the resident had a stroke and physical limitations, and required assistance with activities of daily living (ADL's). The Care Plan directed staff to use a walker and one to two staff for transfers. The Care Plan lacked information about the resident's ambulation status or a restorative or functional maintenance exercise program (FMP). Review of the electronic health record plan of care (POC) ADL for walking dated 3/10/25 - 4/8/25 revealed the following out of 67 possible recorded entries: Walk 10 feet: required partial to moderate assistance 10 times, maximum assistance 19 times, not attempted 5 times and resident refused 8 times. Walk 50 feet with two turns: required partial to moderate assistance 3 times, maximum assistance 7 times, not attempted 3 times, and resident refused 1 time. Walk 150 feet: not attempted 15 times, resident refused 6 times, and not applicable recorded 37 times. The Progress Notes dated 12/1/24 to 4/8/25 revealed the resident used the therapy bike for 15 minutes on 2/12/25 at 4:10 PM and 2/28/25 at 4:30 PM. The Progress Notes lacked any other exercise or restorative activities performed. The PT Treatment Encounter Note dated 3/25/25 revealed the resident had a fall risk and lymphedema. A FMP in place for the SCIfit bike for lower extremity ROM as well as ambulation with staff using a FWW (four wheeled walker) and assistance of one. Per resident report the staff consistently completed this program when a certain CNA (certified nursing assistant) worked. The therapist recommended to encourage other staff learn the program to allow for ongoing consistency even when the CNA was not working. A Summary of Daily Skilled Services Note signed by Staff N, PT, on 3/25/25 at 4:39 PM revealed the resident had reached his maximum potential with skilled services. The resident consistently participated in lower extremity exercises and walked with staff. The PT discharge recommendations included a FMP in place to avoid functional decline. The established FMP included an ambulation program with a FWW and assistance of one, and ROM program with the SCIfit bike for 15 minutes for upper and lower extremity range of motion. The PT Discharge summary dated [DATE] at 8:30 PM revealed the resident had diagnoses of muscle wasting and atrophy, lymphedema, and unsteadiness on feet. The resident had met the following goals: 1. Transitioned to standing out of a wheelchair requiring moderate to maximum assistance on the first attempt. 2. Ambulated 28 feet using FWW and contact guard assistance. 3. Consistently ambulated multiple times a week with staff using a FWW to the bathroom with minimum assistance. Therapy recommended a FMP for the resident's bilateral upper extremities and lower extremities in order to maximize the resident's functional potential. The resident wanted to use the SCIfit (exercise bike) and the lift hand weights. Observations revealed the following: a. On 4/6/25 at 12:50 PM, Resident # 17 sat in a wheelchair in his room. b. On 4/7/25 at 11:05 AM, Resident #17 sat in recliner with his legs elevated. c. On 4/7/25 at 1:30 PM, Resident #17 sat in recliner with his legs elevated and had lymphedema pants on. d. On 4/9/25 at 9:20 AM, Resident #17 sat in recliner in his room. In an interview on 4/6/25 at 12:50 PM, Resident #17 reported he had a stroke. He no longer got therapy services. Resident #17 stated the staff were busy and did not always get his walk done. The resident had a goal to get out of the facility but he needed to be able to do basic cares to take care of himself and he had to have help moving out of the chair. The resident said he sat in the chair all day and he had a sore on his bottom. On 4/9/25 at 10:40 AM, Resident #17 reported he wanted to get better so he could attend a family member's upcoming graduation and wedding events. In an interview on 4/8/25 at 1:45 PM, the Director of Nursing (DON) reported they do not have a restorative aide at the facility. In an interview 4/9/25 at 11:55 AM, Staff O, PT, reported he notified the social worker and the resident and/or family whenever therapy services were ended. Therapy sometimes referred residents to a FMP. Staff O gave the recommendations on what to do to nursing to set up the program. It could be a walk to dine or ROM exercise program. Therapy left the frequency open for nursing to determine what was needed. At the time, the surveyor asked Staff O if he had referred residents to a FMP/ Restorative Program after therapy, and if he had later seen a decline with any of the residents. Staff O replied therapy looked at residents every 3 months to see if a resident needed therapy services or if the resident had triggered for things such as a fall. Therapy re-evaluated the resident and whether the resident needed to be placed back on therapy services. Staff O reported the facility did not have a restorative person. Staff O reported a SCIfit bike in the therapy room for residents to use. Staff would have to let the resident into the therapy room to use the bike. The Facility's Establishment of an Individual Restorative Program Policy and Procedure reviewed 1/3/25 revealed a Restorative Program provided services to maintain and improve functional abilities. Therapy made a referral and recommendations for establishment of a restorative program and the restorative nurse and restorative aid implemented the program. An order for RNP described the program, the number of days per week, and the duration of the program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interview, manufacturer recommendations, and policy review the facility failed to ensure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 30 opportunities for error resulting in an error rate of 6.67 % (Residents #19 and #22). The facility identified a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a diagnosis of diabetes. The MDS documented the resident took insulin 6 of 7 days during the look-back period. The Care Plan initiated 3/26/25 revealed the resident had diabetes. The Care Plan directed staff to administer diabetes medication as ordered by the physician. The Order Summary revealed to inject Novolog flexpen 100 unit/ milliliter (ml) subcutaneous (SQ) after meals and at bedtime related to Type 2 Diabetes Mellitus as per sliding scale: if 150 - 199 = 3; 200 - 249 = 5; 250 - 299 = 7; 300 - 349 = 10; 350 - 399 = 12; 400 - 449 = 14. The Medication Administration Record (MAR) dated 4/1/25 to 4/30/25 for Resident #19 listed Novolog flexpen 3 units SQ administered on 4/8/25 for the 07:00 AM dose by Staff A, Licensed Practical Nurse (LPN). Staff A recorded the BS (blood sugar) of 198. The MAR listed the sliding scale as follows: if 150 - 199 = 3; 200 - 249 = 5; 250 - 299 = 7; 300 - 349 = 10; 350 - 399 = 12; 400 - 449 = 14; The sliding scale order started on 4/8/25 at 6:23 AM. A plastic bin for Resident #19 had the following taped on the inside of the lid: An order dated 3/21/25 at 1:53 PM for Insulin Aspart (Novolog) injection SQ per sliding scale: If 200-249 = 2 units 250-299= 4 units 300-349 = 8 units 350-399 =10 units 400-449 = 12 units During observation on 4/8/25 at 8:00 AM, Staff A, Licensed Practical Nurse (LPN), took a plastic bin with supplies from the medication cart and took to Resident #19's room. Staff A checked Resident #19's blood sugar and reported the blood sugar of 198. Staff A reported the sliding scale insulin order kept on the inside of the plastic bin with insulin and blood sugar supplies. Staff A checked the sliding scale listed on the lid and reported she needed to administer 2 units of insulin. Staff A attached a needle on the end of a Novolog insulin flexpen and turned the dial on the flexpen to 2. Staff A inserted the needle into the resident's left upper arm, pushed the button on the end of the insulin flexpen then removed the needle after one second. Staff A did not prime the insulin pen prior to administering the insulin dose to the resident. During an interview on 4/8/25 at 11:30 AM, Staff A reported she went off the sliding scale listed on the inside of the plastic bin containing blood sugar supplies and insulin for the resident. Staff A stated she didn't realize the order was different in the computer than the sliding scale listed on the inside of the plastic bin. Staff A confirmed she was not aware she needed to prime the insulin pen prior to administering the medication. During an interview on 4/8/25 at 11:53 AM, Staff B, LPN, reported she gave insulin per sliding scale and the resident's blood sugar. The sliding scale was listed on the EMAR (electronic medication administration record) and also taped inside the insulin box for each resident. Staff B reported she always checked the MAR because the orders changed and she wanted to make sure she gave the correct dose. During an interview on 4/8/25 at 1:30 PM, Staff C, Registered Nurse (RN) reported the nurse processed and entered orders in the computer, or the Nurse Practitioner entered their own orders. Staff C stated she printed off the sliding scale order and placed it inside the plastic box with blood sugar supplies labeled with the resident's name. She checked the resident's blood sugar and then checked the sliding scale on the EMAR. During an interview on 4/8/25 at 1:45 PM, the Director of Nursing (DON) reported she processed and entered the physician's orders whenever a resident was admitted to the facility, otherwise the nurse on duty entered the orders. The DON explained the nurse printed off the order and was supposed to place the label inside the resident's plastic bin in the medication cart whenever the sliding scale orders changed. The DON reported she had been working the night shift and had not had a chance to check for any recent orders. She normally checked to ensure the label on the inside of the plastic bin got updated but she had not followed up to see if the label got updated. The DON reported Resident #19's sliding scale orders had recently changed on 4/6/25. The DON reported she expected the nurse to check the resident's MAR before they gave the insulin. The DON reported the facility did not have a policy for medication administration for the insulin flexpen. She expected staff to follow the manufacturer instructions whenever they used an insulin flexpen. During an interview 4/8/25 at 2:50 PM, Staff D, RN, reported for some reason the facility staff printed the sliding scale order and placed it on the resident's insulin box. Staff D stated she questioned if the box got updated when the insulin orders changed. Staff D reported she always checked the insulin before she gave it because she sometimes found the insulin not placed in the right box. During an interview 4/9/25 at 8:00 AM, Staff G, RN, reported she always verified the insulin order and dose to administer on the EMAR. Staff G reported the computer automatically calculated the insulin dose to administer when she entered the blood sugar reading in the computer. During an interview 4/9/25 at 9:05 AM, Staff H, Pharmacist, reported the insulin pens needed to be primed before the insulin dose administered, and the insulin pen needed to be held 5-10 seconds before the needle pulled out to ensure the full dose was administered. According to the Novolog Manufacturer instructions revised 2/2023 revealed the following procedural steps for Novolog insulin injection 100 units/ ml flexpen: a. Attach the needle and turn the dose selector to 2. b. Hold the Novolog flexpen with the needle pointing up. Tap the cartridge gently with your finger to make any air bubbles collect at the top of the cartridge. Keep the needle pointed upward. Press the push button all the way in. If no drop of insulin observed, repeat this step up to 6 times. c. Turn the dose selector to the number of units needed for injection. d. Insert the needle into the skin. e. Press the push button all the way in until the 0 lines up with the pointer. f. Keep the needle in the skin for at least 6 seconds and keep the push button pressed all of the way in until the needle has been pulled out from the skin to ensure the full dose given. A Medication Administration Guidelines policy dated 12/17 revealed medications administered as prescribed in accordance with good nursing principles and practices, and a medication distribution system to ensure safe administration of medications. The five rights (right resident, right drug, right dose, right route and right time) are applied for each medication being administered. The medication and dosage schedule on the resident's MAR are compared with the medication label prior to administration of any medication. The physician's orders are checked for the correct dosage schedule if the label and MAR are different and the container has not already been flagged indicating a change in directions or if there is any other reason to question the dosage or directions. When a medication order is changed and the current supply can continue to be used, the container should be flagged right away and the order change communicated to the pharmacy so the next supply of medication is labeled with the current directions. 2. The MDS Assessment date 2/2/25 revealed Resident #22 had diagnoses of gastro-esophageal reflux disease (GERD) (stomach acid backs up into the esophagus) and dysphagia (difficulty swallowing). Resident #22's Care Plan revealed the resident had a nutritional problem related to GERD and dysphagia. The Care Plan directed staff to administer medications as ordered. The Order Summary Report dated 4/8/25 revealed Omeprazole Delayed Release (DR) capsule (used to treat heartburn/ GERD) by mouth in the morning for GERD. During observation on 4/8/25 at 7:40 AM, Staff F, Certified Medication Aide, prepared Resident #22's medications: a. Two Tylenol 325 milligram (mg) tablets b. Omeprazole DR 20 mg c. Sertraline 50 mg d. Levothyroxine 137 microgram (mcg) Staff F placed the medication into a small bag and crushed the pills together, then mixed the contents with applesauce. Staff F took the medication to Resident #22 and administered the medication. At the time, Resident #22 sat in the dining room eating breakfast. In an interview 4/9/25 at 9:05 AM, Staff H, Pharmacist reported Omeprazole DR needed to be given 1/2 to 1 hour before a meal. Staff H also reported the DR medication should not be crushed or it won't be DR anymore. A Medication Administration Guidelines policy dated 12/17 revealed long-acting or enteric-coated dosage forms should not be crushed; an alternative should be sought. Some long-acting capsules can be opened and administered (without crushing contents). Consult with the pharmacist before opening capsules or for an alternative dosage form of the medication. Crushing medications should be indicated on the resident's orders and the MAR so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety issues and alternatives, if appropriate, during medication regimen reviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview, manufacturer's instructions, and policy review the facility failed to administer insulin according to the physician's orders for sliding scale insulin and per manufacturer instructions to ensure the proper amount of insulin administered for one of two residents observed who received insulin during medication pass (Resident #19). The facility failed to update sliding scale orders inside the plastic bin with blood sugar supplies for one of seven residents who took insulin. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a diagnosis of diabetes. The MDS documented the resident took insulin 6 of 7 days during the look-back period. The Care Plan initiated 3/26/25 revealed the resident had diabetes. The Care Plan directed staff to administer diabetes medication as ordered by the physician and educate caregivers on the correct protocol for glucose monitoring and insulin injections. The Order Summary revealed inject Novolog flexpen 100 unit/ milliliter (ml) subcutaneous (SQ) after meals and at bedtime related to Type 2 Diabetes Mellitus as per sliding scale: if 150 - 199 = 3 (units); 200 - 249 = 5; 250 - 299 = 7; 300 - 349 = 10; 350 - 399 = 12; 400 - 449 = 14. The Medication Administration Record (MAR) dated 4/1/25 to 4/30/25 for Resident #19 listed Novolog flexpen 3 units SQ administered on 4/8/25 for the 07:00 AM dose by Staff A, Licensed Practical Nurse (LPN). Staff A recorded the BS (blood sugar) of 198. The MAR listed the sliding scale as follows: if 150 - 199 = 3; 200 - 249 = 5; 250 - 299 = 7; 300 - 349 = 10; 350 - 399 = 12; 400 - 449 = 14; The sliding scale order started on 4/8/25 at 6:23 AM. A plastic bin for Resident #19 had the following taped on the inside of the lid: An order dated 3/21/25 at 1:53 PM for Insulin Aspart (Novolog) injection SQ per sliding scale: If 200-249 = 2 units 250-299= 4 units 300-349 = 8 units 350-399 =10 units 400-449 = 12 units During observation on 4/8/25 at 8:00 AM, Staff A, LPN, took a plastic bin with supplies from the medication cart and took to Resident #19's room. Staff A checked Resident #19's blood sugar and reported the blood sugar of 198. Staff A reported the sliding scale insulin order kept on the inside of the plastic bin with insulin and blood sugar supplies. Staff A checked the sliding scale listed on the lid and reported she needed to administer 2 units of insulin. Staff A attached a needle on the end of a Novolog insulin flexpen and turned the dial on the flexpen to 2. Staff A inserted the needle into the resident's left upper arm, pushed the button on the end of the insulin flexpen then removed the needle after one second. Staff A did not prime the insulin pen prior to administering the insulin dose to the resident. During an interview on 4/8/25 at 11:30 AM, Staff A reported she went off the sliding scale listed on the inside of the plastic bin containing blood sugar supplies and insulin for the resident. Staff A stated she didn't realize the order was different in the computer than the sliding scale listed on the inside of the plastic bin. Staff A confirmed she was not aware she needed to prime the insulin pen prior to administering the medication. During an interview on 4/8/25 at 11:53 AM, Staff B, LPN, reported she gave insulin per sliding scale and the resident's blood sugar. The sliding scale was listed on the EMAR (electronic medication administration record) and also taped inside the insulin box for each resident. Staff B reported she always checked the MAR because the orders changed and she wanted to make sure she gave the correct dose. During an interview on 4/8/25 at 1:30 PM, Staff C, Registered Nurse (RN) reported the nurse processed and entered orders in the computer, or the Nurse Practitioner entered their own orders. Staff C stated she printed off the sliding scale order and placed it inside the plastic box with blood sugar supplies labeled with the resident's name. She checked the resident's blood sugar and then checked the sliding scale on the EMAR. During an interview on 4/8/25 at 1:45 PM, the Director of Nursing (DON) reported she processed and entered the physician's orders whenever a resident was admitted to the facility, otherwise the nurse on duty entered the orders. The DON explained the nurse printed off the order and was supposed to place the label inside the resident's plastic bin in the medication cart whenever the sliding scale orders changed. The DON reported she had been working the night shift and had not had a chance to check recent orders. She normally checked to ensure the label on the inside of the plastic bin got updated but she had not followed up to see if the label got updated. The DON reported Resident #19's sliding scale orders had recently changed on 4/6/25. The DON reported she expected the nurse to check the resident's MAR before the gave the insulin. The DON reported the facility did not have a policy for medication administration for the insulin flexpen. She expected staff to follow the manufacturer instructions whenever they used an insulin flexpen. During an interview 4/8/25 at 2:50 PM, Staff D, RN, reported for some reason the facility staff printed the sliding scale order and placed it on the resident's insulin box. Staff D stated she questioned if the box got updated when the insulin orders changed. Staff D reported she always checked the insulin before she gave it because she sometimes found the insulin not placed in the right box. During an interview 4/9/25 at 8:00 AM, Staff G, RN, reported she always verified the insulin order and dose to administer on the EMAR. Staff G reported the computer automatically calculated the insulin dose to administer when she entered the blood sugar reading in the computer. During an interview 4/9/25 at 9:05 AM, Staff H, Pharmacist, reported the insulin pens needed to be primed before the insulin dose administered, and the insulin pen needed to be held 5-10 seconds before the needle pulled out to ensure the full dose was administered. According to the Novolog Manufacturer instructions revised 2/2023 revealed the following procedural steps for Novolog insulin injection 100 units/ ml flexpen: a. Attach the needle and turn the dose selector to 2. b. Hold the Novolog flexpen with the needle pointing up. Tap the cartridge gently with your finger to make any air bubbles collect at the top of the cartridge. Keep the needle pointed upward. Press the push button all the way in. If no drop of insulin observed, repeat this step up to 6 times. c. Turn the dose selector to the number of units needed for injection. d. Insert the needle into the skin. e. Press the push button all the way in until the 0 lines up with the pointer. f. Keep the needle in the skin for at least 6 seconds and keep the push button pressed all of the way in until the needle has been pulled out from the skin to ensure the full dose given. A Medication Administration Guidelines policy dated 12/17 revealed medications administered as prescribed in accordance with good nursing principles and practices, and a medication distribution system to ensure safe administration of medications. The five rights (right resident, right drug, right dose, right route and right time) are applied for each medication being administered. The medication and dosage schedule on the resident's MAR are compared with the medication label prior to administration of any medication. The physician's orders are checked for the correct dosage schedule if the label and MAR are different and the container has not already been flagged indicating a change in directions or if there is any other reason to question the dosage or directions. When a medication order is changed and the current supply can continue to be used, the container should be flagged right away and the order change communicated to the pharmacy so the next supply of medication is labeled with the current directions.

