**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review the facility failed to provide bathing assistance for 2 of 4 residents reviewed for bathing (Residents #1 and #2). The facility reported a census of 35 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified bathing activity for Resident #1 was not applicable/not attempted. Resident #1's MDS included diagnoses of cancer, anemia, atrial fibrillation (irregular heart beat), hypertension (high blood pressure), heart failure (heart does not pump blood well), and end stage renal disease (kidney). The Clinical Census documented Resident #1 was admitted to the facility on [DATE] and discharged from the facility on 6/4/25. The Care Plan with a target date of 6/12/25 identified Resident #1 required assistance of 1 staff member to provide bathing. Review of Point of Care (POC) Tasks in the electronic medical record revealed Resident #1 was scheduled for a sponge bath or shower on Monday and Thursday. The bathing records lacked documentation Resident #1 received a bath during her stay at the facility from 5/28 to 6/4/25. The Clinical Record lacked documentation of any other attempts to offer or encourage Resident #1 to shower or bathe. 2. Resident #2's Minimum Data Set (MDS) dated [DATE] assessment identified a BIMS score of 11, indicating moderately impaired cognition. The MDS identified Resident #2 required substantial/maximal assistance with shower/bathing. Resident #2's MDS included diagnoses of hypertension (high blood pressure), peripheral vascular disease, diabetes mellitus, and cerebrovascular accident (CVA) (stroke) affecting the right side. The Care Plan with a target date of 7/1/25 identified Resident #2 required substantial assistance of 1 staff member to provide bathing Review of POC Tasks in the electronic medical record revealed Resident #2 was scheduled for a bath or shower on Wednesday and Saturday. The facility electronic form title Shower/Bath for the last 30 days documented Resident #2 received a bath on 5/17, 5/28 and 6/8. The form documented a shower/bath was refused on 6/4 and not applicable on 6/7. A facility paper form titled Baths for the week of 5/26 to 6/1 documented Resident #2 received a bath or shower on 5/28 and 5/31. The bathing form directed the staff to write down their initials next to each bath/shower that was given. The form documented that any shower/bath not given needed to be reviewed with the charge nurse and communicated to leadership, as each resident was to be offered bathing two times per week. The form indicated if a resident refused their shower, the staff was to try and offer again the next day. A facility paper form titled Baths for the week of 6/2 to 6/8 documented Resident #2 refused a bath on 6/4 and received a bath on 6/7. Review of the Clinical Record and bathing forms revealed Resident #2 did not have a bath or shower from 5/31 to 6/7. The Clinical Record lacked documentation of any other attempts to offer or encourage Resident #2 to shower or bathe. On 6/10/25 at 4 PM, Resident #2 reported he got a bath about once per week and would prefer to have three baths per week. On 6/11/25 at 10:10 AM, Staff A, Certified Nursing Assistant (CNA) reported she was normally scheduled to do baths/showers. Staff A reported the bathing documentation was completed in the resident's electronic medical record. In addition, she said there was a paper list in the shower house that she highlighted when the baths were completed along with documenting her initials next to the resident name. She said she gave the paper list to the DON when she was done. When asked about Resident #2 baths, she reported he refused to take a bath last Wednesday (6/4). She reported when a resident refused to take a bath the staff were to tell the nurse, then ask the resident one more time, then after that the resident had the right to refuse the bath. When asked when not applicable would be charted for bathing, she said it would be charted when the staff did not get the bath done that day as scheduled instead of charting refused. On 6/11/25 at 11:09 AM, the Director of Nursing (DON) reported she had reviewed the paper documentation for bathing for Resident #2 and acknowledged the documentation in POC did not match the paper documentation. The DON reported she was auditing the bathing documentation on paper and it was a work in progress for the staff to document in POC accurately and consistently all the time. She reported if a resident did not get a bath, she expected the resident to be the first one completed the next day and the staff needed to chart the bath was offered. On 6/11/25 at 3:10 PM, the DON verified Resident #1 did not have a bath during her stay from 5/28 to 6/4/25. In addition, the DON acknowledged Resident #2 refused his bath on 6/4/25. The DON verified Resident #2 did not have a documented bath between 5/31 and 6/7. The DON reported she expected staff to re-approach, offer a bath the following day, and document the attempt. A facility policy title Activities of Daily Living (ADLs), Supporting revised March 2018 documented the facility would provide appropriate care and services for the residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene that include (bathing, dressing, grooming and oral care).

Based on clinical record review, facility investigative file review, staff interviews and policy review the facility failed to implement their abuse policies. The facility's staff member with concerns about the treatment of Resident #3 was not reported within two hours of the concerns. The facility also failed to complete a thorough investigation. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. The Clinical Census revealed Resident #3 was discharged from the facility on 4/11/2025. The facility's investigative file contained the following statement from Staff B Licensed Practical Nurse (LPN): -On 2/22/25 (Saturday) I worked the nightshift 10:00 PM-6:00 AM. Staff E Certified Nursing Assistant (CNA) and Staff F CNA were the aides and around 10:30 PM-11:00 PM a resident had her call light on. Staff E heard the call light looked down the hall and stated oh hell no, I am not doing this tonight. When Staff B looked at her, she went down and answered the call light. Both CNAs would leave call lights go for long periods of time, while sitting at the desk talking. Staff B stated she watched and waited to see when rounds were going to be done, rounds were not done until 3-3:30 AM. The was the only time rounds were done, hospice residents were not turned, ice waters were not passed out to the residents, nor were linens. -On 2/23/25 (Sunday) I again worked the night shift 10:00 PM-6:00 AM with Staff E and F. They again were reluctant to answer call lights. The call lights would stay on for more than 5 minutes, while the CNAs sat at the desk talking. A resident had started to open her door and both CNAs yelled from the desk for the resident to lay back down and go to sleep, while pointing into the resident's room, this happened at least two times. A different resident came out of his room in his wheelchair and Staff F grabbed the resident's wheelchair and stated he had to go back to bed. The resident was taken to his room and placed back in bed. Rounds were again started at 3:00 AM and that was the only time rounds were done. Staff B stated she went into Resident #3's roommate's room to do a pre-assessment on the dialysis patient. Resident #3 was sitting up on the side of the bed. She stated she was exercising and was asked if she needed to go to the bathroom. She stated yes and this nurse pulled the call light for the resident. As she was completing the assessment on Resident #3 roommate, Staff E and Staff F came into the room and asked the resident what she was doing, the resident stated she was exercising, both aides started laughing loudly in a condescending manner, and said sure you are. Staff B told the aides that the resident needed to go to the bathroom. The EZ stand (mechanical lift) was brought in to the room and both aides were rude. They stated if she had to go to the bathroom she would need to use the lift. The resident kept stating she did not need to use the lift and that she had gone to the bathroom three other times during the night, by herself. Staff B stated both aides were talking in a manner to which she would not want her loved one being talked to. Resident #3 got more upset and aggressive towards the aides and the aides were telling Resident #3 that they could not take her to the bathroom without the lift but the resident stated she was not going to use the lift. The aides lifted the resident's legs back in to bed and stated then you aren't going to go to the bathroom. The aides did ask Staff B to help them talk to her but she stated that they had already made her mad, she would not listen to her and the resident stated no she wasn't. The statement was signed by Staff B on 2/25/2025 (Tuesday). During an email correspondent with the State Agency's Complaint Intake Specialist on 5/13/2025 at 10:06 AM, she provided the facility initially reported the concern to the State Agency on 2/25/2025 at 5:01 PM. On 5/13/2025 at 2:09 PM Staff B stated the weekend in question in February, she reported her concerns to Staff H Registered Nurse (RN) that worked the day shift that weekend. She was not sure if Staff H had reported these concerns to anyone. Staff B stated she had Monday, 2/24/25 off but the next day she said something to the Director of Nursing (DON). When asked if the facility had an abuse coordinator to report abuse concerns to, she stated she was not sure. The DON was just starting in the facility. They usually have something written down to indicate who is on call, but does not recall if they had done that that weekend. She alleged the concerns took place that Sunday in to Monday morning about 4:30/5:00 AM. Staff B stated she did not know who to call at the time of her concerns, but acknowledged she should have called someone. She thought Staff H would tell Staff G previous Administrator. Staff B stated when she came to work on 2/25/2025 she provided her statement and was written up for not reporting her concerns sooner. On 5/14/2025 at 12:42 PM an attempt to contact Staff H was made; there was no answer, a voicemail was left and a text message was sent. At the conclusion of the investigation there was no return call. On 5/14/2025 at 4:23 PM the DON stated Staff B gave her written statement the same day she reported her concerns on 2/25/2025. The DON acknowledged it was not timely reporting on Staff B's part and she was educated on reporting concerns immediately. When asked who Staff B should have reported her concerns to, the DON stated she should have reported them to the Administrator and/or DON right away. She added they have their phone numbers posted at the nurse's station. The facility provided a document titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, with a revision date of April 2021, documented all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, federal agencies, and thoroughly investigated by facility management, findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law. 3.Immediately is defined as within two hours of an allegation involving abuse. Review of the facility's investigative file included a page of resident questions that was filled out by various staff members. Question #6 asked Do you have any type of mistreatment to report to me now? The Social Worker documented the following information that was provided by Resident #3: I was abused, left hanging on the side of my bed. It was in the middle of the night. I was told by the aide I will not be helping you. I sat there for 2 hours. It caused me great pain. I've never been physically abused. The investigative file lacked any follow up with Resident #3 about her response to question #6. Resident #3's roommate was asked the same question but the file failed to include an interview with the roommate pertaining to the morning in question. The investigative file included interviews with the following staff members: Staff B, Staff E and Staff F. The investigative file failed to include interviews with staff members that took care of the resident on all shifts after the alleged incident occurred as well as no interview with Staff H Registered Nurse (RN) The investigative file also lacked any follow up interview(s) with Resident #3 after the alleged incident to check on her psycho-social status. On 5/13/2025 at 2:09 PM Staff B stated the weekend in question in February, she reported her concerns to Staff H that worked the day shift that weekend. She was not sure if Staff H had reported these concerns to anyone. On 5/14/2025 at 12:42 PM an attempt to contact Staff H was made; there was no answer, a voicemail was left and a text message was sent. At the conclusion of the investigation there was no return call. On 5/16/2025 at 10:48 AM the Social Worker acknowledged she interviewed Resident #3 using the resident questions sheet. When asked what she did with the information after her interview, she stated she gave her interview sheets to the DON. She indicated she did not ask further questions and could not remember if other residents had concerns in regards to the care they received. She would not have asked further questions with Resident #3 because she did not like upsetting her. When asked if the DON said anything when she handed her Resident #3's responses she stated she just handed her the paper and the DON said thank you. On 5/16/2025 at 11:20 AM the DON was read Resident #3's response to the questionnaire completed by the Social Worker. She was asked if she followed up with Resident #3 after the Social Worker had completed her questionnaire with her. The DON denied being aware of that statement. Those concerns should have been reported to her and another investigation should have been started. If they were reported to her, she would have found out more information. The DON indicated she followed up with Resident #3 after the alleged incident to see how she was doing, she checked on her a lot but did not document it anywhere. When she followed up with her the resident was fine, some days she was confused others she was not. When asked if the Social Worker could have followed up with Resident #3 she stated oh absolutely. When asked why the roommate was not asked questions specific to the alleged incident, she stated she should have been asked questions. She acknowledged Staff H was not interviewed. Investigating allegations: 1. All allegations are thoroughly investigated. The Administrator initiates investigations. 7. The individual conducting the investigation as a minimum: e. interviews any witnesses to the incident; f. interviews the resident; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate l. documents the investigation completely and thoroughly. The facility provided a document titled Protection of Residents During Abuse Investigations, with a revision date of April 2021, documented the victim is evaluated for his or her feelings of safety.

Based on record review, facility investigative file review, staff interviews and policy review the facility failed to report concerns about the treatment of Resident #3 within two hours of the alleged concerns observed. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. The Clinical Census revealed Resident #3 was discharged from the facility on 4/11/2025. The facility's investigative file contained the following statement from Staff B Licensed Practical Nurse (LPN): -On 2/22/25 (Saturday) I worked the nightshift 10:00 PM-6:00 AM. Staff E Certified Nursing Assistant (CNA) and Staff F CNA were the aides and around 10:30 PM-11:00 PM a resident had her call light on. Staff E heard the call light looked down the hall and stated oh hell no, I am not doing this tonight. When Staff B looked at her, she went down and answered the call light. Both CNAs would leave call lights go for long periods of time, while sitting at the desk talking. Staff B stated she watched and waited to see when rounds were going to be done, rounds were not done until 3-3:30 AM. The was the only time rounds were done, hospice residents were not turned, ice waters were not passed out to the residents, nor were linens. -On 2/23/25 (Sunday) I again worked the night shift 10:00 PM-6:00 AM with Staff E and F. They again were reluctant to answer call lights. The call lights would stay on for more than 5 minutes, while the CNAs sat at the desk talking. A resident had started to open her door and both CNAs yelled from the desk for the resident to lay back down and go to sleep, while pointing into the resident's room, this happened at least two times. A different resident came out of his room in his wheelchair and Staff F grabbed the resident's wheelchair and stated he had to go back to bed. The resident was taken to his room and placed back in bed. Rounds were again started at 3:00 AM and that was the only time rounds were done. Staff B stated she went into Resident #3's roommate's room to do a pre-assessment on the dialysis patient. Resident #3 was sitting up on the side of the bed. She stated she was exercising and was asked if she needed to go to the bathroom. She stated yes and this nurse pulled the call light for the resident. As she was completing the assessment on Resident #3 roommate, Staff E and Staff F came into the room and asked the resident what she was doing, the resident stated she was exercising, both aides started laughing loudly in a condescending manner, and said sure you are. Staff B told the aides that the resident needed to go to the bathroom. The EZ stand (mechanical lift) was brought in to the room and both aides were rude. They stated if she had to go to the bathroom she would need to use the lift. The resident kept stating she did not need to use the lift and that she had gone to the bathroom three other times during the night, by herself. Staff B stated both aides were talking in a manner to which she would not want her loved one being talked to. Resident #3 got more upset and aggressive towards the aides and the aides were telling Resident #3 that they could not take her to the bathroom without the lift but the resident stated she was not going to use the lift. The aides lifted the resident's legs back in to bed and stated then you aren't going to go to the bathroom. The aides did ask Staff B to help them talk to her but she stated that they had already made her mad, she would not listen to her and the resident stated no she wasn't. The statement was signed by Staff B on 2/25/2025 (Tuesday). During an email correspondent with the State Agency's Complaint Intake Specialist on 5/13/2025 at 10:06 AM, she provided the facility initially reported the concern to the State Agency on 2/25/2025 at 5:01 PM. On 5/13/2025 at 2:09 PM Staff B stated the weekend in question in February, she reported her concerns to Staff H Registered Nurse (RN) that worked the day shift that weekend. She was not sure if Staff H had reported these concerns to anyone. Staff B stated she had Monday, 2/24/25 off but the next day she said something to the Director of Nursing (DON). When asked if the facility had an abuse coordinator to report abuse concerns to, she stated she was not sure. The DON was just starting in the facility. They usually have something written down to indicate who is on call, but does not recall if they had done that, that weekend. She alleged the concerns took place that Sunday into Monday morning about 4:30/5:00 AM. Staff B stated she did not know who to call at the time of her concerns, but acknowledged she should have called someone. She thought Staff H would tell Staff G the previous Administrator. Staff B stated when she came to work on 2/25/2025 she provided her statement and was written up for not reporting her concerns sooner. On 5/14/2025 at 12:42 PM an attempt to contact Staff H was made; there was no answer, a voicemail was left and a text message was sent. At the conclusion of the investigation there was no return call. On 5/14/2025 at 2:54 PM Staff G indicated he reported the concerns to the State Agency he believed immediately. On 5/14/2025 at 4:23 PM the DON stated Staff B gave her written statement the same day she reported her concerns on 2/25/2025. The DON acknowledged it was not timely reporting on Staff B's part and she was educated on reporting concerns immediately. When asked who Staff B should have reported her concerns to, the DON stated she should have reported them to the Administrator and/or DON right away. She added they have their phone numbers posted at the nurse's station. The facility provided a document titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, with a revision date of April 2021, documented all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, federal agencies, and thoroughly investigated by facility management, findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law. 3.Immediately is defined as within two hours of an allegation involving abuse.