Based on observation, menu review, record review, and staff interviews, the facility failed to serve the appropriate portions for two of two residents who received pureed diets (Resident #5 and #25). The facility reported a census of 44 residents. Findings include: The facility's Fall/Winter Week 3 Menu for Monday lunch identified chicken, the vegetable of the day (peas), and a dinner roll to be served as part of the planned pureed textured diet for the lunch meal served on 4/7/25. The facility's Resident Summary Report listing each resident's diet identified two residents on a pureed texture diet. During observation on 4/7/25 at 11:37 AM, Staff E, Dietary Cook, reported two residents on a pureed diet, but she planned to make one additional serving. Staff E placed three dinner rolls and three chicken breasts into a robot coupe container, added some chicken broth, and blended the contents together. Staff C poured the contents into a measuring cup and reported a total of two cups. Staff C then poured the pureed contents into a metal pan on the steam table. On 4/7/25 at 11:44 AM Staff E placed three ladles of peas into a robot coupe container. Staff E stated she didn't know the size of the ladle used, it had a green handle. Staff E blended the peas in the robot coupe, then checked the consistency and poured the contents into a measuring cup. Staff E reported a total of one and one-half cups. Staff C then poured the pureed contents into a metal pan on the steam table. The Dietary Manager and Consulting Dietician observed with the surveyor as Staff E prepared the pureed entrees. During the lunch meal service on 4/7/25 starting at 12:05 PM, Staff E, Dietary Cook, plated food for the residents. During the meal service Staff E plated food for the residents on a pureed diet (Resident #5 and #25). On 4/7/25 at 12:45 PM, Staff E reported she used the following serving sizes: One #8 scoop of pureed chicken One #12 scoop of pureed peas The serving chart revealed a #8 scoop the equivalent of 4 ounces (oz.), and a #12 scoop the equivalent of 2 ½-3 oz. Review of the Pureed Diet Portion Sizes/Scoops posted on the wall near the Robot Coupe mixers revealed the residents on a pureed diet were supposed to get a #6 scoop (a total of 5 1/3 oz.) of pureed chicken and a #8 scoop (a total of 4 oz.) of pureed peas. During an interview 4/7/25 at 12:50 PM, Staff E reported she checked the book that had the food entrees listed for each type of food texture (pureed, mechanical soft, regular diets) to know the size serving to serve for each entree. During an interview on 4/8/25 at 10:05 AM, the consulting dietician reported she expected staff to follow the menu and serve the proper serving sizes. She planned to do some staff education regarding the pureed serving size. She used to do the volume method but they now used a document that listed the scoop or serving size to use for each entree. The surveyor pointed out the dinner roll and broth were added to the chicken, which increased the volume on the pureed chicken. The dietician reported since the dinner roll and chicken were listed separately on the document but the cook puree the dinner roll and chicken together, then the dinner roll serving size and the chicken serving size should be added together to get the scoop/serving size. The dietician said she would review the serving size chart. A Pureed Meat Diet Guidelines policy updated 1/3/25 revealed the following procedural steps: a. Follow the recipe portion size b. Place the desired number of portions into a food processor or blender c. Add broth or other liquid as needed for product consistency d. Blend the mixture to a smooth consistency e. Pour the puree food into a container with calibrated volume markings. f. Divide the total volume of pureed food by the number of portions originally placed in the food processor to determine the portion size. For example: 4 cups total volume divided by 8 portions originally started with equals ½ cup serving.

Based on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to protect the personally identifiable information of residents for 1 of 14 residents reviewed (Resident #96). The facility reported a census of 44. Findings include: The Care plan for Resident #96, completed on 04/07/2025, identified the resident had received a skin graft after cancer surgery. It did not document how often or how to bathe the resident. A direct observation on 04/06/2025 at 10:30 AM revealed a note, taped to the staff schedule and facing the dining room accessible to all visitors in the facility, where Resident #96's care information was posted. It documented Resident #96 had a skin graft, currently had a drainage port, and that the resident was limited to only receiving bed baths due to the skin issues. It identified Resident #96 by full name. A direct observation on 04/06/2025 at 01:31 PM revealed an unidentified staff member take the note down from the staff schedule after lunch dining service. In an interview on 04/09/2025 at 12:23 PM with Staff L, Certified Medication Aide (CMA), she acknowledged she had seen Resident #96's care data on the nursing schedule earlier in the week and that she didn't know who took it down. She stated it should not have been posted where the public could easily access it. She had meant to talk to the nurse whom she believed had placed it there. In an interview on 04/09/2025 at 12:40 PM with Staff J, Certified Nurse Aide (CNA), she stated resident charts and the electronic health record (EHR) is the only acceptable place to store information that could identify a resident beyond their name. She stated it should never be in plain view of the entire facility. In an interview on 04/09/2025 at 12:30 PM with Staff B, Licensed Practical Nurse (LPN), she acknowledged she was aware that Resident #96's identifiable care information. She was not the one who posted it, but stated she did not take it down because she was worried about newer staff missing something if it wasn't posted in plain sight. She acknowledged it should not have been posted there. In an interview on 04/09/2025 at 10:56 AM with the Administrator, he stated Resident #96's information should never have been posted where it was found. He stated it has since been taken care of. Review of a facility provided document titled Privacy Policy, last reviewed 01/03/2025, documented the facility is to limit use, disclosure, and requests of Personal Health Information (PHI) and make sure they meet HIPAA regulations. It further documented all workforce members are responsible for awareness of this policy and adherence to the given directions and guidance.

Based on direct observation, staff interview, facility documentation, and facility policy review, the facility failed to implement measures to ensure safety for each resident identified at risk of injury to themselves. The facility reported a census of 44. Findings include: The significant change Minimum Data Set (MDS) for Resident #7, dated 03/27/2025, documented the resident's Brief Interview for Mental Status score (BIMS) was documented as 02, indicating severely intact cognition. It also documented the following relevant diagnoses: hemiplegia or hemiparesis (partial or full paralysis), anxiety disorder, bipolar disorder, and cognitive communication deficit. A continuous direct observation on 04/06/2025 from 10:06 AM until 10:34 AM revealed the shower room door of the South Hall was open, the floor was visibly wet and the shower was still running. During the observation several residents were walking up and down the hall, with Resident #7 ambulating extremely slowly via wheelchair. During the observation surveyors positioned themselves near the door to the shower room to prevent Resident #7 from wandering into the shower room. At this same time, the hallways in South, West, and East halls were noted to be heavily cluttered with wheelchairs, mechanical lifts, and the treatment and medication cart. During the observation, while surveyors were placed across the hall from the shower room, the surveyors had to move to allow resident's through the hall due to the clutter. A direct observation on 04/09/2025 at 12:22 PM in the South hallway showed two cleaning carts blocking the hallway, with two residents attempting to navigate past the cleaning carts and hallway clutter. In an interview on 04/09/2025 at 12:30 PM with Staff B, Licensed Practical Nurse (LPN), she stated the door should never have been left open, especially not with the water running. She stated it posed a hazard to residents, and noted the door is to be closed and locked unless you're taking a resident into the shower room or leaving. She noted the facility was small, and they didn't know where else to put the clutter in the hallway. In an interview on 04/09/2025 at 12:40 PM with Staff J, Certified Nurse Aide (CNA), she stated the door to the shower room should not have been left open. She stated it posed a hazard to those in the facility who were cognitively impaired, and acknowledged Resident #7 wanders slowly. She also acknowledged the hallways were cluttered, and suggested this had been previously discussed by the facility. In an interview on 04/09/2025 at 10:56 AM with the Administrator, he acknowledged the shower room door should not have been left open, especially with the water running, and explained a CNA had left the door open while preparing another resident for their shower. The door is to remain closed and locked. In an interview on 04/09/2025 at 01:38 PM with the Director of Nursing (DON), she acknowledged the shower room door should not have been left open, and that the halls were cluttered. She stated the facility is small and the rooms do not have space to store resident wheelchairs. She stated the expectation is for staff to clear a path for residents attempting to ambulate through the facility. A policy was not available for review.

Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 44. Findings include: A direct observation on 04/06/2025 from 12:21 PM until 01:31 PM revealed the following: At 12:22 PM the Dietary Manager touched the top of the plate while she served food to a resident. At 12:27 PM Staff B, Licensed Practical Nurse (LPN) placed a clothing protector on a resident, making direct contact with the resident's skin, then served the resident plate while touching the top of the plate without performing hand hygiene. At 12:32 PM Staff B, LPN, again made direct contact with another resident, did not perform hand hygiene, and then began feeding two residents at the same time with no witnessed hand hygiene performed while switching from one resident to another. The Dietary manager was also seen continuing to serve resident meals holding the plates with her thumb near resident food. At 12:35 PM the Dietary manage made direct contact with a resident's food with bare hands, the food was not replaced and it was consumed by the resident. At this same time marker Staff P, Certified Nurse Aide (CNA), was observed making direct contact with a resident's food. The food was not replaced and the resident was observed eating the food. A direct observation on 04/07/2025 from 11:50 AM until 12:25 PM revealed the following: At 12:00 PM Staff E, Cook, placed her hands on top of glasses and bowls as she served lunch from the kitchen. At 12:09 PM Staff L, CNA, was observed serving a resident a plate with her thumb on top of the plate making direct contact with resident food. The resident was observed eating this food. At 12:10 PM Staff L continued to serve residents food with her thumbs on top of the resident plate, again making direct contact with the food the resident was later observed eating. At 12:25 PM Staff L switched tasks and began to assist two residents with eating. She did not perform hand hygiene before assisting either resident and continued to switch tasks multiple times. Hand sanitation was never observed. In an interview on 04/08/2025 at 11:53 AM with Staff B, LPN, she acknowledged she should have avoided handling the eating surfaces of things like plates and silverware. She acknowledged that when she is feeding two residents at the same time she should be sanitizing her hands with hand sanitizer in between each bite. In an interview on 04/09/2025 at 12:23 PM with Staff L, CNA, she stated they should avoid touching or coming into contact with resident food during meal service. She stated they are instructed to avoid feeding two residents at the same time during meals, or they are required to sanitize their hands after every bite they offer. In an interview on 04/09/2025 at 12:40 PM with Staff J, CNA, she stated they are instructed to pick plates up from the bottom and to never place their thumbs on the tops of plates. If she came into direct contact with a resident, such as when touching them to place a clothing protector on, they are instructed to sanitize their hands. She stated if she made direct contact with a resident's food she would be expected to replace it. She also stated when feeding two residents at the same time they are instructed to sanitize after every bite offered to a different resident than who had been just assisted. In an interview on 04/09/2025 at 01:38 PM with the Director of Nursing (DON), she stated her expectation is for staff members to sanitize their hands every time they pass a tray to a resident, when they come into direct contact with a resident, and that they should only touch the bottom of the plate. She also stated her expectation is for staff members feeding two residents at the same time to sanitize their hands between each resident. Review of a facility provided document titled Food Handling and Use of Gloves last revised 01/03/2025, directs staff to use gloves and sanitize hands if making direct contact with resident food, and only when direct contact with resident food is required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, staff competency checklist and policy review, the facility failed to follow enhanced barrier precautions for 1 of 4 residents sampled and required enhanced barrier precautions and 1 of 1 residents observed for catheter care (Resident #26). The facility staff also failed to use a barrier when emptying the catheter. The facility staff also failed to follow infection control practices for 1 of 4 residents observed during cares (Resident #30). The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had diagnoses of neurogenic bladder, urinary retention, diabetes, and non-Alzheimer's dementia. The MDS indicated the resident had an indwelling catheter. The Care Plan revised 5/20/24 revealed Resident #26 had a suprapubic catheter and chronic urinary tract infections. The Care Plan directed staff to utilize a gown and gloves for enhanced barrier precautions (EBP) during high-contact care activities including catheter care. During observations on 4/7/25 at 1:20 PM, Staff J, Certified Nursing Assistant (CNA) donned a pair of gloves and obtained a graduate container from the bathroom. Staff J placed the graduate on the carpeted floor next to the resident's wheelchair, removed the catheter bag from under the wheelchair, then removed the port from the catheter bag holder. Staff J unclamped the catheter, drained the urine contents into the graduate, clamped the catheter, and replaced the port into the holder on the catheter bag. Staff J hung the catheter bag under the wheelchair. Staff J picked the graduate full of urine up and carried the graduate across the room to the bathroom. Staff J used her gloved hand to open the bathroom door, then emptied the urine into the toilet. Staff J turned the water on, took the sprayer and rinsed the graduate container with water, and emptied the contents into the toilet. Staff J placed the graduate on the back of the toilet, then shut the water off and replaced the sprayer hose into the holder. Staff J removed her gloves and washed her hands. Staff J did not wear a gown when she emptied the catheter, did not cleanse the catheter port with alcohol before or after she emptied the catheter, and did not use a barrier prior to placing the graduate on the floor. During an interview 4/8/25 at 11:53 AM, Staff B, Licensed Practical Nurse (LPN), reported EBP's used whenever a catheter or wound care performed. A gown, gloves, mask, and goggles should be worn whenever staff worked with a catheter. During an interview 4/8/25 at 1:30 PM, Staff C, Registered Nurse (RN) reported EBP's used for any sick residents or if a resident had immune issues. The personal protective equipment (PPE) worn for EBP's depended on the resident's illness. Staff should at least wear gloves whenever they emptied a catheter. During an interview 4/8/25 at 1:45 PM, the Director of Nursing (DON) reported EBP's were required whenever a resident had a wound or a catheter. The DON expected staff to wear a gown and gloves during cares for the residents on EBP's. An Indwelling Catheter Competency Checklist revealed the following procedural steps when the down drain bag emptied: a. Assemble supplies b. Perform hand hygiene and don gloves c. Place disposable barrier on the floor below the down drain bag and put graduate on the barrier. d. Open the clamp and drain the urine into the graduate. e. Close the clamp and wipe the tip thoroughly with an alcohol pad, then replace the port into the holder. f. Empty the graduate into the toilet. g. Rinse the graduate then place a dry paper towel in the bottom of the graduate. Store the graduate in a plastic bag in the bathroom. h. Remove gloves and perform hand hygiene. An Enhanced Barrier Precautions policy reviewed 5/15/24 revealed the use of gown and gloves for high-contact resident care activities is indicated for residents with an indwelling medical device, including a urinary catheter. 2. The MDS assessment dated [DATE] revealed Resident #30 had chronic non-pressure ulcer on her buttock, cerebrovascular accident (CVA) (stroke), and dementia. The MDS indicated the resident required substantial to maximum assistance for bed mobility and toileting hygiene. The Care Plan revised on 10/16/24 revealed Resident #30 had impaired skin integrity on her buttock related to incontinence and limited mobility. The Care Plan directed staff to check and change the resident to manage incontinence. During observation on 4/7/25 at 2:48 PM, Staff K, CNA, entered Resident #30's room and washed her hands in the sink. Staff L, CNA, placed a washcloth in the bowl of the sink and ran the water over the washcloth. Staff L then left the room briefly. Staff L returned to the room and placed additional washcloths in the sink under the running water. Staff L poured peri wash on the washcloths then moved the washcloths to the edge of the sink and washed her hands. Staff L then placed the wet washcloths on a dry washcloth on an overbed table. Staff K took a wet washcloth from the overbed table and cleansed the resident's groin and periarea front to back, then took another washcloth and cleansed the resident's buttocks area. The resident's brief was wet and a small amount of stool was present between the buttocks. The resident's labia and buttocks area were reddened. The right buttock had an open area and the left buttock had two small open areas. During an interview 4/9/25 at 9:44 AM, the DON reported Resident #30 had excoriation to her groin and buttock for a week. The staff put a house barrier cream on the resident's bottom. The DON reported she was also the Infection Preventionist at the facility. The DON reported washcloths used for cares should not be left in the same sink used for handwashing. The sink would be considered a dirty area. The DON confirmed Resident #30's roommate also used the same sink for her handwashing and personal cares.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on direct observation, clinical record review, staff interview, and policy review, the facility failed to grant a resident the right to choose to wear personal clothing for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 42. Findings include: The Annual Minimum data set (MDS) for Resident #5, dated 12/22/2023, included the following relevant diagnoses: diabetes mellitus (diabetes), cerebrovascular accident (stroke), above the knee amputation of the left leg. It documented the resident was dependent on staff for dressing his lower body and required moderate assistance to dress his upper body. It further documented the resident was dependent on staff for all transfers. The Quarterly MDS for Resident#5 documented that a 14 out 15 score for the Brief Interview for Mental Status, which indicated intact cognitive skills. The Care Plan for Resident #5, last revised on 11/14/2024, documented Resident #5 required staff assistance to dress. It also advised readers to document observed behaviors and all interventions attempted. In a document provided to surveyors by the facility titled Resident BIMS it documented the residents Brief Interview for Mental Status (BIMS) score as 14, indicating intact cognition. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 12/01/2024 through 12/17/2024 did not document refusal to get dressed as one of the behaviors to monitor. It lacked any documentation from 12/01/2024 to 12/04/2024. It lacked documentation on 12/12/2024 during the 6 pm-6 am shift. It documented No indicating no behaviors occurred from 12/05/2024 to 12/16/2024. The Bedside [NAME] Report, printed 12/17/2024 failed to document a resident preference for wearing a hospital gown or any specific behaviors to watch for. It did advise staff members to document observed behaviors and attempted interventions. The Care Plan history tab of the electronic health record (EHR), failed to document behaviors of any kind within the last six months. The Plan of Care Behavioral Tracking History did not contain documentation of any kind regarding Resident #5's behaviors within the 30 day lookback period. During an interview on 12/16/2024 at 2:03 PM with Resident #5 he stated he did not want to be in what he called a dress. He stated he wished to be wearing normal clothes. He was observed to be in a hospital style gown at this time. During an interview on 12/17/2024 at 9:49 AM with resident #5 he was observed to again be wearing a hospital style gown. When greeted, the resident noted he had been given a new dress, but stated he hoped he would be helped into normal clothes during the day. When asked if he had communicated his desire to wear traditional personal clothing to the facility, he stated he had tried in the past but had given up, as he had been in hospital style gowns for a while. In an interview on 12/17/2024 at 09:02 AM with Staff I, Certified Nursing Aide (CNA), she stated that Resident #5 often likes to wear no clothes at all. They use the hospital gown as a behavioral intervention to ensure he wears some clothes at all. She stated he often refused care, including getting dressed. She was unsure where Nursing staff document behaviors, but stated it was the CNA job to communicate behaviors observed to Nurses so they could document the behaviors. She stated she had never heard him voice a desire to wear personal clothes. In an interview on 12/17/2024 at 09:08 AM Staff C, CNA, reported she believed it was the personal preference of Resident #5 to wear hospital style gowns. She noted he had behavioral issues which prevented some care. When asked if she had witnessed behaviors, she stated she had seen him refuse bathing and nail trimming consistently. She had never seen him lash out or refuse to wear clothes for her. In an interview on 12/17/2024 at 08:28 AM with Staff B, Registered Nurse (RN), reported she believed the rationale for Resident #5 wearing hospital gowns was because of his personal preference. She stated she did know of an incident a while ago when Resident #5 had yelled at staff to help him into personal clothing, but stated she believed this was due to a doctor's appointment. She is unsure if staffed helped him into clothes on this occasion, as she got busy with other residents. When asked if Resident #5 had behaviors, she stated he can refuse care and he had a behavior tracking plan. She stated they document behaviors in the Treatment Administration Record (TAR) and in nursing progress notes. It is the nurses job to enter the nursing progress note and the CNAs job to inform nurses of behavioral issues. In an interview on 12/17/2024 at 09:14 AM with the Director of Nursing (DON), stated her expectation is that staff honor a residents' wishes regarding their choice of clothing. She noted if a resident refused to get dressed during the day she expected it would be tracked via a nursing progress note, and on the treatment administration record. She acknowledged the hospital style gown was an intervention if the resident refused to wear personal clothing that day. If documentation indicated there were no behaviors she would expect the resident to be dressed in personal clothing. She acknowledged four and a half days of documentation was missing from the December TAR, and all other documentation indicated the resident had not had any behaviors. Her expectation is for all documentation to be complete and accurate, and for charting to occur on every shift. She also expects documentation of all interventions attempted with the resident. During the interview she stated she believed there was a behavioral tracking book that might contain more information regarding Resident #5, and halted the interview at 09:22 AM to attempt to find the book. She returned at 09:30 AM and stated she believed the book was no longer available. The facility provided document titled Resident Right's Policy, issued on 02/01/2016, states under section K. all residents retain and use personal possessions to the maximum extent that space and safety permits. The facility provided document titled Comprehensive Person-Centered Care Plan, last revised on 10/23/2019, stated each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to implement the resident's Care Plan for 1 of 3 residents who fell (#3). The facility reported a census of 42 residents. Findings include: The Annual Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) of 02 out of 15 which indicated severely impaired cognition. It included diagnoses of Chronic Kidney Disease (CKD), Diabetes Mellitus (DM), cerebral infarction due to embolism of middle cerebral artery (stroke caused by a blood clot), intracerebral hemorrhage (stroke caused by brain bleed), hemiplegia (one-sided paralysis), aphasia (loss of ability to understand or express speech), and Chronic Obstructive Pulmonary Disease (COPD). It also revealed the resident was independent with oral hygiene, required setup assistance with personal hygiene, supervision with eating and toileting hygiene, moderate assistance with upper body dressing, maximum assistance with bathing and lower body dressing, and was dependent with putting on and removing footwear. A facility reported incident revealed Resident #3 fell on [DATE] at 2:12 AM. A Nurses Note dated 11/6/24 documented the following; Staff hearing resident yelling, entered resident room to find resident laying on back on floor in center of room. wheelchair tipped over lying next to resident. resident alert to staff, and VS taken with neuro's started. resident stated didn't know if he had hit head. complained of (c/o) right hip pain. resident able to move all extremities. No misalignment seen to right lower extremity. Resident assisted/ two assist/ gait belt into bed. Nurses Note dated 11/6/24 at 9:04 AM documented the following; Resident incontinent of BM this morning and screaming in his room. Screaming due to (d/t) back pain. Will address this pain with Advanced Nurse Practitioner (ARNP) today. Lab/Radiology Note dated 11/6/24 at 1:16 PM documented the following; Received x-ray results from Bio Tech. Called ARNP and read results. X-ray revealed acute or chronic subcapital femoral neck fracture (fx). ARNP suggested to call family and see if they would like him to be sent out or they can take resident to be seen by an orthopedic specialist. Incident Note dated 11/6/24 at 3:29 PM documented the following; Text: Resident was out for lunch in a wheelchair for and brought himself back to his room. Approximately 15 minutes later, he was yelling in his bathroom and CNAs found resident on floor in his bathroom. Resident stated he did not hit his head but having pain in his right hip 10/10. Resident was incontinent. Assisted resident into w/c then to bed via gait belt and 2 assist. Cleaned resident, skin assessment performed. Notified ARNP and resident's son,. Talked with the resident's son and he decided it would be best to send resident to the hospital for further evaluation. Incident Note dated 11/6/24 at 3:45 PM documented as follows; Resident was unable to flex and extend right hip, unable to perform dorsiflexion. Resident guarding with movement. Stabilized hip with pillows while resident was supine and waited for EMS to arrive Nurses Note dated 11/12/24 at 10:25 Am documented as follows; Resident here for skilled nursing related to Open Reduction and Internal Fixation (ORIF, repair of broken bones with hardware, such as screw, plated, wires or rods). The Care Plan revised 11/14/24 revealed the resident had a history of falls and directed staff to leave the resident's bathroom light on at all times. Skilled Evaluation dated 11/14/24 at 10:54 AM documented the following; the resident complained of right hip pain, stiffness, and aching, and it was worse with movement. The resident had poor balance. At 12:58 AM, the resident was observed in bed with his bedroom and bathroom lights off. A sign on the resident's bathroom door indicated the resident's bathroom light was to be left on at all times. On 12/17/24 at 9:10 AM, the resident was observed in bed with his bedroom light off. The sign was still on the resident's bathroom door that directed staff to leave the bathroom light on at all times. Staff H, Certified Nurse Aide (CNA) opened the resident's bathroom door. The resident's bathroom light was observed off. Staff H left the light off and closed the bathroom door. On 12/17/24 at 9:33 AM, Staff I, CNA stated she did not know why the resident's bathroom light was off. She turned it on. A policy titled Comprehensive Person-Centered Care Plan reviewed 10/23/19 indicated assigned disciplines will be identified to carry out the interventions. On 12/17/24 at 9:53 AM, the Director of Nursing (DON) stated the staff should read and follow the Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to provide assessment and interventions for 1 of 3 residents who fell (#3). The facility reported a census of 42 residents. Findings include: A Facility reported Incident revealed Resident #3 fell on [DATE] at 2:12 AM. The Annual Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) of 02 out of 15 which indicated severely impaired cognition. It included diagnoses of Chronic Kidney Disease (CKD), Diabetes Mellitus (DM), cerebral infarction due to embolism of middle cerebral artery (stroke caused by a blood clot), intracerebral hemorrhage (stroke caused by brain bleed), hemiplegia (one-sided paralysis), aphasia (loss of ability to understand or express speech), and Chronic Obstructive Pulmonary Disease (COPD). It also revealed the resident was independent with oral hygiene, required setup assistance with personal hygiene, supervision with eating and toileting hygiene, moderate assistance with upper body dressing, maximum assistance with bathing and lower body dressing, and was dependent with putting on and removing footwear. The Electronic Health Record (EHR) progress notes dated 11/06/24 at 2:12 AM revealed the resident had an unwitnessed fall in his room. It also lacked documented follow-up neurological checks (neuro checks). The Client Uploaded Files section did not have a paper neuro check sheet uploaded. The electronic Neurological Check List forms stopped on 9/10/21. The Care Plan revealed the resident had a history of falls and an anti-rollback bar was added to his wheelchair. It did not direct staff to perform neuro checks after a fall. On 12/16/24 at 11:53 AM, Staff B, Registered Nurse (RN) stated staff must perform an initial resident assessment and complete the neuro sheets as indicated. At 11:57 AM, The Director of Nursing stated Staff G, Licensed Practical Nurse (LPN) was the one who scanned sheets into the EHR. At 11:58 AM, Staff G, LPN confirmed she was the one who scans documents into the EHR. She stated she was about a month past due but would go through them and try to locate the neuro sheets. At 12:55 pm, Staff G, LPN confirmed the resident's neuro sheets were not in the stack in her office. At 1:25 PM, Staff G, LPN confirmed the neuro checks for Resident #3's fall on 11/06/24 could not be located. At 4:05 PM, the Administrator stated he was informed the neuro check sheets were no longer available. Staff G, LPN confirmed the facility did not have neuro check sheets for Resident #3's fall on 11/06/24. A policy titled Neurological Evaluation reviewed 3/28/23 indicated the Licensed Nurse shall perform a Neurological Evaluation as followed for a 72 Hour Timeframe, unless otherwise ordered by the Physician. The results will be recorded on the G.8(a) Neurological Evaluation Form. a) Every 15 Minutes X1 Hour b) Every 30 Minutes X1 Hour c) Every 1 Hour X2 Hours d) Every 2 Hours X8 Hours e) Every 4 Hours X12 Hours f) Every Shift X48 Hours On 12/17/24 at 10:00 AM, the Director of Nursing (DON) stated staff should document post fall neuro assessments and maintain paperwork.

Based on observations, staff interview, and policy review the facility failed to implement the infection control policy as staff failed to perform hand hygiene during medication administration for one (1) resident (#4) and between feeding two (2) residents (#10, #11). The facility staff also failed to clean a mechanical lift between two residents' use (#6, #9). The facility reported a census of 42 residents. Findings include: 1) On 12/16/24 at 9:09 AM, Staff A, Certified Medication Aide (CMA) prepared Resident #4's medications at a medication cart. One (1) pill fell into the top drawer and Staff A grabbed it with her bare hand and placed it back into the resident's medication cup. She then took it to the resident. At 12:40 PM, Staff B, Registered Nurse (RN) stated if a medication fell and landed anywhere outside the resident's cup, it should be discarded and replaced. She said it was not ok to grab the pill and put it in the resident's cup and give it to them. At 12:45 PM, Staff A, CMA stated if a med fell anywhere other than the resident's medication cup, it should be discarded. She said it was not ok to pick it up and give it to the resident. She admitted the resident should not have received the medication she picked up with her hand. On 12/17/24 at 10:07 AM, the Director of Nursing (DON) stated staff should have disposed of the pill and performed hand hygiene. 2) On 12/16/24 at 1:02 PM, Staff C, Certified Nurse Aide (CNA) assisted Resident #10 with eating. She picked up Resident #10's fork and fed her. She turned to Resident #11, grabbed her fork and attempted to feed her. She put down the fork, picked up Resident #10's fork and fed her again. She removed a bib from another resident, put it on the table, then wheeled Resident #11 back to her room. Staff C did not perform hand hygiene between feeding each resident. At 1:03 pm, Resident #10 picked up her fork and fed herself. The CMA did not perform HH throughout the process. On 12/17/24 at 10:09 AM, the Director of Nursing (DON) stated staff should have performed hand hygiene between residents or secure the utensils to prevent the resident from grabbing the utensil. A policy titled Standard Precautions reviewed 10/25/22 directed staff to perform hand hygiene before/after direct contact with residents or when Hands are visibly soiled. 3) On 12/16/24 at 1:13 PM, a continuous observation revealed Staff D, Certified Nurse Aide (CNA) and Staff E, CNA transferred Resident #9 from a chair into her bed with a mechanical lift. At 1:17 PM, Staff D, CNA placed the mechanical lift in the hallway without cleaning it. At 2:00 PM, Staff D CNA took the mechanical lift into Resident #6's room and Staff F, Certified Occupational Therapy Assistant (COTA) transferred Resident #6 from his chair to his bed. The mechanical lift was not cleaned between Resident #9 and Resident #6's use. On 12/17/24 at 10:11 AM, the Director of Nursing (DON) stated staff should wipe the equipment down with disinfectant between resident use. A policy titled Standard Precautions reviewed 10/25/22 directed staff to follow procedures for routine care, cleaning and disinfection of environmental surfaces, especially frequently touched surfaces in patient care areas.

Based on observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 42 residents. Findings included: On 12/16/24 at 9:03 AM, two medication carts were observed in front of the nurses' station and facing the dining room Staff A, Certified Medication Aide (CMA) was observed preparing medications at one of the medication carts. She took medications into the dining room with her back positioned toward both medication carts. Both medication carts were observed unlocked with no other staff present. At 9:06 AM, Staff B, Registered Nurse (RN) walked up to the first laptop, put something in the medication cart, then locked it and walked away. At 12:40 PM, Staff B, RN, stated the medication carts should be locked when staff walks away from them. On 12/17/24 at 8:49 AM, Staff A, CMA stated the medication cart should be locked when staff walks away from it and it is never ok to leave it unlocked at that time. She stated she just forgot to lock it on 12/16/24. On 12/17/24 at 9:57 AM, the Administrator stated the medication carts should be locked at all times when staff are not present. A policy titled Storage of Medications revised 11/2018 indicated medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.

Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access. The facility reported a census of 42 residents. Findings include: On 12/16/24 at 9:03 AM, two (2) unlocked laptops were observed sitting on medication carts. Staff A, Certified Medication Aide (CMA) walked away from one of the laptops, turned her back to both, and gave medication to a resident. Both laptop screens faced an occupied dining room and had multiple residents' information visible. At 9:06 AM, Staff B, Registered Nurse (RN) walked up to the first laptop, put something in the medication cart, then locked the laptop screen. At 12:50 PM, Staff B, RN, stated when staff walks away from the medication cart, the laptop screen and cart should be locked. She also stated if staff's back is toward the laptop, the cart and laptop should be locked. On 12/17/24 at 8:49 AM, Staff A, CMA stated the medication cart should be locked when staff walks away from it and it is never ok to leave it unlocked at that time. She stated she just forgot to lock it on 12/16/24. On 12/17/24 at 9:59 AM, the Director of Nursing stated maintain HIPAA (resident privacy) and minimize and/or close the laptops when staff walks away from it. The facility did not have a policy regarding securing resident information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the clinical record review, observation, staff interview, and facility policy review, the facility failed to follow physician orders for 1 of 3 residents reviewed for medication orders (Resident #1). The facility reported a census of 45 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 2 which indicated severe cognitive impairment. The MDS revealed the Resident Mood Interview score of 14 which indicated moderate depression. The MDS revealed the resident did not have any behaviors. The MDS revealed the resident is maximal assist for eating and dependent level of care for oral hygiene, toileting hygiene, bathing, upper and lower body dressing, putting on and taking off footwear, personal hygiene, roll left and right, and transfers. The MDS reflected the resident always incontinent of bowel and bladder. The MDS documented diagnoses that included: Heart Failure, Hypertension, End-Stage Renal Disease, Pneumonia, Cerebrovascular Accident, Non-Alzheimer's Dementia, Malnutrition, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, Unspecified severe protein-calorie malnutrition, Muscle weakness, Dysphagia, Other Pulmonary embolism without Acute Cor Pulmonale, Pulmonary Hypertension, Onychogryphosis, and Muscle wasting and Atrophy. The MDS recorded Antianxiety, Antidepressant, Anticoagulant, Antibiotic, and Opioid use within the last seven days of the assessment. The Care Plan revised 6/17/24 included the following interventions: Oxygen settings-O2 via Nasal Canula (NC) at 3 Liters continuously. Resident is non compliant with oxygen and takes off frequently, Oxygen settings-O2 via NC at 2 Liters as needed, Monitor for signs and symptoms of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, Shortness of Breath at rest, Cyanosis, Somnolence, Head of Bed elevated to 30 degrees or out of bed upright in a chair during episodes of difficulty breathing, and check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles while breathing. The Care Plan revealed no intervention for pulse ox monitoring. The Treatment Administration Record (TAR) dated 6/1/24-6/30/24 indicated Oxygen at 3 Liters via NC to maintain SPO2 > 90% as needed. The TAR revealed no documentation of pulse ox results or as needed oxygen used for 6/1/24-6/30/24. The TAR dated for 7/1/24-7/31/24 indicated Oxygen at 3 Liters via NC to maintain SPO2 > 90% as needed and Monitor pulse oximetry every shift to start 7/9/24 1800. The TAR revealed no documentation of as needed oxygen used and documentation started 7/10/24 for monitored pulse oximetry every shift. The Physician Progress Note dated 1/8/24 revealed the Nurse Practitioner ordered supplemental oxygen as needed to maintain sat >90%, and stated can not maintain oxygen sats without supplemental oxygen. The Nurse Practitioner progress notes from 2/14/24 to 7/15/24 revealed the resident Requiring supplemental oxygen to maintain oxygen sats. Physician Progress Noted dated 6/14/24 documented that the resident required supplemental oxygen to maintain oxygen saturation level, the resident appeared lethargis, but arousable. The Progress Note dated 6/24/24 to 7/9/24 revealed no documentation on the resident. On 8/2/24 at 12:24 PM The Resident in the Dining Room with oxygen therapy in place, staff assisted with the meal. On 8/2/24 at 4:07 PM The MDS Coordinator stated the Staff chart when the residents are unstable, new medication, behaviors, etc. Resident #1 did not have any concerns 6/24/24 to 7/9/24, resulting in no documentation. On 8/3/24 at 12:06 PM the resident was observed lying flat in the bed with no oxygen therapy on, the oxygen concentrator noted off and placed away from bed, oxygen tubing noted in plastic bag connected to the oxygen concentrator, no water in humidifier container on the oxygen concentrator. On 8/3/24 at 12:10 PM The MDS Coordinator checked the resident's oxygen saturation (SPO2) at 88% on room air. She elevated the head of the bed while monitoring the pulse ox, the resident awoke, and her oxygen saturation raised to 93% on room air. No oxygen therapy applied. On 8/3/24 at 12:35 PM The Staff A, CNA took the resident to the Dining Room, placed the resident at the table and obtained the oxygen concentrator. The MDS coordinator stated the resident will state I need my air. On 8/3/24 at 2:28 PM The MDS Coordinator stated the TAR will not if the resident is on oxygen or if the oxygen is as needed. The residents on oxygen as needed the TAR will state as needed oxygen should have a pulse ox check order and an order for the oxygen to be administered, therefore the resident should have two orders. The Staff stated the resident was not assessed during 6/1/24 to 7/10/24 for pulse ox monitoring. The Staff stated the Resident #1 oxygen is as needed to maintain SPO2 > 90%. The facility policy titled Physician Orders, revised 9/28/22, directed staff to provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State and Federal Guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to assure resident's or their representatives completed the Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN)/clarified their wishes for 2 of 3 residents reviewed (Resident #10 and #37). The facility reported a census of 40 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #10 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The SNF ABN form notified Resident #10 beginning on 2/9/24 he may have to pay out of pocket for (skilled) care. The resident signed the form, but the rest of the writing was someone else's. The resident did not choose an option for how he wanted to proceed. The clinical record lacked documentation that the facility asked Resident #10 about choosing an option. 2) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #37 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The SNF ABN form notified Resident #37 beginning on 12/12/23 she may have to pay out of pocket for (skilled) care. The resident's representative signed the form choosing option #1, indicating they wanted the care listed (PT, OT, ST), and wanted Medicare billed for an official decision on payment . The clinical record lacked documentation that the Resident #37 received the care and the facility billed Medicare, or the facility clarified the accuracy of the option with the Representative. On 5/22/24 at 10:43 a.m. the Administrator stated the Social Worker left late last year. The Administrator was helping with things, and he did some of the notices. He didn't know on 1 they had chosen option #1, and another had not chosen an option. The Form Instructions, Advance Beneficiary Notice of Noncoverage (ABN) OMB Approval Number: 09238-0566 directed the ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Employees or subcontractors of the notifier may deliver the ABN. ABN's are never required in emergency or urgent care situations. Options on the form include: OPTION 1. The resident wanted the care listed above and wanted Medicare billed for an official decision on payment. The beneficiary or his or her representative must choose only one of the three options listed. If the beneficiary could not or would not make a choice, the notice should be annotated, for example, the beneficiary refused to choose an option.

Based on personnel file reviews, staff interviews, and policy review the facility failed to complete the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information prior to employment for 1 of 5 employees reviewed (Staff C). The facility census was 40. The personnel file for Staff C, Certified Nursing Assistant (CNA), reflected a rehire date of 3/11/24. The file lacked the background check. On 5/22/24 at 1:37 PM the Business Office Manager reviewed Staff C's personnel file and confirmed the only Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License in the file was dated 10/24/23. The staff completed an online verification via the facility's The Single Contact Repository (SING) account for Staff C's background check. The Business Office Manager acknowledged the facility failed to complete a background check for Staff C prior to rehire. The staff stated the facility practice was only the Business Office Manager was to complete the background checks. The background checks would be for new employees and if staff had been gone from employment for 6 weeks or greater. On 5/22/24 at 4:09 PM the Administrator confirmed Staff C did not have a background check prior to rehire. The Administrator stated a background check must be completed if length of time is greater than 30 days between the end of employment and rehire. The facility followed the standard of practice for completion of background checks prior to hire and did not have a specific policy or procedure for pre-employment. The facility's Abuse Prevention Policy '' revised 4/28/21 revealed the facility would pre-screen all potential new employees for history of abusive behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASSR) evaluations for a change in diagnoses or treatment for 2 of 4 residents reviewed (Resident #40 and #18). The facility reported a census of 40. Findings include: 1) The Quarterly Minimal Data Set (MDS) dated [DATE] documented Resident #40 had a Brief Interview for Mental Status (BIMS) of 1 indicating a severe cognitive impairment. The MDS further documented the resident had diagnoses including depression, anxiety, and a psychotic disorder (other than schizophrenia). The MDS reports the use of high-risk medications including an antianxiety, antidepressant, and antibiotic medications. Current medication orders, as of 5/23/24, include Lamotrigine 25 milligram (mg) daily related to unspecific psychosis (medication initiated on 3/5/24), Sertraline HCl 50mg daily related to anxiety disorder and depression (medication initiated on 2/2/24), Lorazepam 0.5mg three times daily related to anxiety disorder (medication initiated on 3/13/23), and Buspirone HCl 30mg two times daily related to anxiety (2/9/23). Resident #40's current Care Plan, dated 2/9/24, indicated a focus behavioral problem related to anxiety and delusions/hallucination with a goal of no evidence of behavioral problems. Other focus areas include the use of an antidepressant related to depression, use of antianxiety medications related to anxiety disorder, and use of antipsychotic medications related to behavior management. Interventions include: 1. Administering medications as ordered 2. Monitor/document/report As Needed (PRN) any adverse reactions to the antidepressant, antianxiety, antipsychotic medications for adverse reactions 3. Refer to pharmacy for gradual does reduction Documentation from Deer Oaks Med Management Associates show current medications as well as recommended changes (2/28/24, 3/29/24, 4/19/24). The only documented PASSR located in the clinic record is dated 09/21/22. This noted depression/depressive disorder and anxiety diagnoses with the use of Escitalopram 10mg daily. The facility Social Worker interviewed on 5/22/24 at 3:15 p.m. reported being in this position a couple of months. At this time, she is in the process updating resident PASSRs if indicated. When reviewing specifics of Resident #40's PASSR, the social worker acknowledged that an updated revision is indicated due to medication changes. However, she has experienced technical issues when attempting to complete. This error message was verified when she tried to initiated a change on 5/22/24. She explained that calls to PASSR have been made, but this situation remains unresolved. The social worker believed that nursing was completing PASSR during the time frame when the social work position was vacant. The Assistant Director of Nursing (ADON) interviewed on 5/23/24 at 1145a.m. verified that the MDS coordinator completed/updated PASSRs during the time the facility was without a social worker. The MDS coordinator stopped completing PASSRs during the first or second week of March 2024. 2) Review of Resident #18's Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment. The MDS further revealed diagnoses of Non-Alzheimer's Dementia, Depression, and Bipolar Disorder. Review of a facility provided document titled, PASRR Notice of Nursing Facility Approval, dated 6/3/21 revealed a summary of findings indicating that Resident #18 did not meet the criteria for intellectual disability or serious behavioral health condition. The document revealed no mental health diagnoses, dementia/neurocognitive disorders, mental health medications, and no recommended services/supports. The admitting Agency/Facility was Pine Acres Rehabilitation and Care Center. The Electronic Health Record Review(EHR) admission Record form documented Resident #18 was admitted to the facility on [DATE] from another facility. The EHR, admission Record form documented the resident had diagnoses including unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety diagnosed 2/2/23, bipolar disorder, unspecified diagnosed 2/2/23, and depression, unspecified diagnosed 2/2/23. Clinical Physician Orders documented the following orders; a. Donepezil HCI oral tablet 10 MG, give 1 tablet by mouth at bedtime for unspecified dementia b. Sertraline HCI oral tablet 25 MG, give 1 tablet by mouth in the morning related to depression c. Namenda oral tablet, give 1 tablet by mouth 2 times a day related to unspecified dementia d. Clonazepam oral tablet .5 M, give 1 tablet by mouth every 12 hours as needed for restlessness related to bipolar disorder e. referral to hospice services on 4/8/24. On 5/21/24 at 2:40 PM the Social Services/Admissions Coordinator (SS/AC) stated employment to this position for a couple of months. The staff confirmed Resident #18 did not have a PASRR newer than 6/3/21. The SS/AC indicated that the resident should have had a new PASRR completed with mental health diagnoses, and when the resident transitioned to hospice services. On 5/22/24 at 3:41 PM the Director of Nursing (DON) confirmed that the social services department completed PASRRs when needed to be updated, and would expect they would be completed as required. The DON confirmed the current SS/AC had been in the position for a few months, and during an interim between SS/ACs the MDS Coordinator completed the PASRRs. On 5/22/24 at 4:09 PM the Administrator reported the completion of a PASRR for a resident admitted from another facility would be left to the discretion of the SS/AC. If a resident was admitted to the facility from a hospital, the hospital completed the PASRR. The Administrator acknowledged Resident #18 was admitted from a different facility with a PASRR from 2021 and had mental health diagnoses. The Administrator reported the facility did not have a policy specific to PASRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to assure appropriate care of a catheter for 1 resident reviewed with a catheter (Resident #37). The facility reported a census of 40 residents. Findings include: According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #37 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for toileting hygiene. The resident had an indwelling urinary catheter. The resident had diagnoses including obstructive uropathy (blockage in urinary tract). The Care Plan with a goal target date of 10/23/24 identified the resident had bowel incontinence related to immobility. The interventions included checking the resident every two hours and assisting with toileting as needed, providing pericare after each incontinent episode, and utilizing briefs for dignity. The Care Plan revised 5/15/24 identified the resident required an indwelling catheter due to a diagnosis of hydronephrosis (excess fluid in a kidney) with renal and calculus obstruction. On 5/21/24 at 8:17 a.m. the resident's catheter bag hung uncovered underneath the wheelchair, with urine in the bag. The catheter tubing touched the floor. On 5/22/24 at 7:30 a.m. Staff H Licensed Practical Nurse (LPN) , Staff F Certified Nursing Assistant (CNA) and Staff G CNA went to the resident's room. The catheter tubing laid on the floor. The CNA's placed the sit to stand lift and stood the resident. They removed the resident's incontinent pad and the resident had a bowel movement (bm). Staff G wiped the resident with disposable wipes times 3 to remove the bm. Staff F then wet a cloth from soapy water in the sink and wiped the resident from behind to reveal bm, turned cloth wiped more, 3rd more and then came clean. Staff F got another cloth from the water in the sink and sprayed with peri spray. She wiped over the buttocks and anal area multiple times, then used the same cloth to wipe around in the front. Staff F placed a new incontinent pad, and the 2 CNA's transferred the resident to the wheel chair, before changing gloves with hand hygiene. Staff H stated she would do catheter care after the resident laid down after lunch. Staff did not do complete perineal care or catheter care after the resident was incontinent of bm. On 5/22/24 at 1:05 p.m. Staff H and Staff F transferred the resident to bed. Staff H sent Staff F to get a basin. Staff H then ran water in the basin and placed it at the bedside. Staff H wiped each of the resident's groins changing the side of the cloth with each wipe, then over the genital area/urinary meatus (urine outlet). She obtained a new cloth to clean down the catheter tubing, then put the cloth in the basin. Staff H dumped the remaining water in the basin down the sink. On 5/22/24 at 5:12 p.m. the Director of Nursing (DON) stated staff should not put the washcloths in the sink to prepare them for cares. Water used to provide care should be dumped in the toilet, not the sink. Complete perineal care and catheter care should be completed after a bm. When going from back (anal/buttock area) to front (perineal area) staff should change gloves with hand hygiene and obtain a new cloth. The catheter bag and tubing should remain off the floor. The Incontinent Care policy last reviewed 7/21/22 included: performing hand hygiene, applying gloves, removing soiled incontinent pad, cleansing the perineal area, thighs, rectal area and buttocks, then removing soiled gloves, doing hand hygiene, and applying clean gloves before applying a clean incontinent pad and clothing. The facility Catheter Care policy last revised 7/13/22 directed performing incontinence care per facility protocol prior to providing catheter care. The procedure included cleansing down the length of the catheter at least 4 inches.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to assure residents received the recommended dietary interventions for a history of significant weight loss for 1 of 3 residents reviewed (Resident #37). The facility reported a census of 40 residents. Findings include: According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #37 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for toileting hygiene. The resident had diagnoses malnutrition. The Care Plan revised 9/5/23 identified the resident had a potential nutritional problem related to depression, hypertension. The interventions included the resident ate in the dining room (DR), and the registered dietician to evaluate and make diet change recommendations as needed. An EHR Supplement Orders dated 5/22/24 documented Resident #37 had Supplement 2.0, 3 times a day for weight loss. A Nutritional Evaluation dated 5/15/24 documented the the resident had experienced a significant weight changes, and the resident's weight slowly declined - the resident had a history of weight loss due to diuresis - received Furosemide (diuretic). The resident's body mass index (BMI) of 24.7 indicated the resident was within normal limits (WNL). The resident received a regular diet with regular texture in the dining room (DR). She selected from a self select menu- fed self - no problem chewing or swallowing, consumed 50-100% at meals with 240-480 cc's fluid, fluids and snacks were taken between meals as desired, received 60 cc's supplement 2.0, 3 times a day (TID) for additional nutrition - resident able to make needs known. The resident had a Stage 2 pressure ulcer on her right buttock and was healing, no supplements were provided at the time. Recommendations included providing ice cream at lunch and supper. On 5/22/24 at 12:08 p.m. the resident received lunch, the main meal and 2 drinks. with no ice cream. At 12:38 p.m. the resident sat at the (DR) table with no ice cream. At 12:53 p.m. staff wheeled the resident away from the DR table and she had not received ice cream. On 5/22/24 at 2:04 p.m. the Dietician stated she had recommended the resident receive ice cream and the resident should have received ice cream for lunch. The Medication Administration Record for May 2024 showed the entry for supplement 2.0, 3 times a day for weight loss with a start date of 11/10/23. The MAR showed the staff initialed the administration at 8 a.m., 12 p.m. and 6 p.m. daily. The record lacked documentation of how much was given or how much taken. On 5/22/24 at 5:12 p.m. the Director of Nursing (DON) stated they were unable to put how much of the 2.0 supplement the resident received in Point Click Care (PCC) (computer documentation program) but the resident received the typical amount of 60 cc's 3 times a day. They did not document how much the resident took. The facility Weight Variances policy last reviewed 8/9/23 included all residents who experienced significant, insidious and/or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by Registered Dietitian. Recommendations from the Registered Dietitian to include but not limited to adding calorie rich/preferred snacks between meals, fortification, supplements, liberalizing diet, and plan for expected weight changes. Residents receiving supplements would be monitored for acceptance by the Dietary Manager/Nursing Staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to offer and complete the Veterans Administrator form for 1 of 3 residents reviewed for VA (Resident #30). The facility failed to file the residents paperwork for eligibility for 1 of 3 residents reviewed for VA (Resident #22). The facility reported a census of 40 residents. Findings include: 1. The Quarterly Minimum Data Set, dated [DATE] documented Resident#30's admission date was 11/28/23. The facility's Action Summary, revealed Resident #30 admitted to facility on 11/28/2023. The VA paperwork was not found for Resident #30. 2. The facility's Action Summary, revealed Resident #22 admitted to facility on 8/1/2023. The paperwork was not submitted to the VA for eligibility status for Resident #22. On 05/23/24 10:55 AM the Administrator acknowledged unable to locate missing documentation for Resident #30. On 05/23/24 12:02 PM the Administrator acknowledged that paperwork was not submitted to the VA for eligibility for Resident #22. On 05/23/24 12:02 PM the Administrator stated the Social Worker completes the VA form upon admission and submits to VA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide care in a manner to prevent infection for 2 of 13 residents reviewed (Resident #30 and #37). The facility reported a census of 40 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #30 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for toileting hygiene. The resident's diagnoses included a stroke. The Care Plan revised 5/14/24 identified the resident had potential/actual impairment to skin integrity of the buttock and arms related to fragile skin, incontinence, limited mobility moisture associated skin damage to the right and left buttock and sacrum. Interventions included providing peri care after each incontinent episode. On 5/21/24 at 11:45 a.m. Staff I Registered Nurse (RN), Staff E Certified Nursing Assistant (CNA) , Staff F CNA and Staff G CNA went in to change the resident before (wound) treatment. Staff E wet wash cloths in the sink. Staff G removed the resident's wet incontinent pad in the front, cleaned down each groin, then over the genital area including the urinary meatus (opening to urinary tract). On 5/22/24 at 11:45 a.m. Staff E, Staff F, and Staff G to do Resident #30's cares. Staff E put wash cloths in the sink to wet them with soapy water. Staff pulled back the residents incontinent pad and Staff E used a washcloth to perform cleansing of the bilateral groins and genital/urinary meatus areas. Staff E threw the wash cloth on the (carpeted) floor. Staff rolled the resident to her left. The resident had a bowel movement (bm). Staff E used disposable wipes to clean bm from the area, then used washcloths to finish cleaning the anal/buttock region. She had placed a trash bag on the floor to put the cloth in, but left the 1st cloth on the floor. When finished, she continued wearing the same gloves to place a new incontinent pad and assist to turn the resident before changing gloves. 2) According to the MDS assessment dated [DATE], Resident #37 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for toileting hygiene. The resident had diagnoses including obstructive uropathy (blockage in urinary tract). The Care Plan with a goal target date of 10/23/24 identified the resident had bowel incontinence related to immobility. The interventions included checking the resident every two hours and assisting with toileting as needed, providing pericare after each incontinent episode, and utilizing briefs for dignity. On 5/22/24 at 7:30 a.m. Staff H Licensed Practical Nurse (LPN) , Staff F CNA and Staff G CNA went to the resident's room. The CNA's placed the sit to stand lift and stood the resident. They removed the resident's incontinent pad and the resident had a bowel movement (bm). Staff G wiped the resident with disposable wipes times 3 to remove the bm. Staff F then wet a cloth from soapy water in the sink and wiped the resident from behind to reveal bm, turned cloth wiped more, 3rd more and then came clean. Staff F got another cloth from the water in the sink and sprayed with peri spray. She wiped over the buttocks and anal area multiple times, then used the same cloth to wipe around in the front. Staff F placed a new incontinent pad, and the 2 CNA's transferred the resident to the wheel chair. Staff H stated she would do catheter care after the resident laid down after lunch. Staff did not do complete perineal care or catheter care after the resident was incontinent of bm. On 5/22/24 at 1:05 p.m. Staff H and Staff F transferred the resident to bed. Staff H sent Staff F to get a basin. Staff H then ran water in the basin and placed it at the bedside. Staff H wiped the resident each groin changing the side of the cloth with each wipe, then over the genital area/urinary meatus. She obtained a new cloth to clean down the catheter tubing, then put the cloth in the basin. Staff H dumped the remaining water in the basin down the sink. On 5/22/24 at 5:12 p.m. the Director of Nursing (DON) stated staff should not put the washcloths in the sink to prepare them for cares. Water used to provide care should be dumped in the toilet, not the sink. Complete perineal care and catheter care should be completed after a bm. When going from back (anal/buttock area) to front (perineal area) staff should change gloves with hand hygiene and obtain a new cloth. The Incontinent Care policy last reviewed 7/21/22 included: performing hand hygiene, applying gloves, removing soiled incontinent pad, cleansing the perineal area, thighs, rectal area and buttocks, then removing soiled gloves, doing hand hygiene, and applying clean gloves before applying a clean incontinent pad and clothing. The facility Standard Precautions policy last reviewed 10/25/2022 included Handling Soiled Equipment: a. Equipment with blood, body fluids, secretions, and excretions in a manner that prevented mucus membrane exposure, contamination of clothing and transfer of micro-organisms to others and to the environment. Linen: b. Handle, transport, and process used soiled linen in a manner that prevented skin and mucus membrane exposures and contamination of clothing and avoids transfer of microorganisms to the environment and others. The Incontinent Care policy last reviewed 7/21/22 included: performing hand hygiene, applying gloves, removing soiled incontinent pad, cleansing the perineal area, thighs, rectal area and buttocks, then removing soiled gloves, doing hand hygiene, and applying clean gloves before applying a clean incontinent pad and clothing.