Based on record review, facility investigative file review, staff interviews and policy review the facility failed to complete a thorough investigation. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. Record review revealed Resident #3 was discharged from the facility on 4/11/2025. The facility's investigative file contained the following statement from Staff B Licensed Practical Nurse (LPN): -On 2/22/25 (Saturday) I worked the nightshift 10:00 PM-6:00 AM. Staff E Certified Nursing Assistant (CNA) and Staff F CNA were the aides and around 10:30 PM-11:00 PM a resident had her call light on. Staff E heard the call light looked down the hall and stated oh hell no, I am not doing this tonight. When Staff B looked at her, she went down and answered the call light. Both CNAs would leave call lights go for long periods of time, while sitting at the desk talking. Staff B stated she watched and waited to see when rounds were going to be done, rounds were not done until 3-3:30 AM. The was the only time rounds were done, hospice residents were not turned, ice waters were not passed out to the residents, nor were linens. -On 2/23/25 (Sunday) I again worked the night shift 10:00 PM-6:00 AM with Staff E and F. They again were reluctant to answer call lights. The call lights would stay on for more than 5 minutes, while the CNAs sat at the desk talking. A resident had started to open her door and both CNAs yelled from the desk for the resident to lay back down and go to sleep, while pointing into the resident's room, this happened at least two times. A different resident came out of his room in his wheelchair and Staff F grabbed the resident's wheelchair and stated he had to go back to bed. The resident was taken to his room and placed back in bed. Rounds were again started at 3:00 AM and that was the only time rounds were done. Staff B stated she went into Resident #3's roommate's room to do a pre-assessment on the dialysis patient. Resident #3 was sitting up on the side of the bed. She stated she was exercising and was asked if she needed to go to the bathroom. She stated yes and this nurse pulled the call light for the resident. As she was completing the assessment on Resident #3 roommate, Staff E and Staff F came into the room and asked the resident what she was doing, the resident stated she was exercising, both aides started laughing loudly in a condescending manner, and said sure you are. Staff B told the aides that the resident needed to go to the bathroom. The EZ stand (mechanical lift) was brought in to the room and both aides were rude. They stated if she had to go to the bathroom she would need to use the lift. The resident kept stating she did not need to use the lift and that she had gone to the bathroom three other times during the night, by herself. Staff B stated both aides were talking in a manner to which she would not want her loved one being talked to. Resident #3 got more upset and aggressive towards the aides and the aides were telling Resident #3 that they could not take her to the bathroom without the lift but the resident stated she was not going to use the lift. The aides lifted the resident's legs back in to bed and stated then you aren't going to go to the bathroom. The aides did ask Staff B to help them talk to her but she stated that they had already made her mad, she would not listen to her and the resident stated no she wasn't. The statement was signed by Staff B on 2/25/2025 (Tuesday). Review of the facility's investigative file included a page of resident questions that was filled out by various staff members. Question #6 asked Do you have any type of mistreatment to report to me now? The Social Worker documented the following information that was provided by Resident #3: I was abused, left hanging on the side of my bed. It was in the middle of the night. I was told by the aide I will not be helping you. I sat there for 2 hours. It caused me great pain. I've never been physically abused. The investigative file lacked any follow up with Resident #3 about her response to question #6. Resident #3's roommate was asked the same question but the file failed to include an interview with the roommate pertaining to the morning in question. The investigative file included interviews with the following staff members: Staff B, Staff E and Staff F. The investigative file failed to include interviews with staff members that took care of the resident on all shifts after the alleged incident occurred as well as no interview with Staff H Registered Nurse (RN). The investigative file also lacked any follow up interview(s) with Resident #3 after the alleged incident to check on her psycho-social status. On 5/13/2025 at 2:09 PM Staff B stated the weekend in question in February, she reported her concerns to Staff H that worked the day shift that weekend. She was not sure if Staff H had reported these concerns to anyone. On 5/14/2025 at 12:42 PM an attempt to contact Staff H was made; there was no answer, a voicemail was left and a text message was sent. At the conclusion of the investigation there was no return call. On 5/16/2025 at 10:48 AM the Social Worker acknowledged she interviewed Resident #3 using the resident questions sheet. When asked what she did with the information after her interview, she stated she gave her interview sheets to the DON. She indicated she did not ask further questions and could not remember if other residents had concerns in regards to the care they received. She would not have asked further questions with Resident #3 because she did not like upsetting her. When asked if the DON said anything when she handed her Resident #3's responses she stated she just handed her the paper and the DON said thank you. On 5/16/2025 at 11:20 AM the DON was read Resident #3's response to the questionnaire completed by the Social Worker. She was asked if she followed up with Resident #3 after the Social Worker had completed her questionnaire with her. The DON denied being aware of that statement. Those concerns should have been reported to her and another investigation should have been started. If they were reported to her, she would have found out more information. The DON indicated she followed up with Resident #3 after the alleged incident to see how she was doing, she checked on her a lot but did not document it anywhere. When she followed up with her the resident was fine, some days she was confused others she was not. When asked if the Social Worker could have followed up with Resident #3 she stated oh absolutely. When asked why the roommate was not asked questions specific to the alleged incident, she stated she should have been asked questions. She acknowledged Staff H was not interviewed. The facility provided a document titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, with a revision date of April 2021, documented investigating allegations: 1. All allegations are thoroughly investigated. The Administrator initiates investigations. 7. The individual conducting the investigation as a minimum: e. interviews any witnesses to the incident; f. interviews the resident; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate l. documents the investigation completely and thoroughly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review the facility failed to ensure 1 of 9 resident's care plans (Resident #3) was revised once her transfer assistance requirement was changed to the use of a mechanical lift. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. The Care Plan Focus Area titled Activities of Daily Living (ADLs) with an initiated date of 11/25/2024 documented Resident #3 required substantial assistance of two staff for transfers, ambulation, mobility and toileting. The Care Plan lacked documentation for the use of an EZ stand for transfers. Review of Resident #3's visual/bedside [NAME] Report documented she required substantial assistance of two staff for toileting, transfers, mobility and ambulation. On 5/13/2025 at 2:09 PM Staff B Licensed Practical Nurse (LPN) stated in February 2025 Staff E Certified Nursing Assistant (CNA) and Staff F CNA had attempted to assist Resident #3 to the restroom. When they advised her, they needed to get the EZ-Stand (mechanical lift to assist a resident to a sitting position) the resident refused to allow this. On 5/14/2025 at 3:55 PM Staff F stated Resident #3 had put her call light on, when her and Staff E went in her room she was attempting to get up and walk. They reminded her they needed to use the EZ stand to assist her to the bathroom. Staff F stated Resident #3 used to be assisted with two staff, a gaitbelt and walker but she got weak. When asked if she used the care plans when assisting residents, she stated they are never updated so they would have to talk with physical therapy for guidance. On 5/14/2025 at 2:10 PM Staff E stated in February Resident #3 was being combative and hanging off the side of her bed. She was not able to get up on her own, she required the use of an EZ stand for transfers. The previous shift indicated she was using the lift without issues. She tried to explain to the resident that it was their policy that if they required a lift for transfers, they could not, not use it. Staff E stated they had been using the mechanical lift with Resident #3 for about a week or two. She added at times they would use a Hoyer left then were able to downgrade to an EZ stand but the resident did not like the way the straps were positioned. When asked how they were made aware to use the lift, she indicated the staff on the evening shift let them know. On 5/14/2025 at 4:23 PM the Director of Nursing (DON) stated Resident #3 required the use of an EZ stand for transfers or she may have been an assistance of two staff. She knew the resident did not like to use the EZ stand. During a follow-up interview on 5/16/2025 at 11:20 AM she stated the MDS Coordinator completes the main portion of the care plans. If she is not working, anyone can update them as needed. When asked what staff use when caring for the residents, she stated they can use the [NAME], can be pulled up in the resident's Electronic Health Record (EHR), and updated as necessary. Care plans should be updated as needed (PRN), checked quarterly and annually with care conferences. When she was informed that Resident #3's care plan did not reflect the use of an EZ stand for transfers, she stated oh. The facility provided a document titled Care Plans, Comprehensive Person-Centered, with a revision date of December 2016, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.

Based on clinical record review, staff interviews, and facility policy review the facility failed to implement additional individualized interventions for 1 of 3 residents (Resident #3) related to behaviors to assist residents with dementia in the completion of a task. Resident #3 refused staff to assist her to the bathroom and refused staff to check her for incontinence and change her when she was incontinent. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated she had moderate cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. The Care Plan Focus Area titled Activities of Daily Living (ADLs) with an initiated date of 11/25/2024 documented #3 required substantial assistance of two staff for transfers, ambulation, mobility and toileting. The Care Plan Focus Area indicated she had a behavior problem related to her dementia, with an initiated date of 3/27/2025. The Care Plan directed staff to assist Resident #3 in the selection of appropriate coping mechanism, not to argue with the resident and to talk with the resident in a calm voice when her behavior is disruptive. The resident's Clinical Census documented she was discharged from the facility on 4/11/2025. On 5/13/2025 at 2:09 PM Staff B Licensed Practical Nurse (LPN) stated she was in with Resident #3's roommate when Staff E Certified Nursing Assistant (CNA) and Staff F attempted to assist her. The resident was sitting on the edge of the bed when the CNAs came in to the room. She let them know she wanted to go to the bathroom. When they informed her, they needed to get the mechanical lift, the resident refused to use it. The resident became upset when they would not transfer her without the mechanical lift. The CNAs asked Staff B if she was going to help them. She told them no because she was already upset. When the CNAs asked for help she knew Resident #3 was not going allow her to help her because she was already upset. She indicated Resident #3 can be naughty a times, will cuss and hit the staff members. When helping her it's all about the approach you take with her. On 5/14/2025 at 3:55 PM Staff F stated when her and Staff E reminded Resident #3 they needed to use the mechanical lift to transfer her to the bathroom she started to tell them they did not know what they were doing and was dumb founded at the request. The resident began to call them incompetent and used curse words. When they told Staff B about Resident #3 refusing to use the mechanical lift, she went in and told the resident they needed to use the mechanical lift as it's their job, then she walked out. For the rest of the night Staff E and Staff F would go in and check on Resident #3 but she refused to be checked and changed even when she was soiled. Resident #3 was adamant about walking and not waiting to use the mechanical lift, then would not let them change her. Staff B knew everything that was going on with Resident #3 but she did not go in to see if Resident #3 would allow her to assist her. On 5/14/2025 at 2:10 PM Staff E stated Resident #3 was being combative and refused to allow her and Staff F to help her to the bathroom. When her and Staff F went in to the resident's room, she was hanging off the bed. When asked what she was doing and where she was going, she wanted to go to the bathroom. She was not able to get up on her own and required an EZ stand, which she had used that day just fine according to the staffing report. When they informed her they needed to use the mechanical lift, she did not want to use it. Staff E left the resident know per the facility's policy they were not allow to no use the mechanical lift for the transfer. The nurse, Staff B, was in the room with the resident's roommate at the time. Staff B told Staff E and F they have done what they could do. Staff E said she was like what are we supposed to do if she needs to go to the bathroom and Staff B said you done what you can. Staff B added if she is refusing to do anything, we can't do anything but document it. Staff E added the nurse had a whatever type of attitude that night. She felt the nurse should have been able to do more especially since the CNAs worked directly under the nurse. Staff E and F offered to change Resident #3's brief but she would not allow them to complete their check and changes, in fact she barely allowed them to get her back in bed. Staff E stated this was not the first time the resident has had behaviors like this but they were usually able to deescalate the situation. On 5/16/2025 at 11:20 AM the Director of Nursing (DON) was asked what interventions the CNAs should have attempted with Resident #3 when she refused assistance to the bathroom. She indicated she felt approach was a big deal. They could have come back and approached the situation, or the nurse could have helped. If she allowed it, they could have assisted with cares in bed. If she refused that, the nurse should have been notified. They could have called her family as sometimes family can offer some assistance. The DON was asked what the nurse could have done to help the CNAs with their unsuccessful attempts to assist the resident. She stated the nurse could have helped the resident or asked the CNAs to leave the room. She could have asked the CNAs to leave for a bit and come back to approach the task differently. The resident was mad at the CNAs so she may not have been upset with the nurse. She could have gone in there to see if Resident #3 would have allowed her to help. The facility provided a document titled Problematic Behavior Management with a revision date of September 2017 documented problematic behavior and psychiatric symptoms will be identified and managed appropriately. The staff will seek to identify pertinent non-pharmacological interventions to try to address behavior and psychiatric symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review the facility failed to ensure medications and supplies stored in the medication room and medication carts were stored and held within their expiration dates. The facility reported a census of 31 residents. Findings include: On [DATE] at 10:40 AM during a medication room check with Staff B Licensed Practical Nurse (LPN) present observed 12 unopened bottles of Aspirin 81 milligrams (mg), all with an expiration date of 4/2025. Staff B indicated she was under the impression the Director of Nursing (DON) overlooked the items in the medication room. The Regional Nurse Consultant was made aware of the expired Aspirin bottles. On [DATE] at 10:53 AM completed a check of the two medication carts with Staff C Certified Medication Aide (CMA) present. Noted one 3 milliliter (mL) empty syringe with an expiration date of [DATE] and one opened bottle of Aspirin 81 mg with an expiration date of 4/2025. The bottle was filled with tablets to the rim. Staff C was notified of the expired items before leaving the medication cart. On [DATE] at 3:40 PM Staff K Licensed Practical Nurse (LPN) denied having issues with expired items. If she does it's usually treatment stuff that they rarely use but she will toss it. On [DATE] at 4:23 PM the DON stated she tries to go through the medication room. She added the pharmacy goes through the medication room monthly and staff look at the medications and supplies as they are put away. Moving forward she will be the one looking at the expiration dates on the items. The facility provided a document titled Storage of Medications with a revision date of [DATE] indicated the facility stores all drugs and biologicals in a safe, secure and orderly manner.

Based on observations, clinical record review, resident council notes, grievances, staff and resident interviews, and facility policy review, the facility failed to ensure residents received baths twice a week or per their requested amount a week for 6 of 6 residents reviewed (Resident #2, #4, #5, #6, #7, and #8). The facility also failed to offer toileting assistance for 2 of 4 resident reviewed (Resident #5 and #8). The facility reported a census of 31 residents. Findings include: 1. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 3/21/2025, documented Resident #2 had severely impaired cognitive skills for daily decision making. The MDS documented she required partial/moderate assistance for toileting hygiene, lower body dressing, personal hygiene and toilet transferring. In the bathing section not applicable was documented. The following diagnoses were documented for Resident #2: dementia, hyperlipidemia, dementia, malnutrition, and depression. The Care Plan Focus Area Activities of Daily Living (ADLs), with an initiation date of 10/5/2023 documented she required moderate assistance of one staff for bathing. At times she does refuse. Review of Resident #2's shower/bath documentation from 2/1/2025 until 5/15/2025 revealed she was to receive a shower or bath on Mondays and Thursdays during the day shift. The documentation revealed the following: 2/3/2025-resident refused 2/10/2025-not applicable 2/13/2025-not applicable 2/16/2025-she received a bath 2/17/2025-she received a bath 2/24/2025-not applicable 2/27/2025-she received a bath The February bathing record revealed a bath was not documented as being offered from 2/3/2025 to 2/10/2025 and 2/17/2025 to 2/24/2025. The record also revealed she was not offered a bath after she refused or after not applicable was documented. 3/13/2025-resident refused 3/17/2025- she received a bath 3/24/2025-not applicable 3/25/2025 resident received a bath 3/27/2025-resident refused 3/31/2025-resident refused The March bathing record revealed a bath was not documented as being offered from 2/27/2025 to 3/13/2025, 3/17/2025 to 3/24/2025. The record also revealed she was not offered a bath after she refused or after not applicable was documented. 4/7/2025-not applicable 4/10/2025-she received a bath 4/14/2025-not applicable 4/17/2025-not applicable 4/24/2025- she received a bath 4/28/2025-resident refused 4/29/2025-she received a bath The April bathing record revealed a bath was not documented as being offered between 4/17/2025 to 4/24/2025. The record also revealed she was not offered a bath after she refused or after not applicable was documented, with the exception of when she received a bath on 4/29/2025. 5/1/2025-not applicable 5/8/2025-not applicable 5/10/2025-she received a bath 5/14/2025-she received a bath 5/15/2025-not applicable The May bathing record revealed a bath was not documented as being offered between 5/1/2025 to 5/8/2025. 2. According to the significant change MDS assessment tool with a reference date of 3/6/20205 Resident #4 had a BIMS score of 11. A BIMS score of 11 suggested moderate cognitive impairment. The MDS documented she was dependent on staff for toileting hygiene and personal hygiene. In the bathing section not applicable was documented. The following diagnoses were documented for Resident #4: debility, Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation, Alzheimer's, dementia, anxiety, and depression. The Care Plan Focus Area ADLs with initiation date of 10/9/2023 documented she required the assistance of 1 staff for bathing. The Care Plan documented she will refuse her baths multiple times in a row. She has been educated multiple times regarding the importance of good hygiene. She will state I don't care, just leave me alone. Record review revealed the resident was discharged from the facility on 3/16/2025. Review of Resident #4's bath/shower documentation from 2/1/2025 through her discharge date of 3/16/2025 revealed she was to receive a bath/shower on Wednesdays and Saturdays day shift. The documentation revealed the following: 2/1/2025-resident refused 2/8/2025-resident refused 2/12/2025-resident refused 2/15/2025-resident refused 2/19/2025-resident refused 2/22/2025-resident refused The February bathing record revealed a bath was not documented as being offered between 2/1/2025 to 2/8/2025 and 2/22/2025 to 2/28/2025. The record also revealed she was not offered a bath after she refused a bath. The resident did not receive a bath in February. 3/1/2025-resident refused 3/8/2025-resident refused 3/12/2025-resident refused The March bathing record revealed a bath was not documented as being offered between 3/1/2025 to 3/8/2025 and 3/12/2025 to her discharge date of 3/16/2025. The record also revealed she was not offered a bath after she refused a bath. The resident did not receive a bath in March. 3. According to the quarterly MDS assessment tool with a reference date of 5/9/2025 documented Resident #5 had a Brief Interview of BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented Resident #5 did not refuse evaluations or care during the 7-day review period. The MDS documented Resident #5 had no lower or upper extremity impairments and utilized a wheelchair. Resident #7 was dependent on staff to shower or bathe and upper body dressing. The MDS documented the following diagnoses: cerebrovascular disease, anemia, neurogenic bladder, obstructive uropathy, diabetes mellitus, aphasia, anxiety, depression, schizophrenia, morbid obesity, and stroke. The Care Plan Focus Area with an initiation date of 10/9/2023 documented he was dependent on one staff for bathing, upper body dressing and required substantial assistance of two staff for lower body dressing. Review of Resident #5 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Tuesdays and Fridays day shift. The documentation revealed the following: 2/14/2025-resident refused 2/16/2025-he received a bath 2/18/2025-he received a bath 2/21/2025-resident refused 2/25/2025-he received a bath The February bathing record revealed a bath was not documented as being offered from 2/1/2025 to 2/14/2025 and on 2/28/2025 his bath day. The record also revealed he was not offered a bath after he refused. 3/18/2025-resident refused 3/21/2025-not applicable 3/28/2025-he received a bath The March bathing record revealed a bath was not documented as being offered from 3/1/2025 to 3/18/2025, 3/21/2025 to 3/28/2025. The record also revealed he was not offered a bath after he refused a bath or after not applicable was documented. 4/8/2025-he received a bath 4/11/2025-not applicable 4/15/2025-he received a bath 4/29/2025-not applicable The April bathing record reviewed a bath was not documented as being offered between 4/1/2025 to 4/8/2025, 4/15/2025 to 4/29/2025. The record also revealed he was not offered a bath after he refused a bath or after not applicable was documented. 5/2/2025-not applicable 5/7/2025-he received a bath The May bathing record reviewed a bath was not documented as being offered between on 5/6/2025 and from 5/7/2025 to 5/15/2025. The record also revealed he was not offered a bath after not applicable was documented. On 5/15/2025 at 10:37 AM Resident #5 was lying in bed. His finger nails were long, his nails were passed his fingertips. Some of his finger nails were dirty with brown/black debris in his nail beds. When asked how often he received a bath he indicated once a month. He added his last bath was this previous Friday. This was not his choice as he preferred to receive a bath once a week. Resident #5 stated he would like his bath more often. When asked if the facility trims his fingernails he indicated they are supposed to trim them but the podiatrist will trim his toe nails every 3 months. Resident #5 added he will tell staff when his nails need to be trimmed. He stated when they are short staffed he will not get his bath. He added that if they don't have both of the slings they use for his bath cleaned they will not bathe him. When they bathe him they leave one lift under him. After his bath is done, they will put a clean and dry sling under him to get him dressed and ready. If that second sling is not available then he will not get a bath. He added when they are short staffed call lights can take 10 minutes to 1 hour, but not certain how often has happened. At night it seems to be bad. He uses a bedpan to have a bowel movement and when a he has to wait up to an hour for them to answer his call light, he will have an accident. When this happens, Resident #5 stated this makes him feel uncomfortable. Once staff come to his room and notice he had an accident they will ask why he didn't say something. He would tell them he had his call light on for help. Response time all depends on who is working. At 11:09 AM Staff I Certified Nursing Assistant, Staff J non-Certified Nursing Assistant (NA), and Staff B Licensed Practical Nurse (LPN) assisted Resident #5 with getting dressed and transferred to this wheelchair. When Staff I and Staff J removed his sheets and provided cares a strong odor was present. 4. According to the quarterly MDS assessment tool with a reference date of 3/7/2025, Resident #6 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. In the bathing section not applicable was documented. The following diagnoses were documented for Resident #6: heart failure, aphasia, stroke, seizure disorder, depression, schizophrenia, and atrial fibrillation. The Care Plan Focus Area titled ADL's with an initiation date of 5/17/2024, documented Resident #6 was dependent on one staff member for bathing. Review of Resident #6 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Wednesdays and Saturdays. The documentation revealed the following: 2/8/2025-he received a bath 2/12/2025-he received a bath 2/15/2025-he received a bath 2/22/2025-he received a bath 2/27/2025-he received a bath The February bathing record revealed a bath was not documented as being offered from 2/1/2025-2/8/2025 and 2/15/2025 to 2/22/2025. 3/1/2025-resident refused 3/8/2025-resident refused 3/12/2025-he received a bath 3/19/2025-he received a bath 3/27/2025-he received a bath The March bathing record revealed a bath was not documented as being offered from 3/1/2025 to 3/8/2025, 3/12/2025 to 3/19/2025, and 3/19/2025 to 3/27/2025. The record also revealed he was not offered a bath after he refused a bath. 4/2/2025-he received a bath 4/9/2025-he received a bath 4/24/2025-he received a bath 4/26/2025-he received a bath The April bathing record reviewed a bath was not documented as being offered between 4/2/2025 to 4/9/2025, 4/9/2025 to 4/26/2025 and 4/26/2025 to 4/30/25. 5/1/2025-he received a bath 5/7/2025-not applicable 5/10/2025-he received a bath 5/14/2025-he received a bath The May bathing record reviewed a bath was not documented as being offered between on 5/1/2025 and from 5/7/2025 to 5/15/2025. The record also revealed he was not offered a bath after not applicable was documented. 5. According to the quarterly MDS assessment tool with a reference date of 3/14/2025 documented Resident #7 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented not applicable in the shower/bathe self-portion of the assessment. The resident was dependent on staff for upper and lower body dressing. The following diagnoses were listed for Resident #7: right ankle contracture, malnutrition, and depression. The Care Plan Focus Area with an initiation date of 10/11/2023 documented Resident #7 required moderate assistance of one staff for bathing. Review of Resident #7 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed she was to receive a bath/shower on Wednesdays and Saturdays day shift. The documentation revealed the following: 2/9/2025-resident received a bath 2/12/2025-resident received a bath 2/19/2025-resident received a bath 2/22/2025-resident received a bath 2/26/2025-resident received a bath The February bathing record revealed a bath was not documented as being offered from 2/1/2025 to 2/9/2025 and 2/12/2025 to 2/19/2025. 3/1/2025-resident refused 3/8/2025-resident refused 3/19/2025-resident received a bath 3/22/2025-resident received a bath 3/26/2025-resident received a bath 3/29/2025-resident received a bath The March bathing record revealed a bath was not documented as being offered from 3/1/2025 to 3/8/2025, 3/8/2025 to 3/19/2025. The record also revealed he was not offered a bath after she refused a bath. 4/9/2025-resident received a bath 4/12/2025-not applicable 4/25/2025-resident refused The April bathing record reviewed a bath was not documented as being offered between 4/1/2025 to 4/9/2025, 4/12/2025 to 4/25/2025, and 4/25/2025 to 4/30/2025. The record also revealed she was not offered a bath after he refused a bath or after not applicable was documented. 5/1/2025-resident refused 5/7/2025-not applicable 5/8/2025-resident received a bath 5/10/2025-resident refused 5/14/2025-resident refused The May bathing record reviewed a bath was not documented as being offered between on 5/1/2025 to 5/7/2025. The record also revealed she was not offered a bath after not applicable was documented. On 5/14/2025 at 11:04 AM observed the resident lying in bed, resting. Resident #7 indicated she is supposed to get a bath on Wednesdays and Saturdays but lately she has been getting a bath once a week. She has not received a bath yet today. She would preferred to be offered a bath between 10:00 AM and 6:00 PM; she does not like to have a bath earlier than 10:00 AM. She stated there was one month where she did not receive a bath for 3 weeks and she shared that was disappointing to her. She denied being offered wash clothes to freshen up when this happened. She would like to have more baths. 6. According to the quarterly MDS assessment tool with a reference date of 4/11/2025, Resident #8 had a BIMS score of 15. A BIMS of 15 suggested no cognitive impairment. The MDS documented he had an impairment on one side of his lower extremity and utilized a wheelchair. Resident #8 required partial/moderate assistance with upper body dressing, was dependent of staff for lower body dressing and required substantial/maximal assistance with personal hygiene. The MDS documented a toilet transfer was not attempted due to his medical condition. Resident #8 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS documented the following diagnoses for the resident: diabetes mellitus, anemia, depression, weakness, insomnia, and left below the knee amputation. The Care Plan Focus Area with an initiation date of 1/8/2025 documented he required substantial assistance of one staff for bathing and moderate assistance of one staff for upper and lower body dressing. Review of Resident #8 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Mondays and Thursdays. The documentation revealed the following: 2/3/2025-received a bath 2/10/2025-not applicable 2/13/2025-not applicable 2/17/2025-received a bath 2/24/2025-not applicable 2/27/2025--resident refused The February bathing record revealed a bath was not documented as being offered from 2/3/2025 to 2/10/2025 and 2/17/2025 to 2/24/2025. The record also revealed he was not offered a bath after he refused and not offered a bath after not applicable was documented. 3/13/2025-resident refused 3/24/2025-not applicable 3/27/2025--resident refused 3/31/2025-not applicable The March bathing record revealed a bath was not documented as being offered from 3/1/2025 to 3/13/2025 and 3/13/2025 to 3/24/2025. The record also revealed he was not offered a bath after he refused a bath or after not applicable was documented. Resident #8 did not receive a bath in March. 4/7/2025-not applicable 4/10/2025-resident refused 4/14/2025-received a bath 4/17/2025-not applicable 4/28/2025-received a bath The April bathing record reviewed a bath was not documented as being offered between 4/1/2025 to 4/7/2025, 4/17/2025 to 4/28/2025. The record also revealed he was not offered a bath after he refused a bath or after not applicable was documented. 5/1/2025-resident refused 5/8/2025-not applicable The May bathing record reviewed a bath was not documented as being offered between on 5/1/2025 to 5/8/2025 and from 5/8/2025 to 5/15/2025. The record also revealed he was not offered a bath after not applicable was documented. The resident had not received a bath in the first 15 days of May. On 5/14/2025 at 11:28 AM observed Resident #8 sitting in his wheelchair in his room, playing a game on his phone. He stated he is supposed to get a bath two times a week but at times he will only get one a week for a month. He required a mechanical lift to a chair, then uses a slide board to get in the shower chair. Once staff realize the process they will run off and he will not hear back from them on why he did not receive a bath. He indicated there are two staff members that will give him his bath. If they don't have enough staff members they will skip over his bath. Resident #8 stated he has not had a shower in two weeks. Resident #8 stated the wait time for help depends on how many staff members are working. He has had to wait 45 minutes during the day shift when the have two CNAs on the floor. Resident #8 stated he has issues with his bowels and at times he can't hold it while waiting for help on the bed pan. He has had a lot of accidents, more than it should happen. Some of his accidents happen because no CNAs come in to help. This happened at night; he would push his call light, but would fall asleep waiting for someone to come. When he wakes up, he already had an accident and his call light was off. They would come in and shut if off because he was sleeping. Review of the Resident Council Notes revealed the following: -During a meeting dated 2/6/2025 staff documented concerns on showers. -During a meeting dated 2/19/2025 staff documented concerns on showers. -During a meeting dated 4/2/2025 staff documented trim nails. Review of Grievances filed revealed the following: -Resident #11 filled out the form dated 2/13/25 stating she needs more baths. Family member questioned why are they not getting done, residents need care first. -Resident #12 filed out the form dated 2/13/25 stating she does not get a bath when she is supposed to. On 5/13/2025 at 1:19 PM Staff I Certified Nursing Assistant (CNA) stated they need more staff here, staffing can be difficult at times. When asked if baths are getting done, she stated if they have enough people they will get done. They do have an extra staff member that will come in to give baths but when she comes in varies. If they have three CNAs they can do baths but if it's less than that on the morning shift, they do not get done. She indicated having three CNAs on the morning shift happens maybe once a week. Staff I stated when she comes in for her 6:00 AM -2:00 PM shift after Staff N has finished her overnight shift, she finds residents soaked in bed. She has noticed this happens more when there is only one CNA and one nurse on the overnight shift. On 5/13/2025 at 3:40 PM Staff K Licensed Practical Nurse (LPN) laughed when asked how staffing was at the facility. She added when they hire people they do not last long. When asked when they are short staff are baths getting done, she stated that is iffy. On 5/14/2025 at 9:54 AM the Housekeeping Supervisor and Staff M Laundry Aide stated they have noticed residents mainly on the 200 hall to be soaked in bed in the mornings after the night shift has left. They stated it happens a lot with Resident #2 and at times Resident #6. On 5/14/2025 at 12:53 PM Staff L Certified Medication Aide (CMA) stated staffing is good for the most part. When asked if there was enough staff to get their tasks done every day, she stated it depended on the day. She added baths are hard to do but will pick it up on the next shift but sometimes they get missed. She has come into work a few times to residents soaked in bed. She worked the 2:00 PM-10:00 PM shift. On 5/16/2025 at 9:02 AM Staff D CNA stated they are provided weekly bath sheet that is kept under a clipboard in the tub room. Once they are completed and documented on the sheet, they go to the Director of Nursing. CNAs that completed the bath/shower will document in the residents' Electronic Health Record (EHR). When asked why staff would document non-applicable (NA) on a resident's bath day, she stated she would assume the bath was not done. She added they have been told to document NA when they don't have staff to complete the baths or if they were not done, then they would do them on the next shift. They have been told not to leave the bath day blank, something has to be documented. When a bath is given on a non-bath day, they can add an as needed (PRN) bath so it's documented that one was completed. If a resident refuses a bath Staff D stated the CNA attempting the bath is to go back after the bath three separate times. If they are still unsuccessful, they have to tell the nurse so they can offer the bath for the resident and then document their attempts and refusals. Staff D stated baths getting done is dependent on the number of staff working. If they have two staff on the morning shift, they will look to see who is working the next shift and if it's more than two staff members, they will pass the baths onto the next shift. They have a staff member that has come in to complete baths. Staff D stated she has spoken to the DON about coming in after the overnight shift to residents being soaked in bed. She added recently, it has gotten better. Staff D indicated it happened a lot when Staff N was working. On 5/16/2025 at 10:42 AM Staff B LPN stated the CNAs will ask the resident if they want a bath. If they refuse after being offered a bath a couple of times, they will come to her, then she will try to talk with them about taking a bath. If the resident continues to refuse, she will chart it. She will chart a progress note in the resident's Electronic Health Record (EHR). They will relay the information to the next shift to see if the resident will allow the bath to be completed. If not, they will attempt the following day. On 5/16/2025 at 11:20 AM the Director of Nursing (DON) stated the CNAs will have a bathing schedule that she puts in a book on Monday mornings. The staff will highlight the resident's name if the bath was completed. If the name is not highlighted the bath was either refused or not completed. If the bath was refused, she would like staff to notify the nurse so they can intervene, see if they would like it completed later. If the bath is still not completed, it needs to be charted why it was not completed. They can leave the list in the bath house, so the staff coming in the next day can see which baths were not done from the previous shift. They will start with completing those baths first before moving to the baths scheduled that day. When asked what happens when a resident refuses a bath she indicated staff are to notify the nurse, the nurse can attempt to assist with getting the bath done. If the bath continues to be refused they are to notify management or see if another CNA can assist. If the resident refuses three times, the nurse will need to document why and reason they do not want to take a bath, in a progress note. The DON stated staff would document NA in the bathing task if the resident is not in the building, did not have the bath done in the morning shift. Will chart NA on the bath day then ask the evening shift to complete the bath. If they are successful they can chart the bath in an as needed (PRN) section of their chart. These PRN baths would be on the documents provided to the surveyor. Staff could also chart NA if they did not have a bath aide that day. When asked how the staffing was in her facility, she stated it could be better, they need more staff but some days they have a good amount of staff on duty. When they don't have adequate staff, baths do get pushed back a day or two. When asked what staff are to do if a resident falls back asleep after they activate their call light, she stated they should go in the resident's room, ask if they need anything, wake them up to find out. The facility provided a document titled Bath, Shower/Tub with a revision date of February 2018 documented the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath.