Based on observations, staff interview, and policy review, the facility failed to ensure dietary staff practiced food safety procedures when preparing and serving resident meals to reduce the risk of cross contamination and foodborne illness. The facility reported a census of 40 residents. Findings include: During dining observation on 5/20/24 at 12 PM, Staff A, dietary aide, observed wearing a T-shirt with numerous small holes on the front as well as a large, wet stain covering approximately 25%. No apron or clothing protector seen. During kitchen observation on 5/22/24 from 1130 am-1230 am, Staff B, dietary cook, prepared hamburger patties while pureeing lunch items. When she obtained hot water for a puree item, she was seen flipping the hamburger patties as walking by and then resumed pureeing. No hand hygiene was observed in-between these tasks. Staff B, dietary cook, also failed to obtain a final cooking temperature prior to serving the hamburger to residents. Staff B, dietary cook, worked the steam table/prepared resident lunch plates. She was observed coughing and/or sneezing numerous times into her elbow/upper shoulder area. She did turn away from the steam table to cough/sneeze but failed to perform hand hygiene on a consistent basis. Hand hygiene was completed once. Staff A, dietary aide, observed wearing a shirt with a wet, large stain on the front covering approximately 25%. No apron or clothing protection seen as he delivered resident meals from the kitchen to the dining room or resident rooms. This same staff member was observed carrying resident drinking glasses with his fingers inside the glass itself. He proceeded to fill the glasses with the desired beverage and serve to residents. Throughout the kitchen observation, the male staff member was seen gathering dirty dishes, washing dishes at the dish machine, gathering drinks/items for meal trays. No hand hygiene was observed, especially after handling dirty dishes and then putting away clean dishes or prior to serving resident plates. Staff interview with the dietary manager completed on 5/22/24 at 1 pm. The dietary manager acknowledged and also observed that a final cooking temperature was not obtained on the hamburgers. She also acknowledged the limited hand hygiene observed on Staff A, dietary aide, and Staff B, dietary cook. The dietary manager explained that Staff A, dietary aide, needed frequent reminders to perform hand hygiene as he often overlooks this step. The Nutrition Services Hand Hygiene policy with a review date of 11/27/23, indicate employees shall wash hands: 1. After coughing, sneezing, using a handkerchief or tissue 2. After handling soiled equipment 3. As much as possible during food preparation to remove soil/contamination and to prevent cross contamination 4. When changing tasks. The Nutrition Services Personal Hygiene & Appearance policy with a review date of 8/23/23, indicates Personnel shall report to work in clean uniforms according to facility policy with the facility providing aprons and protective equipment. The Nutrition Services Food Safety & Food Handling policy with a review date of 8/16/23, indicate that safe food practices shall be consistent with The Food and Drug Administration (FDA) Food Code. This includes grooming and hygiene of personnel. The FDA Food Code 2017 (9th edition) code 2-304.11 Clean Condition, indicate food service employees to wear clean outer clothing to prevent contamination of food, equipment, utensils, linens, and single-use articles. The Nutrition Services Food Safety & Food Handling policy with a review date of 8/16/23, indicate food handling practices shall be completed in a manner to protect food safety and avoid cross-contamination, to include an internal temperature and rest time of 160° for ground meats.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October 1 - December 31) review, facility staffing reports review, employee time cards review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 40 residents. Findings include: The PBJ Staffing Data Report run date 5/15/24 triggered for Excessively Low Weekend Staffing - submitted weekend staffing data is excessively low, and failed to have licensed nursing coverage 24 hours/day - 4 or more days within the quarter with <24 hours/day licensed nursing coverage with specific infraction dates. The report reflected 19 dates with failure to provide 24 hour/day nursing coverage. Review of Facility Daily Assignment Sheets for each day of the months of October, November and December staffing revealed staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. The documents identified the CNA coverage of shifts by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Minimum Data Set (MDS) Coordinator during both weekday and weekend shifts. These specific staff worked in CNA status for 8 days in weekday coverage and 6 days of weekend coverage. Review of Facility Daily Assignment Sheets for the infraction dates revealed nursing shifts covered by the DON, ADON, and MDS Coordinator for 14/19 dates. Review of time cards for the remaining 5 infraction dates revealed nursing services were provided for 24 hours/day. On 5/21/24 at 10:40 AM the DON stated the nursing administrative staff (DON, ADON, MDS Coordinator) were salaried positions. The staff commented that the data turned in for the PBJ report was inaccurate as it was not reflecting the dates/hours the nursing administrative staff worked in CNA or nursing status, especially on the weekends. The salaried staff do not clock in and out. The DON was unable to explain why the 5 infraction dates not covered by nursing administration were triggered. In interviews on 5/22/24 at 9:36 AM and 1:20 PM the DON indicated staffing during the months of November and December were difficult requiring the nursing administrative staff work as CNAs and nurses. The DON stated that the corporation completed the PBJ reports. On 5/22/24 at 4:09 PM the Administrator confirmed the data submission for the PBJ and staffing reports were completed by the corporate office. On 5/23/24 at 12:10 PM the Regional Director of Operations confirmed the submission of the data for the PBJ was not submitted correctly, as it did not reflect the nursing administration hours worked. A third party submitted the data for the report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, hospital clinical record review, hospital images, staff interviews, and policy review, the facility failed to identify a resident with pressure ulcers/wounds and to assure the resident received treatment and services, consistent with professional standards of practice, to promote healing of ulcers/wounds for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) which may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound. Other staging consideration include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent skin. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #1's MDS (Minimum Data Set) assessment dated [DATE] identified a BIMS (Brief Interview for Mental Status) score of 13, indicating intact cognition. The MDS identified Resident #1 was dependent on staff with bed mobility and did not complete a transfer during the assessment period. The MDS documented Resident #1 was always incontinent of bowel and bladder. The MDS included diagnoses of neurogenic bladder (lack bladder control due to nerve damage), paraplegia (paralysis of the legs and lower body), malnutrition, depression, chronic obstructive pulmonary disease, respiratory failure, and adult failure to thrive. The MDS identified Resident #1 was at risk for developing pressure ulcers. The MDS documented Resident #1 had a pressure reducing device for the bed and application of non-surgical dressing. The Care Plan with target date 7/4/24 contained the following information: a. Resident #1 was bedfast all of the time per resident choice. b. Resident #1 had actual impairments to skin integrity related to history of pressure wounds. The Care Plan directed the following: ·Observe and document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, and maceration to the Physician- 4/27/19 -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short- 4/27/19 -Encourage good nutrition and hydration in order to promote healthier skin- 4/27/19 ·History of methicillin- resistant staphylococcus aureus (MRSA)- 01/18/2021 ·Followed by wound care specialist monthly- 3/30/23 ·Pressure relieving/reducing mattress and pillows to protect the skin while in bed- 4/27/19 ·Use a draw sheet or lifting device for moving- 2/28/23 ·Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations- 4/27/19 A Progress Note dated 3/30/24 at 9:37 AM documented Resident #1 stated he felt like he was going to die and wanted to go to the hospital. Resident #1 refused peri care prior to the transfer. The note revealed, when discussing Do Not Resuscitate (DNR) status, Resident #1 stated he would like chest compressions and intubation. A Progress Note dated 3/31/24 at 1:07 AM documented Resident #1 was admitted to the hospital for shortness of breath and hypotension (low blood pressure). The note revealed Resident #1 was intubated (placement of a tube into the trachea to maintain an open airway) at the hospital. A Hospital record titled Integumentary- Pressure Ulcer assessment dated [DATE] at 4:00 PM documented Resident #1 had the following pressure areas on admission: A. Right Hip: -Pressure Ulcer Wound Bed Description: Discolored -Pressure Ulcer Bed Color(s): Pink -Pressure Ulcer Wound Edge: Approximated -Pressure Ulcer Surrounding Tissue: Intact -Pressure Ulcer Drainage Amount: None -Pressure Ulcer cleanings: Soap and Water -Pressure Ulcer Dressing Type/Treatment: Foam with adhesive -Pressure Ulcer Comment: healing old pressure ulcer B. Right Heel: -Pressure Ulcer Stage: Unstageable -Pressure Ulcer Wound Bed Description: Dry -Pressure Ulcer Bed Color(s): Black -Pressure Ulcer Drainage Amount: None -Pressure Ulcer Cleansing: Soap and water C. Left Heel: -Pressure Ulcer Stage: Unstageable -Pressure Ulcer Wound Bed Description: Dry -Pressure Ulcer Bed Color(s): Black -Pressure Ulcer Drainage Amount: None -Pressure Ulcer Cleansing: Soap and water A Hospital record titled Integumentary- Incision/Wound assessment dated [DATE] at 4:00 PM documented Resident #1 had the following skin areas on admission: A. Right and Left Groin: -Type: Moisture Associated Skin Damage -Dressing Status: Left open to air -Wound Bed Description: Discolored, Partial-thickness -Wound Bed Color(s): Red -Wound Edge: Not Attached -Surrounding Tissue: Erythema -Drainage Amount: Minimal -Drainage Description: Sanguineous A Hospital record titled Integumentary- Incision/Wound assessment dated [DATE] at 8:00 AM documented Resident #1 had the following skin areas/wounds on admission: A. Left Foot: -Type: Venous insufficiency ulcers -Dressing status: Left open to air -Cleansing: Soap and water -Skin Treatment: [NAME] paste/ointment B. Right Foot: -Type: Venous insufficiency ulcers -Dressing status: Left open to air -Cleansing: Soap and water -Skin Treatment: [NAME] paste/ointment Review of a Hospital image taken on 3/30/24 at 4:00 PM revealed the following: A. Right Hip: area approximate size of a softball, discolored (pink and purple in color). The wound appeared dry and shiny in appearance. There were two small scabbed areas towards the bottom/left of the wound and one small scabbed area on the top right of the wound. There was an area of flaky/peeling skin at the top/center of the wound. Review of a Hospital image taken on 3/30/24 at 4:01 PM revealed the following: A. Right Foot: 5 black, dry eschar areas of various sizes and shapes on the outside of the foot below the 5th toe to the heel. Right foot was dry, scaly and discolored with the toes purplish in color. Review of a Hospital image taken on 3/30/24 at 4:02 PM revealed the following: A. Right Groin: erythema present with a small opening (puncture like) Review of a Hospital images taken on 3/30/24 at 4:08 PM revealed the following: A. Right Heel: area of black eschar size of a nickel with surrounding skin dry, cracked and peeling. No drainage noted. B. Left Heel: area of dark brown/black eschar the size of a 50-cent piece with the surrounding skin dry, cracked, peeling and flaky. No drainage noted. Review of a undated and unlabeled Hospital images revealed the following: A. Left Foot- 2nd toe with open area, size of a dime, with skin not approximated. Left foot and toes are very dry with flaky, scaly and built up skin tissue that is yellow in color. Left great toenail jagged. Left foot was discolored and the toes purple in color. B. Left Groin- open slit, red in color A facility skin observation tool dated 3/21/24 documented Resident #1 had a skin tear to the right lower leg, left lower leg and a surgical incision to the left hip. The clinical record lacked documentation of a completed skin observation tool/evaluation after 3/21/24. A Wound Care Telemedicine Follow Up Evaluation dated for 3/28/24 lacked documentation regarding pressure wounds to the right hip, right heel, left heel and skin impairments/wounds to the right foot, left foot, right groin and left groin. A facility form titled Skin Monitoring CNA (Certified Nursing Assistant) Bathing Review dated 3/28/24 directed the CNA to perform a visual inspection of the Resident's skin while bathing and to report the abnormal findings to the Charge Nurse. The Charge Nurse to forward concerns to the wound care nurse/DON for review. The form directed the CNA to use the body chart to describe the body location by number. Review of the form revealed the right foot/toes were circled and the word scabbing written next to the right foot. A facility form titled Shower Skin Observation on 3/12/24 and 3/25/24 documented both of the right and left foot/toes circled on the form indicating there were skin issues. The form was signed by a certified nurse assistant and a charge nurse. On 4/2/24 at 1:59 PM, Staff B, CNA reported Resident #1's right hip would get red sometimes but she did not believe it was opened. She stated Resident #1 had super dry flaky skin on his feet and sometimes they would bleed. She stated she would put a lot of lotion on Resident #1 with encouragement. On 4/3/24 at 9:58 AM, Hospital Registered Nurse (RN) reported she had completed a skin assessment on Resident #1 after admission to the hospital. She stated his right hip had an old pressure area. She stated it was a little smaller than a softball in size and was red, closed and blanchable. She stated his bilateral feet and heels had scabs on them and his feet were cool to touch. She stated there were pictures taken of the skin areas. On 4/3/24 at 11:15 AM, the Director of Nursing (DON) reported before Resident #1 went to the hospital he had a few different scattered areas on his feet. She stated Resident #1 would wear bunny boots in bed and did not want any other treatments to the areas on his feet. She stated he had scarred areas over the bony prominence on his right hip. She stated the pressure area on his right hip healed about a year ago. The DON reported she does not have any documentation regarding the areas to his feet as they were scattered scabbing. She stated she did not recall any ulcers to his heels. She reported she did not recall any skin areas to his bilateral groin. On 4/3/24 at 12:05 PM, Staff A. RN reported she rounded with the wound specialist on 3/28/24 and did not recall any areas to Resident #1's heels. She stated Resident #1 had some scabbed like areas to his toes on both feet. She described it as dead, dry built up skin. She stated Resident #1 would wear bunny boots all the time and would bump his toes. On 4/3/25 at 1:58 PM, the DON stated there was no particular reason Resident #1's skin areas on his feet were not documented in the medical record. She stated if a pressure ulcer was noted it would be measured and documented and the wound specialist would start monitoring the area. She stated non-pressure areas are monitored weekly on a non-pressure skin sheet. She stated she was aware that Resident #1 had areas to his right foot 2nd and 3rd toe. She stated there were not any pressure ulcers to his heels. She stated Resident #1 flopped his feet and sometimes banged his toes. She stated they had used betadine as a treatment in the past but that had been a long time ago. On 4/4/24 at 9:05 AM, Staff C, CNA reported Resident #1 had skin areas to both hips, lower legs and to his feet. She stated his right hip was red but not opened. She stated his feet were dry with flaky skin. She stated his right foot, tops of the toes, had scabbed areas. She stated Resident #1 would hit his toes on the dresser and he would not let the staff move the dresser. She stated he wore boots and had not had areas on his heels since wearing the boots. On 4/4/24 at 9:08 AM, Staff D, CNA reported Resident #1's feet were super dry. She stated she was a bath aide and would give Resident #1 bed baths. She stated she would lotion him up and apply baby oil to help with the dry skin. She stated she did not recall any skin areas to his heels as he wore bunny boots. When asked if he had scabbed areas to his feet, she said she did not think so. When shown the bath records for March she had signed, she stated she was not sure if she circled the right and left toes because of dry skin or if there were skin areas there. She stated she was not 100% sure about his toes. Review of the facility's clinical record lacked documentation of pressure wounds to the right heel, left heel, and skin impairments/wounds to the right foot, left foot, right groin and left groin. The clinical record lacked documentation treatments had been offered to Resident #1 and/or the treatments had been refused. The clinical record lacked documentation of a preventative/protective treatment for the right hip after it was healed. Review of the Medication and Treatment Administration Record for March 2024 revealed lack of treatment orders for the right hip, right heel, left heel, right foot, left foot or bilateral groin areas. A facility policy titled Skin Evaluation dated 12/28/22 documented the facility may conduct head to toe skin evaluation and document on a weekly basis. The weekly skin evaluation will be documented electronically or on the skin observation tool. Any skin abnormalities identified through this evaluation may be documented in the interdisciplinary notes. The policy further directed that the Physician, resident representative, wound nurse and DON would be notified of any abnormalities and treatments would be initiated per the Physician's Order. A facility policy titled Wound Management dated 11/15/22 documented it was the facility policy to promote wound healing of various types of wounds and that the facility would provide evidence-based treatments in accordance with current Standards of Practice and Physician Orders. The policy further documented treatment selection will be based on the etiology of the wound.