Based on observations, review of resident council notes, review of grievances and resident and staff interviews the facility failed to ensure they had adequate staff members to answer resident's call lights, provide baths, and assist with toileting needs. The facility reported a census of 31 residents. Findings Include: 1. According to the quarterly MDS assessment tool with a reference date of 4/11/2025, Resident #8 had a BIMS score of 15. A BIMS of 15 suggested no cognitive impairment. The MDS documented he had an impairment on one side of his lower extremity and utilized a wheelchair. Resident #8 required partial/moderate assistance with upper body dressing, was dependent of staff for lower body dressing and required substantial/maximal assistance with personal hygiene. The MDS documented a toilet transfer was not attempted due to his medical condition. Resident #8 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS documented the following diagnoses for the resident: diabetes mellitus, anemia, depression, weakness, insomnia, and left below the knee amputation. The Care Plan Focus Area with an initiation date of 1/8/2025 documented he required substantial assistance of one staff for bathing and moderate assistance of one staff for upper and lower body dressing. On 5/14/2025 at 11:28 AM Resident #8 was sitting in his wheelchair in his room, playing a game on his phone. He stated he is supposed to get a bath two times a weeks but at this time he is only getting one a week for a month. He required a mechanical lift to a chair, then uses a slide board to get in the shower chair. Once staff realize the process they will run off and will not hear back from them on why he did not receive a bath. He indicated there are two staff members that will give him his bath. If they don't have enough staff members they will skip over his bath. Resident #8 stated he has not had a shower in two weeks. Resident #8 stated the wait time for help depends on how many staff members are working. He has had to wait 45 minutes during the day shift when they have two CNAs on the floor. Resident #8 stated he has issues with his bowels and at times he can't hold it while waiting for help on the bed pan. He has had a lot of accidents, more that it should happen. Some of his accidents happen because no CNAs come in to help. This happened at night; he would push his call light, but would fall asleep waiting for someone to come. When he wakes up, he already had an accident and his call light was off. They would come in and shut if off because he was sleeping. 2. According to the quarterly MDS assessment tool with a reference date of 5/9/2025 documented Resident #5 had a Brief Interview of BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented Resident #5 did not refuse evaluations or care during the 7-day review period. The MDS documented Resident #5 had no lower or upper extremity impairments and utilized a wheelchair. Resident #7 was dependent on staff to shower or bathe and upper body dressing. The MDS documented the following diagnoses: cerebrovascular disease, anemia, neurogenic bladder, obstructive uropathy, diabetes mellitus, aphasia, anxiety, depression, schizophrenia, morbid obesity, and stroke. The Care Plan Focus Area with an initiation date of 10/9/2023 documented he was dependent on one staff for bathing, upper body dressing and required substantial assistance of two staff for lower body dressing. On 5/15/2025 at 10:37 AM Resident #5 was lying in bed. His finger nails were long, the nails were passed his fingertips. Some of his finger nails were dirty with brown/black debris in his nail beds. When asked how often he received a bath he indicated once a month. He added his last bath was this previous Friday. This was not his choice as he preferred to receive a bath once a week. Resident #5 stated he would like his bath more often. When asked if the facility trims his fingernails he indicated they are supposed to trim them but the podiatrist will trim his toe nails every 3 months. Resident #5 added he will tell staff when his nails need to be trimmed. He stated when they are short staffed he will not get his bath. He added that if they don't have both of the slings they use for his bath cleaned they will not bath him. When they bathe him they leave one lift under him. After his bath is done, they will put a clean and dry sling under him to get him dressed and ready. If that second sling is not available then he will not get a bath. He added when they are short staffed call lights can take 10 minutes to 1 hour, but not certain how often has happened. At night it seems to be bad. He uses a bedpan to have a bowel movement and when a he has to wait up to an hour for them to answer his call light, he will have an accident. When this happens, Resident #5 stated this makes him feel uncomfortable. Once staff come to his room and notice he had an accident they will ask why he didn't say something. He would tell them he had his call light on for help. Response time all depends on who is working. At 11:09 AM observed Staff I Certified Nursing Assistant, Staff J non-Certified Nursing Assistant (NA), and Staff B Licensed Practical Nurse (LPN) assist Resident #5 with getting dressed and transferred to his wheelchair. When Staff I and Staff J removed his sheets and provided cares a strong odor was present. 3. Record review revealed the following Progress Note for Resident #5: -On 2/10/2025 at 1:30 PM activities staff member went in to the resident's room and begged him to come to an activity; he would not get up and come down. I let him know that we have the accurate number of staff to get him up; he still declined. Review of the Resident Council Notes revealed the following: -During a meeting dated 2/6/2025 staff documented concerns on showers. -During a meeting dated 2/19/2025 staff documented concerns on showers. -During a meeting dated 3/5/2025 staff documented concerns about needed more Certified Nursing Assistants (CNA). -During a meeting dated 4/2/2025 staff documented trim nails. Review of Grievances filed revealed the following: -Resident Council on 2/6/2026-call light times, it takes them too long to get to us. -Resident #11 filled out the form stating she needs more baths. Family member questioned why are they not getting done, residents need care first. Filled out on 2/13/2025. -Resident #12 filed out the form stating she does not get a bath when she is supposed to. Filled out on 2/13/2025. On 5/13/2025 at 1:19 PM Staff I Certified Nursing Assistant (CNA) stated they need more staff here, staffing can be difficult at times. When asked if baths are getting done, she stated if they have enough people they will get done. They do have an extra staff member that will come in to give baths but when she comes in it varies. If they have three CNAs they can do baths but if it's less than that on the morning shift, they do not get done. She indicated having three CNAs on the morning shift happens maybe once a week. Staff I stated when she comes in for her 6:00 AM -2:00 PM shift after Staff N has finished her overnight shift, she finds residents soaked in bed. She has noticed this happens more when there is only one CNA and one nurse on the overnight shift. On 5/13/2025 at 3:40 PM Staff K Licensed Practical Nurse (LPN) laughed when asked how staffing was at the facility. She added when they hire people they do not last long. When asked when they are short staff are baths getting done, she stated that is iffy. On 5/14/2025 at 9:54 AM the Housekeeping Supervisor and Staff M Laundry Aide stated they have noticed residents mainly on the 200 hall to be soaked in bed in the mornings after the night shift has left. They stated it happens a lot with Resident #2 and at times Resident #6. On 5/14/2025 at 12:53 PM Staff L Certified Medication Aide (CMA) stated staffing is good for the most part. When asked if there was enough staff to get their tasks done every day, she stated it depended on the day. She added baths are hard to do but will pick it up on the next stuff but sometimes they get missed. She has come into work a few times to residents soaked in bed. She worked the 2:00 PM-10:00 PM shift. On 5/16/2025 at 9:02 AM Staff D CNA stated they are provided weekly bath sheet that is kept under a clipboard in the tub room. Once they are completed and documented on the sheet, they go to the Director of Nursing. CNAs that completed the bath/shower will document in the residents' Electronic Health Record (EHR). When asked why staff would document non-applicable (NA) on a resident's bath day, she stated she would assume the bath was not done. She added they have been told to document NA when they don't have staff to complete the baths or if they were not done, then they would do them on the next shift. They have been told not to leave the bath day blank, something has to be documented. When a bath is given on a non-bath day, they can add an as needed (PRN) bath so it's documented that one was completed. If a resident refuses a bath Staff D stated the CNA attempting the bath is to go back and after the bath three separate times. If they are still unsuccessful, they have to tell the nurse so they can offer the bath for the resident and then document their attempts and refusals. Staff D stated baths getting done is dependent on the number of staff working. If they have two staff on the morning shift, they will look to see who is working the next shift and if it's more than two staff members, they will pass the baths on to the next shift. They have a staff member that has come in to complete baths. Staff D stated she has spoken to the DON about coming in after the overnight shift to residents being soaked in bed. She added recently, it has gotten better. Staff D indicated it happened a lot when Staff N was working. On 5/16/2025 at 10:42 AM Staff B LPN stated the CNAs will ask the resident if they want a bath. If they refuse after being offered a bath a couple of times, they will come to her, then she will try to talk with them about taking a bath. If the resident continues to refuse, she will chart it. She will chart a progress note in the resident's Electronic Health Record (EHR). They will rely the information to the next shift to see if the resident will allow the bath to be completed. If not, they will attempt the following day. On 5/16/2025 at 11:20 AM the Director of Nursing (DON) stated the CNAs will have a bathing schedule that she puts in a book on Monday mornings. The staff will highlight the resident's name if the bath was completed. If the name is not highlighted the bath was either refused or not completed. If the bath was refused, would like staff to notify the nurse so they can intervene, see if they would like it completed later. If the bath is still not completed, it needs to be charted why it was not completed. They can leave the list in the bath house, so the staff coming in the next day can see which baths were not done from the previous shift. They will start with completing those baths first before moving to the baths scheduled that day. When asked what happens when a resident refuses a bath she indicated staff are to notify the nurse, the nurse can attempt to assist with getting the bath done. If the bath continues to be refused notify management or see if another CNA can assist. If the resident refuses three times, the nurse will need to document why and reason they do not want to take a bath, in a progress note. The DON stated staff would document NA in the bathing task if the resident is not in the building, did not have the bath done in the morning shift. Will chart NA on the bath day then ask the evening shift to complete the bath. If they are successful they can chart the bath in an as needed (PRN) section of their chart. These PRN baths would be on the documents provided to the surveyor. Staff could also chart NA if they did not have a bath aide that day. When asked how the staffing was in her facility, she stated it could be better, they need more staff but some days they have a good amount of staff on duty. When they don't have adequate staff, baths do get pushed to back a day or two. When asked what staff are to do if a resident falls back asleep after they activate their call light, she stated they should go in the resident's room, ask if they need anything, wake them up to find out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews and facility policy review the facility failed to maintain complete and accurate records for 7 of 7 residents reviewed (Resident #2, #3, #4, #5, #6, #7, #8). The facility reported a census of 31 residents. Findings include: 1. Review of Resident #2's shower/bath documentation from 2/1/2025 until 5/15/2025 revealed she was to receive a shower or bath on Mondays and Thursdays during the day shift. The documentation revealed the following: 2/3/2025-resident refused 2/10/2025-not applicable 2/13/2025-not applicable 2/24/2025-not applicable 3/13/2025-resident refused 3/24/2025-not applicable 3/27/2025-resident refused 3/31/2025-resident refused 4/7/2025-not applicable 4/14/2025-not applicable 4/17/2025-not applicable 4/28/2025-resident refused 5/1/2025-not applicable 5/8/2025-not applicable 5/15/2025-not applicable Record review revealed there were only two notes documented about her bathing refusals on 4/8/2025 and 4/29/2025. The progress notes lacked documentation about other bathing refusal and the reason for not applicable being documented. Review of Resident #4's bath/shower documentation from 2/1/2025 through her discharge date of 3/16/2025 revealed she was to receive a bath/shower on Wednesdays and Saturdays day shift. The documentation revealed the following: 2/1/2025-resident refused 2/8/2025-resident refused 2/12/2025-resident refused 2/15/2025-resident refused 2/19/2025-resident refused 2/22/2025-resident refused 3/1/2025-resident refused 3/8/2025-resident refused 3/12/2025-resident refused Record review revealed there was only one not documenting her bath refusals on 2/9/2025. The progress notes lacked documentation about other bathing refusals. Review of Resident #5 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Tuesdays and Fridays day shift. The documentation revealed the following: 2/14/2025-resident refused 2/16/2025-he received a bath 2/18/2025-he received a bath 2/21/2025-resident refused 2/25/2025-he received a bath 3/18/2025-resident refused 3/21/2025-not applicable 4/11/2025-not applicable 4/29/2025-not applicable 5/2/2025-not applicable Record review of Resident #5's Progress Notes from 2/1/2025 through 5/15/2025 revealed it lacked documentation of bath refusals and reason for not applicable documentation. Review of Resident #6 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Wednesdays and Saturdays. The documentation revealed the following: 3/1/2025-resident refused 3/8/2025-resident refused 5/7/2025-not applicable Record review of Resident #6's Progress Notes from 2/1/2025 through 5/15/2025 revealed there were no notes about his bath refusals and why not applicable was documented. Review of Resident #7 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed she was to receive a bath/shower on Wednesdays and Saturdays day shift. The documentation revealed the following: 3/1/2025-resident refused 3/8/2025-resident refused 4/12/2025-not applicable 4/25/2025-resident refused 5/1/2025-resident refused 5/7/2025-not applicable 5/10/2025-resident refused 5/14/2025-resident refused Record review revealed there were no notes about his bath refusals and why not applicable was documented. Review of Resident #8 bath/shower documentation from 2/1/2025 through 5/15/2025 revealed he was to receive a bath/shower on Mondays and Thursdays. The documentation revealed the following: 2/10/2025-not applicable 2/13/2025-not applicable 2/24/2025-not applicable 2/27/2025--resident refused 3/13/2025-resident refused 3/24/2025-not applicable 3/27/2025--resident refused 3/31/2025-not applicable 4/7/2025-not applicable 4/10/2025-resident refused 4/17/2025-not applicable 5/1/2025-resident refused 5/8/2025-not applicable Record review revealed there was only one note documenting her bath refusals on 4/15/2025. The progress notes lacked documentation about other bathing refusals. The facility provided a document titled Bath, Shower/Tub with a revision date of February 2018 documented the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: -If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. Reporting: -Notify the supervisor if the resident refuses the shower/tub bath. 2. According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. The Care Plan Focus Area titled Activities of Daily Living (ADLs) with an initiated date of 11/25/2024 documented #3 required substantial assistance of two staff for transfers, ambulation, mobility and toileting. Review of Resident #3's visual/bedside [NAME] Report documented she required substantial assistance of two staff for toileting, transfers, mobility and ambulation. The Clinical Census revealed Resident #3 was discharged on 4/11/2025. Record review 2/1/2025 thru 2/26/2025 revealed it lacked Progress Notes related to her behaviors that were experienced on 2/23/2025 and 2/24/2025. On 5/13/2025 at 2:09 PM Staff B Licensed Practical Nurse (LPN) stated in February 2025 Staff E Certified Nursing Assistant (CNA) and Staff F CNA had attempted to assist Resident #3 to the restroom. When they advised her, they needed to get the EZ-Stand (mechanical lift to assist a resident to a sitting position) the resident refused to allow this. On 5/14/2025 at 3:55 PM Staff F stated Resident #3 had put her call light on, when her and Staff E went in her room she was attempting to get up and walk. They reminded her they needed to use the EZ stand to assist her to the bathroom. On 5/14/2025 at 2:10 PM Staff E stated in February Resident #3 was being combative and hanging off the side of her bed. She was not able to get up on her own, she required the use of an EZ stand for transfers. The previous shift indicated she was using the lift without issues. She tried to explain to the resident that it was their policy that if they required a lift for transfers, they could not, not use it. On 5/14/2025 at 4:23 PM the Director of Nursing (DON) stated Resident #3 required the use of an EZ stand for transfers or she may have been an assistance of two staff. She knew the resident did not like to use the EZ stand. During a follow-up interview on 5/16/2025 at 11:20 AM she stated the MDS Coordinator completes the main portion of the care plans. If she is not working, anyone can update them as needed. When asked what staff use when caring for the residents, she stated they can use the [NAME], can be pulled up in the resident's Electronic Health Record (EHR), and updated as necessary. Care plans should be updated as needed (PRN), checked quarterly and annually with care conferences. When she was informed that Resident #3's care plan did not reflect the use of an EZ stand for transfers, she stated oh. The DON stated it was not acceptable to update a care plan three months after the resident was noted to be using an EZ stand. On 5/16/2025 at 9:15 AM the DON was asked if they had any documentation about Resident #3 using an EZ Stand for transfers. She said she would look. On 5/16/2025 at 9:23 PM in an email correspondence with Staff A Administrator from a sister facility, sent an email that contain Resident #3's care plan. The care plan attached documented Resident #3 required substantial assistance of two staff and used the EZ stand as needed (PRN). Staff A was asked when the care plan had been updated and she stated it was added on 5/16/2025. On 5/13/2025 at 2:09 PM Staff B Licensed Practical Nurse (LPN) stated she was in with Resident #3's roommate when Staff E Certified Nursing Assistant (CNA) and Staff F attempted to assist her. The resident was sitting on the edge of the bed when the CNAs came in to the room. She let them know she wanted to go to the bathroom. When they informed her, they needed to get the mechanical lift, the resident refused to use it. The resident became upset when they would not transfer her without the mechanical lift. The CNAs asked Staff B if she was going to help them. She told them no because she was already upset. When the CNAs asked for help she knew Resident #3 was not going allow her to help her because she was already upset. She indicated Resident #3 can be naughty a times, will cuss and hit the staff members. When helping her it's all about the approach you take with her. During a follow up interview on 5/16/2025 at 10:42 AM Staff B stated when a resident has behaviors and she is aware of them, she is to chart them in a behavior note and intervene. When asked if she documented on the weekend in February when Resident #3 was refusing cares, she indicated she could not remember if she charted that weekend on her behaviors. She added, she does not believe she charted because she thought her behaviors were justified on her behalf. On 5/14/2025 at 3:55 PM Staff F stated when her and Staff E reminded Resident #3 they needed to use the mechanical lift to transfer her to the bathroom she started to tell them they did not know what they were doing and was dumb founded at the request. The resident began to call them incompetent and used curse words. When they told Staff B about Resident #3 refusing to use the mechanical lift, she went in and told the resident they needed to use the mechanical lift as it's their job, then she walked out. For the rest of the night Staff E and Staff F would go in and check on Resident #3 but she refused to be checked and changed even when she was soiled. Resident #3 was adamant about walking and not waiting to use the mechanical lift, then would not let them change her. Staff B knew everything that was going on with Resident #3 but she did not go in to see if Resident #3 would allow her to assist her. When asked where staff are to document these kinds of behaviors, she stated there is a behavior task that the CNAs can chart on. On 5/14/2025 at 2:10 PM Staff E stated Resident #3 was being combative and refused to allow her and Staff F to help her to the bathroom. When her and Staff F went in to the resident's room, she was hanging off the bed. When asked what she was doing and where she was going, she wanted to go to the bathroom. She was not able to get up on her own and required an EZ stand, which she had used that day just fine according to the staffing report. When they informed her they needed to use the mechanical lift, she did not want to use it. Staff E left the resident know per the facility's policy they were not allow to no use the mechanical lift for the transfer. The nurse, Staff B, was in the room with the resident's roommate at the time. Staff B told Staff E and F they have done what they could do. Staff E said she was like what are we supposed to do if she needs to go to the bathroom and Staff B said you done what you can. Staff B added if she is refusing to do anything, we can't do anything but document it. The rest of the night Resident #3 was very agitated and continue to not let them do anything such as checking and changing her, she was hanging on her wheelchair, not wanting to be in bed. Every time they would try to check and change her she would scratch and hit at staff. Staff E added the nurse had a whatever type of attitude that night. She felt the nurse should have been able to do more especially since the CNAs worked directly under the nurse. Staff E and F offered to change Resident #3's brief but she would not allow them to complete their check and changes, in fact she barely allowed them to get her back in bed. Staff E stated this was not the first time the resident has had behaviors like this but they were usually able to deescalate the situation. The CNAs can document in the tasks tab but they also told the nurse about more of her behaviors and assumed she would have done it too. On 5/16/2025 at 11:20 PM the DON indicated there is a supplemental tab for behaviors that nurses will use to document behaviors and in the progress notes. The CNAs can chart as well. She acknowledged the behaviors that Resident #3 had experienced on the weekend of 2/22/2025 should have been documented by the nurse and CNAs. When asked what should have been documented she stated what was offered, refusals, should have showed the refusal of any interventions that were attempted and what ever they did to assist the resident. The facility provided a document titled Problematic Behavior Management with a revision date of September 2017 documented problematic behavior and psychiatric symptoms will be identified and managed appropriately. The staff will seek to identify pertinent non-pharmacological interventions to try to address behavior and psychiatric symptoms. 3. Record review revealed Resident #5's Progress Notes lacked documentation of failed attempts to set up Telehealth appointments with his endocrinologist. On 5/15/2025 at 10:37 AM Resident #5 stated he was supposed to be seen by the Endocrinologist but have since tried to get him to be seen via Telehealth. He has since been on a Telehealth call with an Endocrinologist. The facility has told him they got a letter that the Endocrinologist has discontinued his services because he has not been to the clinic. The facility has also told him the clinic is refusing to assist with setting up the Telehealth appointments. On 5/16/2025 at 9:00 AM management was asked if they had any documentation for Resident #5's Telehealth meetings with his Endocrinologist. The MDS Coordinator stated she dropped the ball on the documentation part. She has been in contact with the clinic and given them various options to set up Telehealth meetings but they are not being receptive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, staff interviews and policy review the facility failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately assessing the use of an anticoagulant for 1 of 5 residents reviewed (Resident #6). The facility reported a census of 38 residents. Finding include: The MDS dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented use of an anticoagulant. Review of Resident #6's Care Plan revealed focus, goal, and interventions for an anticoagulant. On 1/27/25 at 3:09 PM Resident #6 stated the only blood thinner (anticoagulant) she took was baby Aspirin. Review of Resident #6's Medication Administration Record (MAR) documented a physician's order for Aspirin 81 mg one tablet by mouth daily for pain. On 1/29/25 at 9:41 AM Staff A, MDS coordinator stated that Aspirin 81 mg was identified as an anticoagulant on the MDS because Resident #6 had a history of blood clots. Staff A acknowledged Resident #6 was on Aspirin and the MDS reflected use of an anticoagulant because of the use of Aspirin. On 1/29/25 at 5:25 PM Staff B Regional Clinical Reimbursement Specialist stated her expectation was that Aspirin would be coded as an anti-platelet not an anticoagulant and that was per the RAI guidelines. Staff B stated a resident coded with Aspirin as an anticoagulant would be coded incorrectly on the MDS. Review of policy revised 11/19 titled, Resident Assessments documented the MDS Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews. All persons who have completed any portion of the MDS Resident Assessment Form must sign the document attesting to the accuracy of such information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview and policy review the facility failed to provide appropriate infection prevention practices when administering medications for 1 of 4 residents reviewed (Resident #15). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #15 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented Resident #15 had diagnoses of quadriplegia. On 1/28/25 at 9:21 AM an observation revealed Staff C, Registered Nurse (RN) completed hand hygiene, applied gloves and flushed Resident #15's enteral tube with 50 cc of water from pump prior to medication administration. Staff C administered medications to Resident #15 through the enteral tube. Gloves removed and hygiene completed. Gown was not donned by Staff C for medication administration for Resident #15. Review of Resident #15's Treatment Administration Record documented a physician's order for enhanced barrier precautions due to feeding tube every shift and a physician's order to administer all medications together ensuring enteral tube patency before and after medications are administered 4 times a day. On 1/30/25 at 11:29 AM Staff E, Director of Nursing (DON) stated the facility's expectation was appropriate Personal Protective Equipment (PPE) would have been worn during administration of medication through an enteral tube for any resident with an enteral tube placed. The DON acknowledge Resident #15 required use of an enteral tube for medication administration. The DON stated a gown should have been worn during administration of medication to Resident #15. Review of policy revised 3/28/24 titled, Enhanced Barrier Precautions documented the facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC. An order for EBP (in accordance with physician-approved standing orders) will be initiated for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. The facility will make gowns and gloves available immediately near or outside of the resident ' s room. Personal protective equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident ' s room. High-contact resident care activities include Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 7/11/24 and updated 7/12/22 revealed recent changes included, additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of multidrug-resistant organism (MDRO) colonization among residents in this setting. Expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status). Expanded MDROs for which EBP applies. Clarified that, in the majority of situations, EBP are to be continued for the duration of a resident's admission. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The MDS for Resident #37 dated 1/24/25 documented a BIMS score as 15 indicating no cognitive impairment. The MDS documented admission to the facility on 1/3/25. Electronic Health Record (EHR) titled Care plan for Resident #37 dated 1/3/25 directed staff of 1 to assist with transfers and to encourage resident to use call light for assistance. In an interview on 01/27/25 at 1:02 pm Resident #37 revealed she required staff assistance with transfers and when she pushed the call light, she had to wait for long periods of time. During a recent family visit, she needed assistance for a chair accommodation for her son but no one assisted her after she pushed the call light and her family didn't get a chance to sit down during the visit. 4. The MDS for Resident #21 dated 1/14/25 documented a BIMS score as 13 indicating no cognitive impairment. The MDS documented admission to the facility on 1/8/25. The MDS reflected total dependence with transfers, 2-person physical assistance with a mechanical lift. In an interview on 1/27/25 at 1:37 pm Resident #21 stated the staff didn't answer his call lights for long periods of time and about a week ago he waited over an hour while on a bedpan for staff to assist him. Based on clinical record review, resident interviews, observations, and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 16 resident reviewed (Resident #15, #20,#21 and #37). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #15 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS indicated Resident #15 was frequently incontinent of urine and frequently incontinent of bowel. The MDS indicated Resident #15 was dependent on staff for eating, oral hygiene, toileting, personal hygiene, transfers and rolling left to right. The MDS documented Resident #15 had diagnoses of quadriplegia and resided in room [ROOM NUMBER]. On 1/27/25 at 1:16 PM Resident #15 stated through his communication device call lights frequently take longer than 20 minutes to answer. Resident #15 stated through his communication device call lights take up to an hour to answer on overnight shift. Resident #15 stated through his communication device that he could see and read the clock and the time was 1:20. On 1/28/25 at 8:57 AM observation of call light on room [ROOM NUMBER] Resident #15's room turned on. On 1/28/25 at 9:14 AM a CNA entered the room and the light was answered and shut off. The CNA left the room and told Staff C that Resident #15 wanted to be covered up. On 1/28/25 at 3:28 PM Resident #15 acknowledged through his communication device the call light was on for longer than 15 minutes and was requesting to be covered up with the blanket. 2. The MDS dated [DATE] for Resident #20 documented a BIMS score of 14 indicating no cognitive impairment. The MDS documented Resident #20 had a diagnoses of Multiple Sclerosis. On 1/28/25 at 10:06 AM Resident #20 stated he turned on the call light at 8:10 AM and the call light was not answered until 8:30 AM. Resident #20 stated he had a clock and could read the clock. Resident #20 stated he does not face a wall that does not have a clock. Resident #20 stated his wheelchair has a clock built into it. Resident #20 stated frequently it takes longer than 30 minutes for staff to answer the call light. On 1/28/25 at 3:08 PM Staff D, Certified Nursing Assistant (CNA) stated when there were only 2 CNAs on the floor it was very difficult to answer call lights in a timely manner. Staff D stated a couple times a week call lights take longer than an hour to answer. Staff D stated that was usually related to staffing numbers. On 1/30/25 at 11:29 AM Staff E, Director of Nursing (DON) stated the facility's expectation was that call lights would be answered within 15 minutes of activation. The DON stated the facility had no policy related to answering call lights.