Based on the review of the Quality Assurance Performance Improvement (QAPI) sign in sheets, staff interview, and policy review, the facility failed to ensure all required members attended the quarterly Quality Assessment and Assurance (QAA) meetings. Specifically, the Director of Nursing (DON)/Infection Preventionist(IP) failed to be present for 2 of the 4 quarterly meetings reviewed. The facility reported a census of 45 residents. Findings include: Review of the QAPI meeting sign-in sheets from April 2023 to March 2024, provided by the Administrator on 4/2/24, revealed the DON/Infection Preventionist attended the meeting on 4/18/23 and 3/12/24. On 4/4/24 at 10:58 AM, the Administrator acknowledged and verified the QAPI sign in sheets lacked the DON/IP signatures except for the months of April 2023 and March 2024. The facility policy titled QAPI last reviewed on 8/20/20 documented the QAA will meet monthly and include the following team members: Administrator, DON, Medical Director, IP, Social Services Designee, Activities Director, Environmental Services, Dietary Manager, Medical Records, Human Resources, and Pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #39's MDS assessment dated [DATE] identified a BIMS score of 7, indicating moderately impaired cognition. The MDS included diagnoses of a cerebrovascular accident (stroke), altered mental status and bilateral aphakia (a condition in which the lens is missing inside the eye resulting in blurry vision). The MDS indicated the resident had not fallen within six (6) months prior to admission to the facility. The Electronic Health Record (EHR) listed diagnoses dated 11/1/22 of unsteadiness on feet and history of falling. The Fall Scale - Morse assessment dated [DATE] listed a fall risk score of 30, indicating a moderate fall risk. The assessment indicated that Resident #39 had no prior falls. The Incident Report dated 1/22/23 at 9:55 AM indicated that Resident #39 fell the previous Friday evening (1/20/23) at 10:30 PM. The resident who lived across the hall reported the concern to the nurse. The Incident Report included documentation that Resident #39's Power of Attorney (POA) received notification on 1/22/23 (Sunday) at 10:49 AM and her provider received notification on 1/22/23 at 10:42 AM. The _Nurses Note dated 1/22/23 at 10:55 AM documented an assessment on Resident #39 for a fall follow-up. Resident #39 could move all extremities without difficulties and had no injuries noted. Resident #39 voiced no complaints or discomfort. Resident #39 sat in the dining room visiting with her granddaughters. The review of the progress notes lacked notification of a fall to Resident #39's Power of Attorney (POA) or her provider prior to 1/22/23. A review of all Resident #39's active and inactive Physician's Orders lacked an order related to the follow-up of her fall. On 3/29/23 at 2:02 PM, Staff K, Registered Nurse (RN), stated the following steps are required when a resident falls. The nurse was expected to: a. Complete a resident head-to-toe assessment including vital signs b. Complete a risk assessment in the EHR c. Complete neurologic assessments, if suspected injury or neurologic involvement on paper d. Complete transfer documents, if the resident has to be sent out to an acute care facility e. Notify the physician, the POA, and the Director of Nursing (DON) f. Document the fall and notifications in the progress notes. On 3/30/23 at 12:27 PM, Staff L, RN, explained that during her evening shift on 1/21/23 after dinner, staff notified her that Resident #39 fell on 1/20/23 during the evening shift. She thought that Resident #39's POA called her regarding her prior fall. Staff L explained that she learned of the fall because of the call. She added that Resident #39's roommate initiated the call bell until Staff M, CNA, arrived and told her that she heard Resident #39 yelling. Staff L said that the roommate reported that the fall occurred during the evening shift on 1/20/23. Staff L explained that she contacted the DON, who instructed her to complete an assessment. Staff L stated that she did not complete any incident report since it did not occur during her shift. She also stated that she did not enter any documentation in the resident's EHR regarding any details of this incident. On 3/30/23 at 2:56 PM, the Administrator provided an incident report dated 1/22/23 with documentation that Resident #39 fell on 1/20/23 at approximately 10:30 PM. A policy titled Notification of a Change in a Resident's Condition dated 11/1/18 directed the staff to report a resident's significant change to the physician and resident's representative, then document the notification information in the Interdisciplinary Team (IDT) notes. Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide timely notification to the physician and family when changes occurred in the resident's physical or mental condition for 2 of 2 residents reviewed (Residents #6 and #39). The facility reported a census of 42 residents. . Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) score of 0 indicating severely impaired cognition. The MDS further revealed the resident required limited physical assistance from one person with transfers and personal hygiene. Resident #6 required extensive assistance from one person with toilet use. The MDS included diagnoses of non-Alzheimer's dementia, cerebrovascular accident (stroke), and repeated falls. The Physicians Telephone Order/Communication dated 3/13/23 and signed by the provider on 3/14/23 identified an order for Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat Resident #6 due to recent falls. The Physical Therapy Treatment Encounter Note dated 3/14/23 identified PT received the provider ' s order, completed the evaluation, and developed a plan of treatment on that date. The OT Therapy Progress Report for the dates of service: 3/15/23 - 3/29/23 indicated Resident #6 started care on 3/15/23 with OT. The clinical record lacked documentation notifying Resident #6's Power of Attorney (POA) of the order. During an interview on 3/27/23 at 2:32 PM, the Resident #6 ' s POA explained that Resident #6 received an order for and received OT/PT services at that time. Resident #6 ' s POA reported that they did not know about the order and services received until she received an Explanation of Benefits (EOB) statement from Resident #6's insurance company. During an interview 3/29/23 at 11:02 AM, the Director of Rehabilitation services explained that the Social Worker usually contacted the resident's representative if they receive an order for therapy. On 3/29/23 at 12:20 PM, the Administrator said that Resident #6 received an order for therapy because of her falls. The Administrator added that it is not standard practice to notify a POA when a resident received an order for therapy. The Administrator acknowledged that Resident #6's POA liked to be involved in her care. On 3/29/23 at 12:32 PM, the Social Worker revealed that she did not notify the residents ' representatives when a resident received an order for therapy. On 3/29/23 at 12:41 PM, the Director of Nursing (DON) reported that when a resident receives an order for therapy the charge nurse processes that order and notifies the family. The DON added that Resident #6's POA wanted the resident to go through therapy anytime Resident #6 had a decline, however they did not think someone documented that in the one and a half years the DON worked at the facility. The Notification of a Change in A Resident's Condition policy reviewed 4/28/21 instructed that the resident ' s representative will be notified of a change in a resident's condition per standards of practice, Federal, and/or State regulations. The policy directed the staff to document in the Interdisciplinary Team (IDT) notes the notification made to the resident ' s representative.