Based on clinical record review, resident interviews, staff interviews, and facility policy review the facility failed to speak in a dignified manner around residents and failed to speak to residents in a dignified manner to 3 of 4 (Resident #5, #6 and #8) residents reviewed. The facility reported a census of 30 residents. Findings include: 1. According to the annual Minimum Data Set (MDS) with a reference date of 5/22/24, Resident #5 had a Brief Interview of Mental Status (BIMS) score of 13. A BIMS score of 13 suggested no cognitive impairment. On 6/25/24 at 2:52 PM when Resident #5 was asked how Staff P Licensed Practical Nurse (LPN) was during medication pass and treatments she stated she is a b*tch. When asked to elaborate she stated last week she told her roommate to get up by herself but she only needed a little boost and would not help her. Staff P is just a bitter person. Resident #5 had asked Staff P to shut the over head light in her room, she told her no, she's passing pills, I am busy, I can't help you. Resident #5 stated she sees and hears how testy she gets with the CNAs and nurses. 2. According to the admission MDS with a reference date of 5/8/24, Resident #6 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. On 6/27/24 at 10:35 AM Resident #6 stated Staff P does not take care of him but he can hear her while she's at the nurse's station. His room is located next to the nurse's station. Resident #6 stated she is a rude and not a nice person. She will come to the nurse's station cussing about other residents, while there are residents present. She says the f word a lot and sh*t. He added she talks like this after she leaves a resident's room or helps them. She is just not a nice person. She sits at the computer at the nurse's station and makes rude comments about residents. 3. According to the quarterly MDS with a reference date of 3/6/24, Resident #8 had a BIMS score of 14. A BIMS score of 14 suggested no cognitive impairment. On 6/19/24 at 1:10 PM Resident #8 was lying in bed and used a communication board to communicate. One side of the board has simple phrases, the other side has individual numbers and letters. When the resident is asked a question, he points to the letters to spell out words, making sentences. When asked how staff are with him, he spelled out Staff P is not nice when speaking with him, she's not rough, just not nice. On 6/19/24 at 10:06 PM Staff I Certified Nursing Assistant (CNA) stated Staff P is not the best, to be perfectly honest, when asked how she is to work with. When asked to elaborate he stated every other work is f*ck or sh*t. She cusses and complains about the residents all the time. If the residents need something she will mutter under her breathe, she is just not his favorite nurse to work with. She does not appear happy when she's at work and does not really think she cares about the residents. She is always complaining about them. He has never witnessed her being mean or unkind to residents, just always speaking negatively about them. On 6/21/24 at 3:23 PM Staff E CNA stated that residents have told her that Staff P speaks rudely to them and does not help the residents when they need help. When asked which residents, she stated Resident #5 had reported some concerns today to her; all residents would probably talk about Staff P and how rude she is. Staff E indicated she reported to the Director of Nursing (DON) her concerns on how she speaks rudely to residents, her tone. The DON indicated it was unacceptable and she would speak with her. On 6/26/24 at 12:08 PM Staff H LPN stated Staff P is not a nice person when asked how she was as a co-worker. Staff P will sit at the nurse's station using not so nice words. Residents would be around the nurse's station within listening distance when she would talk like this. They always worked opposite halls so she never saw her being rude or mean to residents. She does know that Resident #5 will not allow Staff P to do her pressure ulcer treatments because how Staff P is. On 6/27/24 at 12:24 PM Staff P acknowledged it was possible for her to be at the nurse's station using that colorful language, and that it's common nowadays. She may cuss but is not bad mouthing the residents. On 7/1/24 at 2:01 PM the Director of Nursing (DON) stated staff are to treat residents with dignity, respect and kindness. The DON stated she's never had issues with Staff P on a respect side of things until they did the self-report. When she was informed of the resident and staff interviews that were completed about Staff P, she stated wow this is new for them. She acknowledged they have to hold staff accountable for being negative and try to create a positive environment at the facility. The facility provided a document titled Resident Rights with a revision date of 12/2016 with a policy statement that read, employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence b. be treated with respect, kindness and dignity The facility provided a documented titled Dignity with a revision date February 2021 with a policy statement that read, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility investigation review, staff interviews and facility policy review the facility failed to supervise 1 of 3 cognitively impaired residents (Resident #1). Staff were unaware Resident #1 had left the building on 5/26/24 at approximately 4:50 PM. Staff responded to an alarmed door, looked out the door window, disarmed the door alarm and went back to work. The staff member failed to go outside to visually check to see if a resident had left the building. The staff member assumed he saw another staff member in the vicinity. The staff member also failed to initiate a head count to ensure all residents were accounted for. The facility reported a census of 30 residents. Findings include: According to the annual Minimum Data Set (MDS) assessment tool with a reference date of 3/13/24 Resident #1 had a Brief Interview of Mental Status (BIMS) score of 7. A BIMS score of 7 suggested mild cognitive impairment. The MDS documented he did not exhibit wandering behavior during the review period. The MDS documented the following diagnoses: major depressive disorder, dementia and malnutrition. The Care Plan focus area with initiation date of 9/22/23 documented he ambulated with assistance of one staff; utilized a wheelchair for mobility. The Care Plan focus area with an initiation date of 2/23/24 documented he is an elopement risk related to he likes to go outside and forgets to tell staff that he is going outside. The care plan directed staff to alert other staff of his behavior as needed, staff are to approach him positively and, in a calm, accepting manner. Assigned staff to account for his whereabouts throughout the day and distract him from wanting to go outside unassisted by offering pleasant diversions, structured activities, food, conversation, TV shows and books that he prefers. Review of the Wandering Evaluations completed on 12/11/23, 12/19/23, 3/1/24, 5/26/24 revealed he was at low risk of wandering. A wandering evaluation completed on 6/11/24 documented he was at high risk for wandering. A Progress Note on 5/26/24 at 6:30 PM documented the nurse gave Resident #1 his PM medications at 4:40 PM and sent him to the dining room. He was visibly seen wheeling to the dining room at 4:45 PM. Staff H Licensed Practical Nurse (LPN) and Staff I Certified Nursing Assistant (CNA) were at the nurse's station when they heard the staff entrance door alarm go off at 4:50 PM. Staff I went to check the alarm and did not see anyone. At 4:57 PM Staff G Assistant Living (AL) Attendant brought Resident #1 back from Assisted Living. The resident had no injuries and he stated he had just wanted to go outside. Observation on 6/18/24 at 12:07 PM revealed the hall leading to the dining room had a set of fire doors on the left, half way to the dining room. On one of the doors was a sign posted to keep doors closed at ALL times. Once through the fire doors is a door with a box to the left for a code to be entered before opening the door. Once the egress door is engaged an alarm sounds for 15 seconds before the door opens and a louder alarm activates. Once outside there is a white vinyl fence to the left, a garage/building direction in front of the door. To the right is the Assisted Living (AL) building and the staff parking lot. There was a key pad to get back in to the building. Staff T Registered Nurse (RN) came to the door, silenced the alarm, then went outside, walked around and came back through the front entrance. Observation on 6/20/24 at 3:10 PM revealed it is 40 steps from the back entrance that Resident #1 exited the building to the AL building. Once inside the AL building there is a long hall straight ahead and the dining room to the right. If the resident self-propelled approximately 900 feet downhill he would have come to a four-lane highway and a heavily trafficked truck stop exits. The facility's investigative file included the following staff statements: a. Staff J CNA's statement: on Sunday May 26, 2024; I was in a resident's room, assisting the resident to the bathroom. I heard the alarm, was unable to leave the resident's room. I took the resident to the dining room for supper. The Dietary Manager told me that the AL Attendant had brought one of the nursing home residents back to us. I immediately reported this to the charge nurse on duty that day. b. Staff I statement: I believe I had just come out of another resident's room when the alarm went off, and I didn't see which door had opened but I assumed it was the employee entrance as that door alarm tends to set off randomly if another employee leaves and doesn't close it enough. I went to shut off the alarm as it had be going off for around 5-10 seconds, and when I got to the door I looked out the window to see what could have cause it, and I assumed who or what I had seen was Staff J going out for a smoke break, as it looked similar to her height and was around where she typically parks her car. So, I thought nothing of it until someone later came and told me the resident had been brought back from the assisted living side of the facility. That's about what happened, I don't remember much of what happened because it was a hectic time of day trying to get people up and to the dining room for dinner. The facility's investigative file included the following Missing Resident Exercises that had been completed: a. On 3/27/2034 at 1:30 PM staff utilized high risk wandered for missing resident drill by escorting/accompanying resident to the back patio. The dayroom/patio alarm was set off and waited for staff to respond. Staff responded and located the missing resident. The names of people participating did not include Staff I. b. On 4/13/2024 at 11:45 AM the Director of Nursing (DON) set off the door alarm at the end of hall 100 to make it appear a resident exited the building. Staff immediately responded and searched the perimeter and announced overhead. Two other staff went room to room to verify head count to ensure all residents were accounted for. The names of people participating did not include Staff I. On 6/18/24 at 5:36 PM Staff G stated while on the AL side of the building she got the steam table from the kitchen, plugged it in in the dining room and when she looked to the left she saw a male resident in a wheelchair coming towards her. She said to Resident #1 to come with her and she took him over to the nursing home side of the building. Once on the nursing home side, she told the staff members where he was but they did not seem to know he was out of the building. Staff G stated the fire doors leading down the hall to the dining room on the nursing home side of the building were open and he managed to get out the back-service door. She indicated once outside the door, the maintenance garage is right there, attached to the laundry area. In order to get back in to the nursing home, a code has to be keyed in then the door opens. To exit the building, you have to push the door handle for 15 seconds, as it alarms, then it opens with the alarm still sounding. The day she found Resident #1 he wore tennis shoes, dark parks and a light-colored t-shirt. Staff G stated it was not raining at that time. She assisted Resident #1 back to the nursing home at 4:57 PM that day. On 6/19/24 at 10:06 AM Staff I CNA stated the day Resident #1 left the building, the resident got out the back door that is typically served for employees and staff. He added that door has a tendency for the alarm to go off randomly if it's not shut all the way. Staff I went back there because that is what he thought had happened. He looked out the door window and thought he saw Staff J Certified Medication Aide (CMA) going out for a smoke break. He assumed she had stepped out for a smoke break. He was a little busy at that time and thought she had stepped out. Staff I admitted he did not know if he saw someone, thought he did and thought it was Staff J. When asked how he could have mistaken Staff J a female staff member walking for Resident #1, a male resident in a wheelchair. Staff I stated he was unsure how he thought that, he was just rushing. He rarely gets time to stop to think, he admitted he was not thinking at that time. Later someone had told him that Resident #1 had gotten out and went to the AL side of the building. He was not around when Resident #1 was returned back to the building, he was just informed of what had happened. He stated that's the [NAME] of it, did not think much of it at the time. When asked which door alarmed that day, he stated the door is behind the double doors that are normally shut but they were left open that day. When asked about what time the alarm went off, he stated about 4:30 PM because it was around the time they typically are getting people up for supper. Staff I stated he was coming out of another resident's room when the alarm first sounded. He went to the door and shut the alarm off. The alarm does not shut off unless you enter a code. The alarm sounds throughout the facility and theirs a board by the nurse's station that will show them what door is alarming. Another alarm sounds when the door is opened with out the code or after the 15 seconds passes. At the time Resident #1 left the building, he was an assistance of one to do a stand and pivot to his wheelchair. Once he is in his wheelchair, he is independent in the facility. Staff I was asked what the facility's procedure is when a door alarm sounds, he stated typically now we will go to the door, shut off the alarm, check outside to ensure no residents have eloped. If no one is out there, they will go about their business. Before that, there was not anything they did; just do a quick glance outside. He added head counts are done now. Staff I indicated he has worked at the facility for 3 years as of May this year. On 6/20/24 at 9:15 AM Staff K CMA stated that if she heard a door alarm sounding, she would go to the door that is sounding to see if a resident had walked out the door. If she was unable to see a resident, they would complete a head count. When a door alarm sounds, it could be heard throughout the facility and they have a panel that lights up with what door is sounding. On 6/20/24 at 9:26 AM Staff L non-CNA stated that when a door alarm goes off, she would go see where it's alarming then make sure no residents were outside. If she did not see a resident she would make sure all residents were accounted for by completing a head count. On 6/20/24 at 12:57 PM Staff H Licensed Practical Nurse (LPN) stated the day Resident #1 exited the building she gave him his medications at 4:45 PM as he was in bed. They assisted him up to his wheelchair and asked him to start heading to the dining room for dinner. At 4:50 PM Resident #1 by her in wheelchair as she was at her medication cart at the nurse's station. Shortly after she saw him the back-door alarm went out. She had Staff I to go check the door alarm; he did but he did not go outside to look to ensure no one was outside. At about 4:55 PM-4:56 PM the staff AL brought the resident back to the building. After that they ensured all residents were accounted for and initiated one to one supervision on Resident #1. When asked how long after the alarm sounded did Staff I respond, she stated not long. But he just went to the door, put the code in to silence the alarm, looked out the door window but did not physically go outside to see if anyone had gone out the door. When the AL staff member returned Resident #1, Staff H completed an assessment, while in his wheelchair, which revealed no injuries or abnormalities. When she asked the resident what he was doing, she stated he just wanted to go outside. He then ate his supper and went back to his room. When asked if Resident #1 would easily mistaken for a facility staff member, she did not think so. She added she did know of staff members going outside at that time. At the time Resident #1 left the building, the double doors located on the hall leading to the dining room were left open. There are signs on the doors that says to leave them shut. Staff H was asked what the facility's procedure is for when a door alarm sounds, she stated staff are to check the alarm and if you can't verify who went outside, one staff member goes outside to look for anyone that may have left and the other staff member completes a head count. The staff working will go down the halls to make sure all residents are accounted for. But Staff I did not say why he did not do that, that day. If a resident is found outside, staff are to bring the resident back in. Staff H indicated Resident #1 had no