Based on policy review, employee files review, and staff interviews the facility failed to implement the abuse and neglect policy by not completing a background check on one of five staff reviewed (Staff C, Cook). The facility reported a census of 42 residents. Findings include The Abuse Prevention policy provided by Administrator reviewed 8/28/21 instructed the following: a.The facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals or misappropriation of property. b.The facility will pre-screen all potential new employees and residents for a history of abusive behavior. Staff C's employee record revealed a hired date of 5/13/22 Staff C's Abuse Registries Background Check listed the background check complete as of 5/17/22. Staff C's Time Card Report dated 5/13/22 to 5/17/22 indicated that they worked a. 5 hours on 5/14/22 b. 7 hours on 5/16/22 c. 6 hours on 5/17/22 On 3/28/23 at 1:42 PM Staff E, Business Office Manager, reported Staff C's hire date as 5/13/22. On 3/28/23 at 2:35 PM the Administrator stated they expected the background check would be completed prior to an employee getting hired. The Administrator declined knowing why the background check did not get completed before Staff C got hired. On 3/30/23 at 1:39 PM Staff E explained that the background check should be completed prior to the employee being hired. Staff E stated the Corporate Office expects that background checks are completed prior to hiring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to refer one of two sampled residents (Resident #2) with a negative Level I result for the Pre-admission Screening and Resident Review (PASRR), who had a possible serious Mental Disorder, Intellectual Disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination. The facility reported a census of 42 residents. Findings include: Resident #2 ' s Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS included diagnoses of anxiety disorder and depression (other than bipolar). with no other identified psychiatric/mood disorders nor potential indicators of psychosis. The assessment indicated Resident #2 took antidepressant medications for seven of seven days during the lookback period. The PASRR review dated 5/2/22 listed Resident #2 ' s Level I Outcome as no Level II required due to no significant mental illness, intellectual disabilities, and/or no related conditions. The rationale indicated that the Level I screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. A review of Resident #2's Care Plan revision dated 1/13/23 revealed an added hallucination intervention. A review of progress notes revealed documentation of Resident #2's hallucinations and delusions. A record review revealed Resident #2 was diagnosed with hallucinations and prescribed antipsychotic medication on 1/27/23. The MDSs dated 1/27/23, 2/15/23, and 2/28/23 for Resident #2 included anxiety disorder and depression (other than bipolar) diagnoses with hallucinations and delusions. The assessments indicated the resident took antipsychotic and antidepressant medications during the 7-day lookback period. The Physician Progress Note dated 1/30/23 at 1:17 PM listed that the staff reported that Resident #2 had hallucinations and memory difficulties. The Physician added a diagnosis of visual hallucination and planned to have her continue her Seroquel (medication used to treat hallucinations and paranoia). The Risk Note dated 2/7/23 at 2:48 PM indicated that Resident #2 had frequent hallucinations, delusions, and paranoid behaviors noted. A document task list record review on 3/29/23 at 1:40 PM indicated Resident #2 had no PASRR II completed. On 3/29/23 at 1:40 PM, the Social Worker (SW) reported that the facility scanned all PASRR forms into each resident's Electronic Health Record (EHR). The SW explained the facility had no outstanding PASRRs. She added that they did not have a system in place to alert her of a change in a resident's diagnosis or condition that warranted a PASRR review. She stated that she relied on the staff to notify her if a resident had a change of condition, behavior, or diagnosis. The clinical record lacked documentation that the facility staff referred Resident #2 for a PASRR re-evaluation and determination after a change in her mental health diagnoses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to follow the Care Plan for the proper transfer technique for one of 14 residents reviewed (Resident #44). Resident #44 had an injury of unknown origin of a pathological fracture. The facility reported a census of 42 residents. Findings include: Resident #44's Minimum Data Set (MDS) dated [DATE] included diagnoses of Post-Polio Syndrome, Muscle Wasting, and Atrophy. The MDS indicated that Resident #44 required extensive assistance from one person for personal hygiene, bed mobility and toilet use. The MDS listed that Resident #44 required total dependence from one person for transfers. The MDS recorded that Resident #44 did not walk and required a wheelchair for mobility. Resident #44 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment for decision-making. Resident #44's Care Focus with a target date of 10/28/22 indicated that Resident #44 had an activities of daily living (ADL) self-care deficit. The intervention created 9/20/22 directed that Resident #44 required the assistance from two staff and a full-body mechanical lift (Hoyer) to transfer. The Patient Report dated 12/31/22 listed that Resident #44 had an X-ray due to pain, bruising, and swelling to her left knee. The Findings/Impression indicated that Resident #44 had a comminuted proximal tibia fracture (break in the bone just below the knee) that involved the lateral tibial plateau (the outer side of the shin bone just below the knee involving the cartilage that connects the bones) and most likely the medial tibial plateau (inner side of the shin bone just below the knee involving the cartilage that connects the bones). Resident #44 also had a mildly displaced fracture of the proximal fibula (the skinnier inner bone of the lower leg). Resident #44 had demineralized (weakened) bones with limited ability to position. The report included a handwritten note dated 1/4/23 by an Advanced Registered Nurse Practitioner (ARNP) that indicated the injury appeared to be potentially pathological (a spontaneous or trauma-induced fracture that occurs in a bone that has been weakened by disease) in nature. On 3/29/23 at 12:14 PM the ARNP reported that the staff called and stated that Resident #44 started complaining of pain. The ARNP told them to get her X-rays. The facility got the results and sent them to the emergency room (ER). The ARNP described Resident #44 as a very frail woman, she did not think the staff treated her rough, she did not eat well with her, malnutritioned, history of polio, and the ARNP thought the fracture resulted from her being so frail. The ARNP thought it could be pathological but she did not know for sure. The ARNP explained that it could have resulted from something that has been there for a while. Resident #44 always hurt and had pain. The ARNP reported that she did not think the staff did anything to her, but if it did happen when the staff turned her it would be due to her fraililty. The ARNP explained that supposedly the staff reported that injury occured while the staff turned her, but the ARPN did not know how that could of happened, with the positioning of her legs. On 3/29/23 at 2:50 PM Staff P, Certified Nurse Aide (CNA), reported that she no longer worked at the facility as of 1/30/23. Staff P explained that the staff always transferred Resident #44 with a standing mechanical lift (EZ stand) and two staff. On a good day Resident #44 could transfer with three staff and a gait belt. Staff P explained that Resident #44's Care Plan directed to use an EZ stand. Staff P denied ever using the Hoyer lift on her. On 3/29/23 at 3:06 PM Staff Q, Licensed Practical Nurse (LPN), reported that she worked at the facility for almost one year on the 6 AM - 6 PM. Resident #44 required full care, had moments of confusion and moments of clarity, had a smart mouth and had a snappy attitude. Staff Q explained that Resident #44 required assistance from two people and an EZ stand. Staff Q explained that she thought the night nurse said that an incident occurred with Resident #44. Resident #44 complained of pain in her leg and she gave her some Tylenol. Staff Q added that she complained of the pain after the transfer. The staff reported to her that Resident #44 had a sore leg. The staff took her to the shower room and noticed that her leg turned outward. Staff Q explained that she did not know for sure how the girls transferred her. Resident #44 complained about pain during breakfast, but nothing more than normal, then she went to shower room, where she observed that Resident #44's leg did not appear in the right alignment. Staff Q reported that Resident #44 had a lot of pain, no bruising, external rotation, and no swelling. When asked about what happened to her, Resident #44 reported that the person that put her to bed laid on her leg and it snapped, snapped, snapped. Resident #44 described the person as the heavy set one, but did not know any names. The hospital (nurse) told her it was a stress fracture when she called the hospital to check on her. The two staff that helped that night worked for an agency, Staff Q reported that Resident #44 never had full range of motion (ROM) of her legs, she sat in a spread-eagle type of position in her wheelchair. On 3/29/23 at 4:20 PM Staff I, CNA, reported that she last worked at the facility on the previous Monday. Staff I explained that she worked at the facility since 11/21/22 and worked the 6 AM - 6 PM shift. On 12/30/22 she explained that she got up in the morning, completed her care, sat in the dining room through lunch, then helped her back to her room, and changed her. Resident #44 sat out in the dining room for most of the day. Staff I reported that she got trained to transfer Resident #44 with two persons and a gait belt. Staff I denied ever using a lift with her. Staff I added that she did not find out until after the incident that Resident #44's Care Plan directed the use of a lift. Staff I reported the facility had a master [NAME] (pocket Care Plan) book that has how all of the residents' transfer. The book had a sheet for each hallway, in a black cabinet at the nurse's station. When she started she did not know about the book and found out about it later. Staff I denied that Resident #44 ever reported any abuse to her. Staff I thought that Resident #44 had constant pain, everything that you did with her, she would say it hurt. For instance, if you moved her arm, brushed her hair, she would state that her whole body hurt. Resident #44 took some pain medication, and Staff I thought that it helped. Staff I added that Resident #44 did not have straight legs, her hips to her knees appeared outward, while her knees to toes went in. Staff I reported that she always completed perineal (peri) care with two staff as she did not turn easily. The Comprehensive Person-Centered Care Plan policy reviewed 10/23/19, instructed the following: a. Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. b. Staff approaches are to be developed for each problem/strength/need. On 3/30/23 at 2:38 PM, the Director of Nursing (DON) confirmed that Resident #44 used a Hoyer to transfer with the assistance from two persons. The DON explained that she expected the staff to follow the resident's Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to fully review and revise the comprehensive care plan for 1 of 2 residents (Resident #3) who were sampled for care plan review. The facility reported a census of 42. Findings include Resident #3's Minimum Data Set (MDS) dated [DATE] reflected that she had no swallowing disorders, coughing, or choking during meals or when swallowing medications. The MDS included diagnoses of a prior stroke, heart failure, and respiratory failure. The MDS indicated that Resident #3 required supervision when eating independently. The _Nurses Note dated 2/28/22 at 5:04 AM identified that while in the common area Resident #3 drank water and aspirated. Resident #3 continued to cough and got the water back up. Resident #3 denied having any issues prior to this incident. The Physician Progress Note dated 2/28/22 at 9:28 AM labeled as a Late Entry indicated that Resident #3 saw the provider due to concerns of aspiration (liquids/food inhaled into the lungs) with a cough while drinking water on 2/28/22 in the morning at breakfast. Resident #3 denied dyspnea (shortness of breath) or further cough on exam to the provider. Resident #3 denied a history of it. The provider ordered a chest X-ray to determine her baseline (usual). The provider directed to call if Resident #3 continued to have concerns or if she had persistent dysphagia (difficulty swallowing) can consider swallow evaluation (test to watch where items go when swallowed). The provider gave new diagnoses of dysphagia and cough, unspecified. The Nutritional Assessment signed 6/7/22 by Staff B, Regional Dietitian (RD), indicated that Resident #3 had a regular diet with a mechanical soft texture and had no problems chewing or swallowing. The Nutritional Assessment signed 11/1/22 Staff B indicated that Resident #3 continued with the same diet but coughed and choked at meals. The documented assessment identified that Speech Therapy (ST) did not identify a cause of her coughing at meals. The MDS dated [DATE] included coughing or choking during meals or when swallowing medications The Comprehensive Care Plan lacked a focus area for coughing or choking during meals or a difficulty with swallowing. During an observation on 3/27/23 at 12:51 PM, the resident repeatedly and consistently coughed while she ate lunch. No staff members responded. On 03/29/23 at 10:20 AM, Staff H stated she was not aware of the issue and there were no special interventions to address the resident choking while eating. She stated the resident coughs a lot. Resident #3's Medical Diagnoses reviewed 3/30/23 listed that she had gastro-esophageal reflux disease (acid reflux) but lacked diagnoses or disorders related to swallowing. Resident #3's Clinical Physician's Order reviewed 3/30/23 indicated that she had an order for a regular diet with mechanical soft texture and thin consistency. On 3/30/23 at 8:51 AM, a Change of Condition policy On 3/30/23 at 9:41 AM, Staff B reported being the person responsible for updating dietary focus in the Care Plan. She stated that ST evaluated Resident #3 and did not identify a cause. She said that the Care Plan should have been updated with a focus of choking with meals and that she overlooked it. She stated the interventions should direct the staff to the following: a) Monitor for signs of dysphagia b) Monitor intake c) ST evaluated resident with no recommendations d) Monitor for choking Resident #3's therapy notes lacked a ST evaluation or treatment. On 3/30/23 at 10:28 AM, the Director of Rehabilitation Services reported Resident #3 did not have documentation of a ST evaluation. He said that when Resident #3 admitted to the facility, the facility had a contract in place with his therapy. The Therapy Services Contract signed on 2/16/18 by the facility's Chief Executive Officer and the therapy group's Chief Operating Officer indicated an agreement between the two organizations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to assess and/or provide interventions following a fall for 1 of 1 resident reviewed (Resident # 39). The facility reported a census of 42 residents. Findings include: Resident #39's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 7, indicating moderately impaired cognition. The MDS included diagnoses of a cerebrovascular accident (stroke), altered mental status and bilateral aphakia (a condition in which the lens is missing inside the eye resulting in blurry vision). The MDS indicated the resident had not fallen within six (6) months prior to admission to the facility. The Electronic Health Record (EHR) listed diagnoses dated 11/1/22 of unsteadiness on feet and history of falling. The Fall Scale - Morse assessment dated [DATE] listed a fall risk score of 30, indicating a moderate fall risk. The assessment indicated that Resident #39 had no prior falls. The Incident Report dated 1/22/23 at 9:55 AM indicated that Resident #39 fell the previous Friday evening (1/20/23) at 10:30 PM. The resident who lived across the hall reported the concern to the nurse. The _Nurses Note dated 1/22/23 at 10:55 AM documented an assessment on Resident #39 for a fall follow-up. Resident #39 could move all extremities without difficulties and had no injuries noted. Resident #39 voiced no complaints or discomfort. Resident #39 sat in the dining room visiting with her granddaughters. The review of the progress notes lacked documentation of the fall, a post-fall assessment, notification related to the fall to Resident #39's Power of Attorney (POA) or her provider. A review of the Morse Fall scale dated 1/22/23 indicated a fall risk of 70, indicating a high fall risk. It also contained documentation that the resident had prior falls. The Fall Scale - Morse assessment dated [DATE] listed a fall risk score of 70, indicating a high risk for falls. The assessment indicated that Resident #39 had a prior history of falls. A review of all Resident #39's active and inactive Physician's Orders lacked an order related to the follow-up of her fall. The MDS assessment dated [DATE] indicated Resident #39 had no falls since admission to the facility or her previous MDS assessment. The MDS assessment dated [DATE] revealed that Resident #39 had two (2) falls since the previous MDS assessment. Resident #39's Care Plan Focus indicated that Resident #39 had a history of falls, hypotension (low blood pressure), and poor balance. The Care Plan included the following interventions added on 3/8/23. a. Continue interventions on the at-risk plan. b. For no apparent acute injury, determine and address causative factors of the fall. c. Neuro-checks per facility standard of practice The Care Plan had no prior Focus or Interventions regarding falls. On 3/27/23 at 1:40 PM, Staff I, Certified Nurse Aide (CNA), stated that Resident #39 fell in January 2023. She said that if a resident fell, they should notify the nurse and stay with the resident. She explained that the nurse would complete neurologic assessments on paper. After that, the CNA had no required further action. On 3/27/23 at 2:34 PM, observed Resident #39 sitting in the dining room in a wheelchair, requesting assistance. Staff J, Licensed Practical Nurse (LPN), stated that Resident #39 is kept in the dining area because she fell a lot in her room and she didn't want to do all that paperwork. She stated the paperwork involved in a resident fall included a hot chart that contained specific resident information used to alert other staff members of residents' needs. The Hot Chart for 1/20/23 revealed an OK status for Resident #39. The Hot Chart for 1/23/23 revealed an OK on fall follow-up with 0 injury status on 1/23/23. The facility lacked Hot Chart documents for 1/21/23 or 1/22/23. On 3/29/23 at 2:02 PM, Staff K, Registered Nurse (RN), stated the following steps are required when a resident falls. The nurse was expected to: a. Complete a resident head-to-toe assessment including vital signs b. Complete a risk assessment in the EHR c. Complete neurologic assessments, if suspected injury or neurologic involvement on paper d. Complete transfer documents, if the resident has to be sent out to an acute care facility e. Notify the physician, the POA, and the Director of Nursing (DON) f. Document the fall and notifications in the progress notes. On 3/29/23 at 2:12 PM, the DON said that she expected all fall related documentation must be completed by the end of the shift. She reported that the facility did not have a policy for time frames but if the fall occurred late in shift, she expected the following shift to finish the post-fall process and document it. On 3/30/23 at 9:37 AM, the Assistant Director of Nursing (ADON) stated Resident #39's fall occurred prior to her morning shift on Sunday 1/22/23. The ADON denied any other recollection of the shift details. On 3/30/23 at 12:27 PM, Staff L, RN, explained that during her evening shift on 1/21/23 after dinner, staff notified her that Resident #39 fell on 1/20/23 during the evening shift. She thought that Resident #39's POA called her regarding her prior fall. Staff L explained that she learned of the fall because of the call. She added that Resident #39's roommate initiated the call bell until Staff M, CNA, arrived and told her that she heard Resident #39 yelling. Staff L said that the roommate reported that the fall occurred during the evening shift on 1/20/23. Staff L explained that she contacted the DON, who instructed her to complete an assessment. Staff L stated that she did not complete any incident report since it did not occur during her shift. She also stated that she did not enter any documentation in the resident's EHR regarding any details of this incident. A policy titled Notification of a Change in a Resident's Condition dated 11/1/18 directed the staff to report a resident's significant change to the physician and resident's representative, then document the notification information in the Interdisciplinary Team (IDT) notes.