behaviors prior to him leaving the building that would indicated he wanted to leave. During a follow-up interview on 6/26/24 at 12:08 PM Staff H stated after she asked Staff I to check the sounding door alarm, she continued to pass medications at the nurse's station. When Staff I returned he said he did not see anyone, so she continued to pass her medications until Staff J let her know Staff G had returned Resident #1 from the AL side of the building. When asked if she initiated a head count after Staff I stated he did not see anyone, she denied starting a head count and added maybe she should have started one. On 6/20/24 at 1:15 PM the Nurse Consultant stated they were unable to find a policy or protocol for staff to follow if they are unable to visualize a resident outside the building after a door alarm has sounded. She has looked through their elopement/wandering policy for this. She acknowledged it is standard of practice to do a head count if staff cannot visualize that a resident has left the building. On 6/20/24 at 1:59 PM Staff J stated she was in a resident's room taking a resident to the bathroom when she heard the door alarm. She could not leave the resident she was with. She could not remember exactly what time but would say it was between 4:15 PM and 4:45 PM. When she was done assisting that resident, she took them to the dining room. The Dietary Manager told her an AL staff member had brought Resident #1 back from their side of the building. He had returned around the same time the alarm had sounded. When asked what staff are to do when they hear a door alarm sound they are to see where the alarm is coming from to see if anyone is outside. If she saw someone she would go get them and bring them back in if it was a resident. She would then let the nurse know. If she did not see anyone outside, she would report to her nurse and assume they would do a head count to ensure all residents were there, are safe and accounted for. At the time Resident #1 left the building he was in a wheelchair. On 6/21/24 at 10:33 AM Staff M CNA stated she was taught that if a door alarm was sounding and she was in the middle of assisting a resident, if that task could be stopped she would stop and go see where the alarm was sounding. She would silence the alarm and let the charge nurse know what was going on. She was never taught to go outside and check the surroundings. She added a head count should be completed immediately. On 6/21/24 at 12:34 PM Staff N CNA stated if she heard a door alarm sounding she would look at the board to see what door it was. She would go to the door, check outside to see if she could find anyone that may have left; staff or resident. If she did not see anyone then she would go back inside and do a head count to ensure all residents were accounted for. When asked if she saw a staff member outside what she would do, she stated she would ask if they just went outside. If they said yes, she would silence the alarm. On 6/21/24 at 1:05 PM Staff O CNA stated if an alarm was sounding, she would check the board to see what door it was. She would go to that door, open it to check to see if anyone was outside. If she did not see anyone, no resident in sight or no staff in sight, she would go inside and make sure all residents are accounted for. On 6/21/24 at 3:32 PM Staff E CNA would go check to see what door was alarming, then see if any resident was outside. She went go let the nurse know and do a head count. If she saw a staff member outside she would go speak with that staff member to make no residents were with them. Then she would turn the alarm off. On 6/25/24 at 10:13 AM the Director of Nursing (DON) stated she was not in the building the day Resident #1 eloped. It happened on a weekend. She received a call from Staff H charge nurse letting her know about an elopement with Resident #1. She was not sure on exact time, it was 4 something that afternoon. From the time the alarm went off and when returned, it was 7 minutes. After talking to all staff, she heard Staff I heard back service door going off and responded to it. Staff I looked out the door window but did not open the door. Staff I said he saw someone he thought was Staff J, the other aide working, who is shorter with short hair. Staff I reset alarm and went back to work. Shortly after, an AL staff member brought Resident #1 back to nursing home side. Apparently, the resident came in the AL building through the door facing the parking lot. Once through that door one could go straight down hall or to the right to the dining room. Resident #1 came through that door and went to the AL dining room, asked staff if they could help him back to his room. Staff then brought him back to the nursing home side. The DON reported they complete multiple elopement drills monthly, started to do them weekly and more. They complete the drills on all shifts and on the weekends. The DON stated the back-service doors are kept closed, with signage up. The day he went out, one was opened and one closed which was not uncommon. When she spoke with Resident #1, he told her he wanted to go outside for some sunshine. She indicated his daughter comes up and takes him outside to get some sun. Keeping them closed and signage does help keep people from trying to get out that way. While doing their drills they have staff initiate a head count to see who went out and who did not. When staff are not sure if a resident had left or not, they still must initiate a head count. Once Resident #1 was back at the facility they immediately placed him on one on one supervision, within line of sight when out of his room. They did that for 3 days to monitor him, talked with him to gauge how he was doing and what he was thinking, to monitor his patterns. Resident #1 did not go towards the doors or wander after that. The next day they did elopement drills on every shift, put out education to all staff. At time of the elopement he was not on increased supervision and had not tried to get out of the building before. Since his elopement there have been no changes in his mental status or need to want to go outside that day. When asked what Staff I should have done differently she stated she did one on one talk with him. He told her he answered the door alarm, and looked out the window. She told him when you respond to an alarm, and you cannot identify who went in or out, you have to initiate elopement protocol and do head count, you have to physically go outside and look. They need to have someone look on the premises, and get the charge nurse right away. Someone should alert all staff right away. Staff I acknowledged he messed up and should have gone outside. They have completed a lot of drills with back service doors. Those back service doors some employee just thinks oh it's an employee that set that alarm off, not a resident. The DON added staff need to take alarms seriously. When asked how he one could assume Resident #1 was Staff J when Resident #1 is a male, with gray/white hair, in a wheelchair and Staff J is an ambulatory female with dirty blonde, brown hair; she stated she said the same thing. [NAME] has dirty blonde brown hair and [NAME] in wheelchair how do you mix that up. On 6/25/24 at 10:40 AM the State's Climatologist reported on 5/26/24 at 4:50 PM at the facility location the temperature was 64-degree Fahrenheit, humidity was 88%, winds were out of the North at 6 miles per hour (mph) with wind guys up to 26 mph, overcast conditions, raining at the time. On 6/27/24 at 12:24 PM Staff P LPN stated if she heard a door alarm sounding she would go to that door, make sure no one was outside. She would come back in and do a head count to make sure everyone was where they were supposed to be. Review of Staff I's employee file revealed an Employee Acknowledgement Form-Emergency Preparedness was signed and dated by Staff I on 5/27/21. The form acknowledged that he understands the policy and procedures of the facility Fire Drill, Missing Resident Drill, and Severe Weather Drill. He acknowledged that the emergency preparedness binder is in the large copy room and is available to view at any time. The facility provided a policy titled Wandering and Elopements with a revision date of March 2019. The policy statement documented: the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The facility provided an Elopement Drill Procedure with an effective date of January 2022. This document sets forth the facility's procedure completing an Elopement Drill/Missing Resident Drill. Staff will be trained on procedures for elopements through quarterly drills. Procedure: 4. The ensure search process of the facility and grounds, from the time the resident is missing will be completed within thirty minutes. 5. If the search fails to locate the missing resident within thirty minutes from the time the resident is found to be missing, then the Administrator and/or designee places a mock telephone call to the community agency, Administration, the resident's representative and attending physician. Staff will provide the police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex and clothing, if known. The facility provided a document titled Elopement Prevention. The purpose of this document is to maintain resident safety and prevention of injury. Guidelines: 9. All staff will respond promptly to all door alarm activation. If immediate reason for the door alarm is not determined, all residents will be accounted for at this time. 11. Quarterly Elopement Drills are highly recommended. a. All staff are involved in elopement drills. b. Send a person out to hide where a resident might elope. c. Initiate the search.

Based on observations, resident and staff interviews and facility policy review the facility failed to properly dispose of room trays with left-over food in a timely manner. The facility reported a census of 30 residents. Findings include: On 6/20/24 at 11:17 AM Staff S Dietary Aide stated when she comes in after having the weekend off she will find dishes still in resident's room from who knows what meal since she was gone all weekend. On 6/23/24 at 5:53 PM observed on Resident #12 entry table a white plate with a slice of wheat bread on it, bowl with milk in it, biscuit, egg, sausage sandwich on the plate as well. Also observed two drinking glasses, 1 of the glass was ½ full of milk. When asked how long those dishes has been there she stated breakfast and lunch. This happens all the time on the weekends, when staff not picking up her dishes. She indicated she went to the dining room this evening for dinner. On 6/27/24 at 3:39 PM observed on Resident #7's bedside table a white plate on top of a plate cover. A set of silverware lying on top of the plate, an empty sour cream packet and a coffee mug on top of the plate. At 4:15 PM the dishes remained on her bedside table. At 4:45 PM the plate, silverware and coffee mug were not on her bedside table. On 7/1/24 at 2:01 PM the Director of Nursing (DON) indicated it's a shared effort when it comes to picking up room trays from resident's rooms; it can either be dietary or nursing staff. They are already looking at the policy a little further and will create an action plan for that. She added some residents will have their meals delivered to their rooms and eat off them for a while. Those trays will get picked up late or left in there. When asked when trays should be removed from resident rooms, she indicated it's at the discretion of the resident, when the meal is completed or when the resident is done eating. There's some gray area in the policy it stated 30 minutes to an hour after the meal is served. When asked what the facility's meals times are she stated breakfast is served at 7:30 AM, lunch is served at 11:45 AM, and supper is served at 5:00 PM. The facility provided a document titled Room Service, February 2016 edition. The policy statement read residents who are unable to come to the dining room or who desire to dine in their own room shall be provided with room service. Procedure: 6. Nursing and/or Dietary Services will be responsible for collecting soiled trays in the following manner: d. Collect soiled tray only after the resident has completed meal or indicates the same. 8. All soiled trays will be returned to the Dietary Services Department within an hour of completion of the tray.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and facility policy review the facility failed to ensure 2 of 2 residents' (Resident #6 and #7) vape pens were properly stored. The facility also failed to ensure 1 of 2 residents (Resident #7) used her vape pen outside in the designated smoking areas. The facility reported a census of 30 residents. Findings include: 1. Review of Resident #6's clinical record revealed no documentation related to him being able to smoke with or without supervision. On 6/18/24 at 11:45 AM observed three vape pens in Resident #6's room on his dresser. On 6/23/24 at 5:32 PM observed Resident #6 outside with staff. Staff were assisting Resident #6 with his vape pen. 2. Review of Resident #7's clinical record revealed no documentation related to her being able to smoke with or without supervision. Clinical record revealed Resident #7 was admitted to the facility on [DATE]. On 6/18/24 at 11:24 AM Staff D Registered Nurse (RN) stated she has been around vape pens before and knew that's what Resident #7 had in her room. Staff D acknowledged Resident #7 would use her vape pen in her room. She added residents like Resident #7 have told her the pens have THC in the pen. Staff D suggested talking with other nurses and Certified Nursing Assistance (CNAs) about this because a lot of staff knew about the vape pens. On 6/18/24 at 2:25 PM observed Resident #7 lying in bed watching television. She held a red vape pen throughout our conversation, and her room smelt fruity. The resident let me look at the vape pen; at the base of the pen, but the mouth piece is a compartment that contained what appeared to be an oily substance. On the side of the pen is a name Batch. Resident #7 was asked what the red vape pen was for, she stated it was prescribed to her to help with pain management. She indicated it helps her tolerate her sciatic nerve pain. Resident #7 was asked what was in the pen to help manage her pain, she indicated CBD (cannabidiol) and THC (tetrahydrocannabinol). She added a friend brings in the oil cartridge, he brings them in a paper sack. Resident #7 stated that's just so weird that people can bring this stuff out in public and that she is used to smoking it but not through a pen. She stated she is not used to smoking it in public or people bringing it in for her. Resident #7 stated she has a medical card to use it and has been using marijuana since she was [AGE] years old. She again stated it's weird to be smoking it in public like this. She indicated she has had the pen since she came to the facility and it really helps her. Throughout the interview the resident's eyes were glassy and would not maintain eye contact. On 6/20/24 at 1:59 PM Staff J CNA stated she knew Resident #7 had a vape pen in her hand a lot, so she was capable of using it herself. On 6/25/24 at 1:02 PM during a follow- up interview with Resident #7, she stated the Administrator and DON told her she could have her pen if she got in the mechanical lift, in her wheelchair and went outside off the facility's property. The resident indicated she is unable to do this because of the sores she has on her bottom. She had told them she also had two jars of THC gummies in her night stand. They removed those and her vape pen from her room when a police officer came to the facility. On 7/1/24 at 2:01 PM the DON stated if a resident wishes to smoke, they need to have a smoking evaluation completed. If a resident wished to utilize a vape pen, they would need to go outside with staff members to do so. When asked about Resident #7 and her vape pens, she indicated up until the other day she never went outside to smoke. The first month Resident #7 was in the facility, before the DON started, she had a doctor's appointment in the city. A couple of their CNAs assisted with getting the resident up and apparently Resident #7 took out her vape pen and took a hit off it. After Resident #7 left for her appointment they reported this to the Administrator and the resident was informed she could not vape in the building. The resident apologized and claimed she had gotten rid of the vape pen while at her appointment. The day before the survey started, the DON got a call in the middle of the night that Resident #7 had a THC vape pen and gummies in her room. Resident #7 was provided education about not being able to have those items in the facility. She handed the items over to management staff. The facility provided a document titled Smoking Policy-Residents with a revision date of 7/2017 and a policy statement that read the facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation 1. Upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. If allowed by the facility, smoking is only permitted in designated resident smoking areas, which are located outside of the building. Electronic cigarettes are not permitted inside the facility and in designated areas only. Otherwise, smoking is not allowed inside the facility under any circumstances. 7. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: a. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 8. The staff shall consult with the Attending Physician and the DON to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 12. Residents who have smoking privileges are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable lighters are permitted.