Based on observation, document review, staff interview, and facility policy review the facility failed to store food and follow proper sanitation to prevent the spread of illness in accordance with professional standards for 42 of 42 residents. The facility reported a census of 42 residents. Findings include On 3/29/23 from 11:40 AM through 1:30 PM during a continuous observation during lunch and tour of the kitchen after lunch revealed: 1. The reach-in refrigerator had open and undated bottles of a 20 ounce (oz.) ketchup and a 20 oz caramel syrup . 2. The reach-in freezer had open and undated bags of pepperoni and a diced turkey. 3. The dry storage area had an open and undated bag of powdered sugar, vegetable paste, chicken paste, beef paste, and 8 oz. thickener. 4. The review of temperature / sanitizer March 2023 log for the low temperature dish machine lacked a. AM (morning) shift temperatures documented prior to 3/8/23. b. PM (evening) shift temperatures documented prior to 3/9/23. c. AM or PM shift sanitizer level documented. 5. The review of temperature logs for refrigerators and freezers lacked a. AM temperatures for any refrigerators in the kitchen from 3/10/23 through 3/29/23. b. PM temperatures for any freezers in the kitchen 3/10/23 through 3/29/23. On 3/29/23 at 1:20 PM Staff A, Dietary Aide, reported they checked the sanitizer level with strips from a container on the counter across from the dish machine. Staff A explained that he usually checked the level. On 3/29/23 at 1:20 PM observed as Staff A completed a strip test for the sanitizer level. The test resulted in no change in the strip used. The investigation determined Staff A used a chlorine strip used to check the sanitizer level. The facility failed to have sanitizer strips available at the facility. On 3/29/23 at 1:40 PM Staff B, Regional Dietitian, brought sanitizer level strips into the kitchen. The test results of the sanitizer strip test indicated a sanitizer level of 100 parts, indicating an appropriate range. On 3/29/23 at 1:00 PM Staff B reported the facility expected that the sanitizer level be checked after each meal during dishwashing. Staff B stated the facility expected that the refrigerator and freezer temperatures should be checked twice a day. Staff B added that the facility expected that all open food is stored in an airtight container that is dated with the date opened. On 3/29/23 at 12:55 PM Staff D, Cook, stated the facility's expectation is that all food opened should be dated the date of opening. Staff D explained that the facility's expectation is that the sanitizer level should be checked in the low temperature dishwasher after each meal when washing dishes. Staff D said that the facility's expectation is that the refrigerator and freezer temperatures should be checked on the AM shift and the PM shift. On 3/29/23 at 1:10 PM Staff C, Cook, explained that the facility's expectation is that all open food would have the date of opening. Staff C stated the facility's expectation is the refrigerator and freezer temperatures should be checked two times a day on the AM and the PM shifts. Staff C stated temperatures in the freezer and refrigerators are checked but he forgets to write the temperatures down. The Warewashing policy reviewed 3/31/21 instructed that test strips shall be available for pot sink and low temperature dish machine sanitizer. Results shall be checked and recorded daily. The Refrigeration policy reviewed 3/31/21 directed that 1. Refrigeration units shall have temperatures monitored twice daily by the Manager or his/her designee. Temperatures shall be recorded daily and maintained in the Manager's office for a period of one year. 2. Opened or leftover condiments such as salad dressings, catsup, mustard, pickles, relishes, shall be dated with a thirty day expiration date. The Dry storage policy reviewed 3/31/21 directed that all leftovers or opened packages shall be labeled, dated, and stored in an airtight container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to provide a complete, accurate, and detailed record for changes in a resident's physical condition to maintain the resident's highest practical well-being for 1of 8 residents reviewed (Resident #39). The facility reported a census of 42 residents. Findings include: Resident #39's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 7, indicating moderately impaired cognition. The MDS included diagnoses of a cerebrovascular accident (stroke), altered mental status and bilateral aphakia (a condition in which the lens is missing inside the eye resulting in blurry vision). The MDS indicated the resident had not fallen within six (6) months prior to admission to the facility. The Electronic Health Record (EHR) listed diagnoses dated 11/1/22 of unsteadiness on feet and history of falling. The Fall Scale - Morse assessment dated [DATE] listed a fall risk score of 30, indicating a moderate fall risk. The assessment indicated that Resident #39 had no prior falls. The Incident Report dated 1/22/23 at 9:55 AM labeled Privileged and Confidential - No part of the Medical Record indicated that Resident #39 fell the previous Friday evening (1/20/23) at 10:30 PM. The resident who lived across the hall reported the concern to the nurse. The _Nurses Note dated 1/22/23 at 10:55 AM documented an assessment on Resident #39 for a fall follow-up. Resident #39 could move all extremities without difficulties and had no injuries noted. Resident #39 voiced no complaints or discomfort. Resident #39 sat in the dining room visiting with her granddaughters. The review of the progress notes lacked documentation of the fall and follow-up fall assessments. The review of the progress notes lacked notification to Resident #39's Power of Attorney (POA) or her provider. A review of the Morse Fall scale dated 1/22/23 indicated a fall risk of 70, indicating a high fall risk. It also contained documentation that the resident had prior falls. Resident #39's Care Plan Focus indicated that Resident #39 had a history of falls, hypotension (low blood pressure), and poor balance. The Care Plan included the following interventions added on 3/8/23. a. Continue interventions on the at-risk plan. b. For no apparent acute injury, determine and address causative factors of the fall. c. Neuro-checks per facility standard of practice The Care Plan had no prior Focus or Interventions regarding falls. On 3/27/23 at 1:40 PM, Staff I, Certified Nurse Aide (CNA), stated that Resident #39 fell in January 2023. She said that if a resident fell, they should notify the nurse and stay with the resident. She explained that the nurse would complete neurologic assessments on paper. After that, the CNA had no required further action. On 3/27/23 at 2:34 PM, observed Resident #39 sitting in the dining room in a wheelchair, requesting assistance. Staff J, Licensed Practical Nurse (LPN), stated that Resident #39 is kept in the dining area because she fell a lot in her room and she didn't want to do all that paperwork. She stated the paperwork involved in a resident fall included a hot chart that contained specific resident information used to alert other staff members of residents' needs. The Hot Chart for 1/20/23 revealed an OK status for Resident #39. The Hot Chart for 1/23/23 revealed an OK on fall follow-up with 0 injury status on 1/23/23. The facility lacked Hot Chart documents for 1/21/23 or 1/22/23. On 3/29/23 at 2:02 PM, Staff K, Registered Nurse (RN), stated the following steps are required when a resident falls. The nurse was expected to: a. Complete a resident head-to-toe assessment including vital signs b. Complete a risk assessment in the EHR c. Complete neurologic assessments, if suspected injury or neurologic involvement on paper d. Complete transfer documents, if the resident has to be sent out to an acute care facility e. Notify the physician, the POA, and the Director of Nursing (DON) f. Document the fall and notifications in the progress notes. On 3/29/23 at 2:12 PM, the DON said that she expected all fall related documentation must be completed by the end of the shift. She reported that the facility did not have a policy for time frames but if the fall occurred late in shift, she expected the following shift to finish the post-fall process and document it. On 3/30/23 at 12:27 PM, Staff L, RN, explained that during her evening shift on 1/21/23 after dinner, staff notified her that Resident #39 fell on 1/20/23 during the evening shift. She thought that Resident #39's POA called her regarding her prior fall. Staff L explained that she learned of the fall because of the call. She added that Resident #39's roommate initiated the call bell until Staff M, CNA, arrived and told her that she heard Resident #39 yelling. Staff L said that the roommate reported that the fall occurred during the evening shift on 1/20/23. Staff L explained that she contacted the DON, who instructed her to complete an assessment. Staff L stated that she did not complete any incident report since it did not occur during her shift. She also stated that she did not enter any documentation in the resident's EHR regarding any details of this incident. A policy titled Notification of a Change in a Resident's Condition dated 11/1/18 directed the staff to report a resident's significant change to the physician and resident's representative, then document the notification information in the Interdisciplinary Team (IDT) notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, document review, manufacturer ' s instructions, facility policy, and staff interview the facility failed to provide appropriate infection prevention practices for three of three residents (Resident #4, Resident #21, and Resident #41) requiring insulin. The facility reported a census of 42 residents. Findings included: 1. Resident #4 ' s Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 2/26/16. The MDS identified a Brief Interview of Mental Status (BIMS) of 2, indicating severe cognitive impairment. The MDS included a diagnosis of diabetes mellitus. The MDS indicated that Resident #4 received insulin for seven out of seven days in the lookback period. On 3/28/23 at 11:38 AM with the Assistant Director of Nursing (ADON), observed Staff N, Licensed Practical Nurse (LPN) check Resident #4 ' s blood sugar level. Staff N opened the case for blood glucose (sugar) checking machine and carried it down hall to Resident #4's room. Once Staff N entered Resident #4 ' s room she failed to complete hand hygiene prior to applying her gloves or checking the blood glucose level. After checking Resident #4 ' s blood glucose, Staff N removed her gloves and failed to complete hand hygiene. Staff N removed Novolog (Aspart or insulin) from the case, without sanitizing the top of the flex pen (Novolog) she applied the needle. Staff N continued without completing hand hygiene and applied new gloves the provided Resident #4 their insulin. After completing the insulin injection, Staff N wore her gloves into the hallway and removed them at the medication cart. At this time, Staff N sanitized her hands for the first time in the observation. 2. Resident #21 ' s MDS assessment dated [DATE] listed an admission date of 7/6/21. The MDS identified a BIMS score of 12, indicating moderate cognitive impairment. The MDS included diagnoses of septicemia (blood infection), diabetes mellitus, and candidiasis of skin and nail (yeast infection). On 3/28/23 at 11:45 AM with the ADON, watched Staff N give Resident #21 ' s insulin. Staff N removed the Novolog insulin pen from the case and applied the needle to the top of the flex pen without sanitizing the connection on the pen. After administering the insulin to Resident #21, Staff N exited the room while still wearing her gloves into the hallway. Staff N removed her gloves at the medication cart then, she sanitized hands. On 3/28/23 at 11:50 AM Staff N explained that the facility expected the staff to use hand sanitizer with glove changes and during any contamination (made dirty). Staff N stated that the facility expected the septum (top of pen used to connect the needle) of flex pen to be sanitized prior to application of the needle. On 3/28/23 at 12:07 PM the ADON reported that they expected staff to use hand sanitizer between all glove changes and when contaminated (dirty). The ADON said that hands should be sanitized every time in or out of the resident ' s room and with any resident contact. The ADON explained that the facility's expectation is for the septum of the insulin flex pen to be sanitized with alcohol prep pad prior to applying the needle tip. 3. Resident #41 ' s MDS assessment dated [DATE] listed an admission date of 1/13/23. The MDS identified a BIMS score of 15, indicating no cognitive impairment. The MDS included a diagnosis of diabetes mellitus. The MDS indicated that Resident #41 took insulin for seven out of seven days in the lookback period. On 3/28/23 at 11:38 AM witnessed Staff O, Registered Nurse (RN), check Resident #41 ' s blood glucose and administer insulin. Staff O entered Resident #41 ' s room and applied gloves without completing hand hygiene. After checking Resident #41 ' s blood sugar, Staff O removed her gloves and without hand hygiene prepared the insulin pen for injection. Staff O applied new gloves without completing hand hygiene, dialed 9 units of insulin then administered the insulin after cleaning the right lower abdomen with an alcohol wipe. Staff O continued to wear her gloves into the hallway until she arrived at the medication cart, then she sanitized her hands. The Administration Procedures for All Medications policy revised August 2014 directed to cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a med pass, before handling medication, and before contact with a resident. The Centers for Disease Control and Prevention (CDC) website titled, Medication Preparation Questions answered the question of how should medications get drawn up? Parenteral (injected) medications should be accessed in an aseptic (clean) manner. This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it. The Hand Hygiene policy revised 4/28/22 directed the following information 1. Hand hygiene should be performed following the clinical indications: a. Before / After providing care. b. Contact with blood, body fluids, or contaminated surfaces. c. Before / After applying / removing gloves / PPE. d. After handling soiled linens/items potentially contaminated with blood, body fluids, or secretions. 2. Hand sanitizer: employees may use an alcohol based hand rub when hands are not visibly soiled. a. Apply alcohol based hand rub to the palm of one hand b. Rub hands together, covering all surfaces of hands and fingers until hands are dry. The review of the Novolog FlexPen manufacturer instructions dated 2016 titled, Using Your FlexPen emailed by administrator listed to wipe the rubber end of the pen with an alcohol swab. On 3/29/23 at 1:04 PM the Director of Nursing (DON) explained that she expected hand hygiene would be performed with every glove change and glove removal. The DON stated facility has no policy or procedure for injectable medications. DON stated manufactures guidelines state must sanitize septum of flexpen only when opened. DON stated the facility has no expectation for the septum of insulin flexpen to be sanitized between each use, only when opened.

Based on policy review, document review, and staff interview the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property for one of five staff reviewed (Staff C, Cook) The facility reported a census of 42 residents. Findings include The Abuse Prevention policy reviewed 4/28/21 instructed that all facility staff shall be in-serviced upon initial employment, and at least annually thereafter, regarding Resident's Rights, including freedom from abuse, neglect, mistreatment, misappropriation of property, exploitation and the related reporting requirements and obligations. Employees will also be notified of their rights and the facility will post information on employee rights including the right to be free from retaliation for reporting a suspected crime. The policy continued to direct to train employees, through orientation and on-going sessions on issues related to abuse prohibition practices such as: Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. How staff should report their knowledge related to allegations without fear of reprisal. How to recognize signs of burnout, frustration and stress that may lead to abuse. What constitutes abuse, neglect, exploitation, and misappropriation of resident property. 1. The Director of Nursing (DON) and Staff E, Business Office Manager, failed to provide the Staff C ' s Dependent Adult Abuse/Mandatory Reporter Certificate upon request. On 3/28/23 at 2:46 PM the DON stated the follow up on the Dependent Adult Abuse training is completed by the head of the department that the staff member works in and the business department. The DON reported that Staff C did not have Dependent Adult Abuse training completed and the facility's expectation is completed within the first six months. 2. On 3/28/23 at 2:30 PM the DON provided Staff F ' s, Certified Nurse Aide (CNA), Dependent Adult Abuse certificate. The review of Staff F ' s Dependent Adult Abuse Certificate provided by the DON listed a completion date of 2/22/20. The current Dependent Adult Abuse certificate listed a completion date of 3/28/23 (day of request for the certificate). 3. Request made to the DON on 3/28/23 at 12:31 PM for Staff G, Registered Nurse (RN) ' s Dependent Adult Abuse certificate document. On 3/28/23 at 12:31 PM DON stated waiting for document to be sent by Staff G On 3/28/23 at 2:30 PM, and 4:30 PM requested Staff G ' s Dependent Adult Abuse Certification again from the DON. On 3/29/23 at 8:30 AM and 11:00 AM additional requests for Staff G ' s certificate to the DON before the DON provided Staff G ' s Dependent Adult Abuse certificate. Staff G ' s Dependent Adult Abuse certification listed a date of completion as 2/4/20 for their previous Dependent Adult Abuse certificate. Staff G ' s current Dependent Adult Abuse certificate listed completion date of 3/29/23 (day after initial request for the certificate). On 3/29/23 at 4:41 PM the Administrator explained the facility ' s expectation for the employee's completion of Dependent Adult Abuse prior to being employed for 6 months. The Administrator stated with the staff turnover in the business office the completion of Dependent Adult Abuse training fell through the cracks. On 3/30/23 at 2:23 PM the DON reported the facility ' s expectation is that Dependent Adult Abuse training would always be current for the staff while they are employed with the facility. On 3/30/23 at 3:10 PM the Administrator presented Staff C ' s Dependent Adult Abuse certificate completed. The Mandatory Reporter Information from the State of Iowa Department of Health and Human Services dated 2023 directed that Every individual required to report suspected abuse must complete two hours of mandatory reporter training within their first six months of employment or self-employment and one hour of additional training every three years (unless otherwise specified by federal regulations).

Based on document review and staff interview the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a Certified Dietary Manager. The facility reported a census of 42 residents. Findings include The request for documentation from Staff B, Regional Dietitian, regarding the qualifications of the facility ' s Dietary Manager revealed they did not have a certification or documentation. On 3/29/23 at 1:00 PM Staff B explained that she thought the Dietary Manager had a year to obtain a license. Staff B reported that the Dietary Manager did not have the following a. Dietary Manager Certificate b. Food Service Manager Certificate c. National Certification for Food Service Management and Safety from a national certifying body. d. An associate's degree or higher in food service management or in hospitality e. 2 or more years of Experience in the position of Director of Food and Nutrition services in a nursing facility setting. The Medicare Program; Prospective Payment System and Consolidated [NAME] for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2023; Changes to the Requirements for the Director of Food and Nutrition Services and Physical Environment Requirements in Long-Term Care Facilities A Rule by the Centers for Medicare & Medicaid Services on 8/3/22 directed that an experienced director of food and nutrition services could have one year to obtain training necessary to qualify for the position. Experience plus a minimum course of study is one of five ways to qualify for the position of the director of food and nutrition services. The publication instructed that specifically, an individual who, on the effective date of this final rule, has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management by no later than October 1, 2023, along with the other requirements set out at § 483.60(a)(2), is qualified to be the director of food and nutrition services.

Based on clinical record reviews and staff interviews at the time of the investigation, the facility failed to complete timely resident assessments on admission and readmission for 3 of 4 residents reviewed who required wound care assessments (Resident #1, #2, and #3). The facility identified a census of 43 residents. Findings include: 1. A Minimum Data Set (MDS) assessment form dated 10/26/22, documented Resident #1 with diagnoses of anemia, arthritis, hip fracture, other fracture, anxiety, depression, chronic pain and pressure ulcer of sacral region. The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 13, indicating no impairment with decision making abilities, no behaviors and no resisting of cares. The assessment also documented the resident as needing extensive assistance of two for bed mobility, dressing, and toilet use. The resident did not transfer or ambulate. The MDS identified the resident as being occasionally incontinent of bowel and bladder. The assessment documented the resident at risk for pressure ulcers and with no unhealed pressure ulcers/injuries and resident with surgical wounds, skin tears and moisture associated skin damage (MASD). The New admission Screening/History dated 10/20/22 at 4:10 p.m. documented the following; Skin Assessment: a. right trochanter (hip), surgical incision b. left trochanter (hip), surgical incision c. right heel (outer), boggy d. right ankle (outer), excoriation e. left ankle (outer), excoriation f. sacrum, Moisture associated skin damage The Patient Discharge and Transfer form dated 10/20/22 and signed by the physician documented: Skin cares: see provided wound care orders and wound care orders are attached; a. left and right hip incisions - betadine daily and cover with 4 by 4 gauze and secure with tape b. buttocks, including bilateral ischial wounds and coccyx wound - apply skin protectant three times a day c. right lower extremity and right lateral ankle wounds - apply allevyn bordered foam dressing every other day The Nurses Progress Notes documented the following on: a. 10/20/2022 at 4:47 p.m. Resident #1 has a non-weight bearing status to bilateral lower extremities. Dressings are intact to both hips, with left hand skin tears intact. Inside Resident #1 ' s abdominal folds contain pillow cases to prevent breakdown and/or moisture. A barrier cream applied to Resident #1 ' s bottom. Redness noted to the right heel, a pillow positioned to float the heel. Resident #1 reported pain of 7 out 10 and requested pain medication. b. 10/27/22 at 1:36 p.m. the wound physician documented that Resident #1 discharged from the facility to the hospital due to surgical wound dehiscence. Due to the hospitalization, the wound physician could not see Resident #1. The Clinical Record lacked any documentation of admission skin assessment with measurements completed on admit from the hospital. 2. A MDS assessment form dated 10/28/22, documented Resident #2 with diagnoses of a neurogenic bladder, malnutrition, cognitive communication deficit, lack of coordination and right below knee amputation. The assessment documented a BIMS score of 0 and short term memory ok with modified independence for daily decision making abilities, no behaviors or resisting of cares. The assessment also documented the resident as needing extensive assistance of two for dressing, personal hygiene, and toilet use. Resident #2 could move independently for bed mobility, transfers, and locomotion on and off the unit. The MDS identified Resident #2 as being always incontinent of bowel with an urinary catheter. The assessment documented the resident at risk for pressure ulcers and with one unhealed pressure ulcers/injuries at a stage 4. The Nursing admission Screening/History dated 11/4/22 at 12:38 p.m., documented, Resident #2 went to hospital for sudden vision loss and returned to the facility. The Skin Assessment indicated a right thigh (rear) pressure area, stage 4. The Progress Notes dated 10/27/22 documented by the wound physician that the patient's visit has been rescheduled. Patients outside of the facility for an appointment, will be rescheduled. The Clinical Record lacked any documentation of the admission/readmission skin report completed with measurements. 3. A MDS assessment form dated 11/11/22, documented Resident #3 with diagnoses of hypertension, arthritis, adult failure to thrive, and a hip replacement. The assessment documented the resident with a BIMS score of 15, indicating no cognitive impairments for decision making abilities. The assessment also documented the resident as needing limited assistance of one for personal hygiene and toilet use with supervision for bed mobility, transfers, and locomotion on and off the unit. The assessment documented the resident at risk for pressure ulcers with a surgical wound with wound dressings. The Nursing admission Screening/History dated 11/5/22 at 6:41 p.m., documented an admission to the facility for therapy after hip replacement. The Skin assessment indicated a right trochanter (hip) incision with no measurements. During an interview on 11/08/22 at 12:30 p.m. Staff A (XXXXX) confirmed and verified that the skin assessment needed to be completed on all residents that returned from the hospital and also on new admits. Staff A confirmed that the clinical record lacked documentation of skin sheets being completed. During an interview on 11/14/22 at 1:30 p.m. Staff B (Director of Nursing) confirmed and verified that the nursing staff are expected to do an initial and readmission skin assessments on residents. Staff B explained the facility did not have a policy or procedure, but standard of practice is that skin assessments are completed upon admission and readmission. The clinical record lacked any measurements and skin assessments upon admission and readmission. During an interview on 11/21/22 at 2:30 p.m. Staff C (Registered Nurse) confirmed and verified that all skin sheets need to be completed on all new admits and residents that are re-admitted from the hospital. Staff C verified that the clinical record lacked documentation of the skin assessments, being completed as standard of practice.