Based on observations, clinical record review, resident, family, and staff interviews, and facility policy review the facility failed to provide baths for 3 of 4 residents (Resident #5, #8 and #9) reviewed. The facility also failed to provide personal hygiene for 2 of 4 residents (Resident #8 and #11) reviewed. The facility reported a census of 30 residents. Findings include: 1. According to the annual Minimum Data Set (MDS) assessment tool with a reference date of 5/22/24 Resident #5 had a Brief Interview of Mental Status (BIMS) score of 13. A BIMS score of 13 suggested no cognitive impairment. The Care Plan focus area with an initiation date of 10/9/23 documented Resident #5 required the assistance of 2 staff for bathing. Review of the past 30 days of bathing documentation for Resident #5 revealed her bath days were Mondays and Thursday. Staff documented Resident #5 received a bath on the following dates: a. 5/27/24 Monday b. 5/30/24 Thursday c. 6/3/24 Monday d. 6/10/24 Monday e. 6/13/24 Thursday f. 6/17/24 Monday g. 6/20/24 Thursday h. 6/24/24 Monday Staff failed to give Resident #5 a bath on 6/6/24. On 6/23/24 at 6:27 PM Resident #5 was asked how often she received a bath/shower, she stated once a week but is supposed to get two a week. When asked why that is, she stated they tell her they don't have enough staff to get them done. She could get two a week if she hounds staff enough. Her face appeared unshaved and when asked if staff assist her with shaving, she stated they do once week. She is fine with them doing so once a week. 2. According to the quarterly MDS assessment tool with a reference date of 3/6/24 Resident #8 had a BIMS score of 14. A BIMS score of 14 suggested no cognitive impairment. The Care Plan focus area with an initiation date of 10/9/23 documented he required total assistance of staff for bathing. Review of the past 30 days of bathing documentation for Resident #8 revealed his bath days were Tuesdays and Fridays. Staff documented Resident #8 received a bath on the following days: a. 5/28/24 Tuesday b. 5/31/24 Friday c. 6/4/24 Tuesday d. 6/9/24 Sunday e. 6/11/24 Tuesday f. 6/14/24 Friday g. 6/18/24 Tuesday h. 6/21/24 resident not available i. 6/25/24 resident not available On 6/19/24 at 1:10 PM resident was lying in bed and used a communication board to communicate. One side of the board has simple phrases, the other side has individual numbers and letters. When the resident is asked a question, he points to the letters to spell out words, making sentences. Observed his fingernails to be long. When asked if he gets his bath/showers, he spelled out at one time he hasn't had one for a month. When asked if staff ask him if he wants one, he spelled out no. When asked if they tell him why it would not get a bath, she spelled out no. When asked if they cut his nails, he shook his head no then spelled out he has to ask to get them cut. When ask if they complete oral cares for him, he again spelled out he has to ask. 3. According to the quarterly MDS assessment tool with a reference date of 5/22/24 Resident #9 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The Care Plan focus area with an initiation date of 10/11/23 documented he required assistance of two staff for bathing. Review of the past 30 days of bathing documentation for Resident #9 revealed his bath days were Wednesday and Saturdays. Staff documented Resident #8 received a bath on the following days: a. 5/29/24 Saturday b. 6/5/24 Friday c. 6/8/24 Monday d. 6/12/24 Friday-resident not available e. 6/19/24 Friday received two baths The records revealed Resident #9 did not receive a bath from 6/9/24 until 6/19/24, he went 10 days without a bath. On 6/20/24 at 9:21 AM Resident #9 was asked how often he received a bath or shower he stated he gets one 3 times a week. His hair was disheveled and appeared to not have been brushed. On 6/27/24 at 10:20 AM the resident laid in bed with family visiting, hair disheveled. On 6/25/24 at 5:44 PM Resident #9's son stated when they first brought his dad to the facility they were told he would get three baths a week on Monday, Wednesday, and Saturday. If he wanted/needed more he could request it. There are a lot of times they are not giving him his baths and he found out a while ago they somehow changed it to two times a week on Mondays and Wednesdays. There are times his dad would not get a bath at all. When he asks questions they tell him it's because they are short staff and they have no time to do it. They will come in at the beginning of the shift and tell him we will get your bath done today. Later in the day they will come back in a say we are understaffed we can't do it right now. By the end of their shift they will come in a says they will get to it tomorrow. He has been known to not get a bath for two weeks. He asked one of the nurses to look at the logs and she was able to verify that this was accurate. He has filed grievances on his dad's behalf before. 4. According to the admission MDS assessment tool with an assessment date of 5/15/24 Resident #11 had a BIMS score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented she required partial/moderate assistance with personal hygiene such as shaving. The Care Plan focus area with an initiation date of 10/11/23 documented Resident #11 required the assistance of one staff for personal hygiene. During continuous observations on 6/18/24, 6/20/24, 6/23/24 and 6/25/24 Resident #11 ambulated throughout the facility with shorts on. It was noted Resident #11's leg hair to be long and in need of being shaved. On 6/25/24 at 3:02 PM Resident #11 stated she gets her baths/showers twice a week. When asked if staff assist with shaving her legs, she stated no. Resident #11 answered yes when asked if she would want staff to shave her legs. Review of Resident Council Meeting Notes revealed during the council meeting on 3/1/24 residents indicated baths are not getting done on time. On 6/18/24 at 11:58 AM Staff F CNA stated baths were not getting consistently completed because they just did not have enough staff on the floor. On 6/19/24 at 10:06 AM Staff I CNA stated he does not do baths on the evening shift, they do not have enough staff to do that. If they do have time and staff is available they will get them done on the evening shift, but it does not happen often. On 6/21/24 at 10:33 AM Staff M CNA stated she did not believe the baths got done yesterday for 4 residents. Baths are to be completed on the day shift. At times they only have two CNAs on the floor, then management will bring out a note of certain baths that need to be done on the evening shift before they leave most of the time, they are not able to get them done. On 6/21/24 at 12:54 PM Staff N CNA stated she believed residents are getting their baths twice a week. If they had some left over for the evening shift and if they had enough staff they would do them or push the bath to the following day. On 6/21/24 at 1:05 PM Staff O CNA stated there have been a couple occasions where baths are not getting done. On 7/1/24 at 2:01 PM the Director of Nursing (DON) stated residents are to get baths at least twice a week. She added one resident is care planned to receive three a week. If a resident refuses a bath, they will try to offer a bath at another time. If the resident has something going on like an appointment or going out with family on their bath, then they will move their bath to the next day or make sure they get a bath within that same week. The DON indicated residents are getting their baths twice a week unless they are refusing them. When asked when resident's nails are to be trimmed, she stated during their bath time. When she was informed that Resident #8's fingernails were long, she stated he is usually pretty particular about his nails being cut. The DON indicated women's legs are shaved at the resident's discretion. She indicated they would get Resident #11's leg shaved when she was informed her leg hairs were long and the resident stated she wanted them shaved. The facility provided a document titled Resident Rights with a revision date of 12/2016 with a policy statement that read, employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: When assisting with care, residents are supported in exercising their rights. For example, residents are: a. Groomed as they wish to be groomed (hair styles, nails, facial hair, etc.) The facility provided a document titled Activities of Daily Living (ADLs), Supporting with a revision date of 3/2018 with a policy stated that read, residents will be provided with care, treatment and services as appropriate to maintain and improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident council meeting notes, grievance/concerns investigation forms, resident and staff interviews, and facility policy review the facility failed to ensure the facility had sufficient staffing to meet the needs of residents that included answering resident's call lights in a timely manner. The facility reported a census of 30 residents. Findings include: Observations on 6/23/24 from 5:10 PM until roughly 6:30 PM revealed numerous call lights going off on the 200 hall: a. room [ROOM NUMBER] call light on at 5:10 PM, off at 5:32 PM; call light was on for 22 minutes b. room [ROOM NUMBER] call light on at 5:40 PM and remained on when checked on at 6:07 PM; at that time call light was on for 27 minutes. c. room [ROOM NUMBER] call light on at 6:07 PM, off at 6:23 PM; call light was on for 16 minutes. d. room [ROOM NUMBER] call light on at 6:00 PM, off at 6:16 PM; call light was on for 16 minutes. e. room [ROOM NUMBER] call light on at 5:36 PM, off at 6:16 PM; call light was on for 40 minutes. Review of Resident Council Meeting Notes revealed during the council meeting on 3/1/24 Resident #9 stated he turns his call light on and it takes quite a while to answer his light. He said it takes quite a while for him to get transferred from his chair to his wheelchair and vice versa. Review of Resident Council Meeting Notes revealed during the council meeting on 5/2/24, residents reported call lights not getting answered timely. Residents stated they come to the resident council meetings but nothing gets done with their complaints and they have brought some of these things up several meetings before. Review of Grievance/Concern Investigation Forms revealed the following grievances: a. 3/1/24 Resident #9 indicated his call light was not getting answered very fast. It takes quite a while to get his call light answered and his call light is not always in reach for him to use and ends up yelling for help. b. 5/23/24 Resident #6 indicated he laid in his urine and waited 45 minutes for his call light to be answered. Action and follow-up: resident was immediately cleaned, staff educated on 15-minute timing for answering call lights. On 6/18/24 at 11:58 AM Staff F CNA stated call lights could take over 30 minutes to be answered because they did not have enough staff on the floor. They do not have enough staff for the quantity of resident they have. She would have issues getting to her check and changes when she worked overnights because they only had one CNA and one nurse working. On 6/19/24 at 9:49 AM Resident #13 stated it could take up to 20-25 minutes for her call light to be answered. Staff will come in and say they need to go check on something but never come back or don't do what they say. The resident stated communication is bad here. They bring up these concerns during resident council but nothing gets done about it. Observed Resident #13 to be wearing a watch at the time of the interview. On 6/19/24 at 10:06 AM Staff I CNA stated for the most time they can answer call lights timely. If they have three staff on the floor, one staff member will answer call lights and assist those that require one staff for assistance while the other two assist those residents that require assistance of two staff. Staff I stated you can spend roughly 5-10 minutes in a resident's room getting them to bed, once you're done you have 4-5 more lights on. When asked how staffing was he stated it depends on which shift. The day shift usually has 4-5 people working the floor with 1 doing baths. On the evening shift they will have 2-3 on the floor depending on the day of the week. Weekends they will have 2 on the floor, maybe 3 for half the shift. Most weekends worked can be hectic especially with 2 people on the floor; they have a lot of residents that are 2 assists for transfers, plus more residents needed things at once. On 6/20/24 at 9:26 AM Staff L non-CNA smiled when asked how staffing was, then stated it could be better. On the morning shift they usually have two CNAs on the floor and one bath aide doing baths. They will not pull the bath aide to help. With two CNAs on the floor and a lot of residents that are two person assists it's tough. When asked if any tasks get missed or pushed to the side when they only have two CNAs on the floor she stated they don't do it on purpose. Call lights can take along time to get to those. She added when they are short sometimes residents don't get turned every 2 hours, usually every 2.5-3 hours; they get there when they can. When they have more time, they will go around and ask residents if they need anything so they are not on their call lights a lot. At times they don't have time to do that. On 6/20/24 at 1:59 PM Staff J CNA was asked if staff are able to get to call lights timely, within 15 minutes. She stated probably not. You can be in a room busy with another resident and not hear the call lights going off. You don't know how long they have been on, so will go answer them when they can. On 6/21/24 at 10:33 AM Staff M CNA laughed and said she was sure the surveyor knew how staff was. She added it's chaotic. She stated she is not one to berede the office people but they are day they are drowning on the floor but no one will pick up their phones or check messages when they reach out for help. When they need help, they need help. Office staff should be looking out for their own staff. Staff M reported the Administrator told them they could call and call and she would not answer her phone. When they are busy and low staff they will push back when they pass drinks and snacks, so they can answer call lights and get other things done. When they have two people on the floor, one person has to be in the dining room assisting residents with their meals while the other resident is answering call lights and meet those resident's needs by themselves. On 6/21/24 at 12:54 PM Staff N CNA stated on the evening shift; 2:00 PM-10:00 PM they give two staff. There are a lot of residents that require the assistance of 2 staff. When there are only two CNAs working one has to go to the dining room while residents are in their eating while the other resident is answering call lights, passing room trays, and it's hard. On 6/21/24 at 1:05 PM Staff O CNA stated it can be hard when there's only 2 staff on the floor with a lot of residents that require the assistance of 2 staff. During dinner one aide needs to be in the dining room to help and feed residents while the aide passes trays and answers call lights. When asked if they are able to complete their tasks for their shift she indicated that all depends on call lights and how early/late people want to go to bed. She indicated 9 times out of 10 not everything will get done like not getting all the trash out of resident's rooms, some residents will still be up when the overnight shift staff come in. Also, little things like stockings will not get done. She stated staffing is just really stressful; 30 residents with half of them 2 assistance of staff plus trying to keep any eye on everyone else is stressful. On 6/23/24 at 5:35 PM Staff I stated they had one call-in for this shift. He stated he sent a text out to everyone to see if they could come in but no one was available. At 6:15 PM overheard Staff I state this is when I wish our 3rd CNA was here. On 6/23/24 at 6:27 PM Resident #5, who resided in room [ROOM NUMBER], sat in her wheelchair in her room with her call light on. The surveyor acknowledged the resident's call light had been on for a long time this evening. When asked if this was normal during the evening shift, she acknowledged it was. She added she wants to go to bed but she has to wait and it happens a lot on this shift. Resident #5 stated she has to wait a long time to go to bed at this time during the day on the weekends. The resident stated she requires the assistance of two staff and a mechanical lift. When she has to wait this long it results in her not wanting to get out of bed because she does not know when she will be able to get back to bed. Resident #5 stated right now I am waiting for Staff I to find another staff member to assist him with her transfer. At 6:31 PM Staff I came in and informed Resident #5 he was trying to find Staff J CMA to help him. On 6/24/24 at 8:55 AM the Administrator sent an email that indicated the facility has nine residents that required the assistance two staff for transfers, bed mobility and ambulation. On 6/27/24 at 10:35 AM Resident #6 indicated it could take up to an hour and half for his call light to get answered. He has a clock on his wall by his TV and a digital clock on his motorized wheelchair. He added he always knows what time it is. On 6/27/24 at 2:00 PM Resident #14 stated it usually takes up to 30 minutes for staff to answer his call light. Observed a call on his wall to the left of his TV. On 7/1/24 at 2:01 PM the DON stated the facility's staffing is good and they staff based on their census. When their census is below 30 they will have 2-3 CNAs and a nurse on the floor. When they can, they will have another CNA come in from 6:00 PM to 10:00 PM to help get residents to bed for the night. Herself and the Assistant Director of Nursing (ADON) will fill vacancies on the overnight shift if they need to. She acknowledged they try to increase staff but when they do, staff will call in. When asked if they take in account the acuity of their residents to help with staff, she indicated they do not; they look at their census. When discussing call light concerns, she stated she expected staff to answer resident call lights within 15 minutes. She was informed this was not the case on 6/23/24 when the surveyor came to the building that Sunday. When Staff T Registered Nurse (RN) called her to let her know a surveyor was in the building, she had no idea how crazy it was. She came in to the facility and assisted until about 8:00 PM or so. When asked if she felt call lights were getting answered within 15 minutes, she stated typically yes, with some outliers absolutely. Their leadership team can still answer call lights to see what the resident needs, then go from there. Any clinical staff can answer the call light and assist the resident. The facility provided a document titled Answer the Call Light with a revision date of 3/2021 with a purpose that read the purpose of this procedure is to ensure timely responses to the resident's requests and needs. Steps in the Procedure 1. Identify yourself and politely respond to the resident by his/her name. a. If the resident needs assistance, indicate the approximate time it will take for you to respond. b. If the resident's request requires another staff member, notify the individual. c. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for help.

Based on grievance/concern investigation forms, staff interviews, employee file review, and review of job descriptions the facility failed to ensure qualified staff assisted in the kitchen when they did not have adequate staff working. The facility reported a census of 30 residents. Findings include: Review of Grievance/Concern Investigation Forms revealed the following grievances: a. 4/23/24 a resident expressed frustration with staffing in the kitchen. Stated she's sick of not getting what she orders and the Administrator needed to figure it out. Action and follow-up: dietary manager was out unexpectedly. Administrator pulling staff from other departments to help cook and serve meals. b. 5/3/24 a resident asked for a peanut butter sandwich and they brought her the bread and the peanut butter packet, told her to make her own sandwich. She said for what she pays to stay here, her sandwich should be made for her. Action and follow-up: dietary manager spoke to all cooks about making the sandwich. This was done by a nursing staff that filled in as a cook. Education was provided. On 6/18/24 at 11:24 AM Staff D Registered Nurse (RN) stated she has noticed Certified Nursing Assistants (CNAs) and nurses in the kitchen cooking and working as a dietary aide without trainings or being certified. Staff D stated she has witnessed Staff E CNA in the kitchen cooking. She indicated any staff member would be willing to speak of this too as well as residents. On 6/18/24 at 11:58 AM Staff F CNA stated she would see CNAs in the kitchen cooking if they did not have a cook for that day. When asked how often this happened she stated it just depended on kitchen staffing for the day. She acknowledged she assisted in the kitchen by serving the meal and setting up room trays. She denied receiving training from the facility prior to assisting with kitchen duties. On 6/19/24 at 10:48 AM Staff Q Maintenance stated he has helped with meal service before but only as a dietary aide. He would deliver drinks and food trays, he cannot cook because there are different diets and orders. He just helps when they need it because they can't keep kitchen staff right now. On 6/20/24 at 9:15 AM Staff K CMA stated they have asked her to help in the kitchen but she declines. She works on the floor not in the kitchen. On 6/20/24 at 9:26 AM Staff L non-CNA stated they have asked her to help in the kitchen, but she has refused to do so because she was not hired for that. On 6/20/24 at 12:57 PM Staff H Licensed Practical Nurse (LPN) stated she has never helped in the kitchen but has noticed CNAs and other nurses helping. She added Staff E CNA has gone in the kitchen to cook before. She has also noticed the Activity Director assisting as well. On 6/20/24 at 1:59 PM Staff J CMA state she had been asked to help in the kitchen and she does help. When asked what she helped with she stated delivered trays to residents, set drinks out on tables, set up trays, picked up trays, did dishes and makes sure the kitchen and dining room was tidy. She denied cooking in the kitchen and did not have any extra training to help with dietary tasks or certifications. On 6/21/24 at 10:33 AM Staff M CNA stated they ask her to help in the kitchen all the time but she refuses to help. When asked if she has noticed other CNAs or nurses in the kitchen helping, she stated Staff P LPN will go back to the kitchen when not doing medication pass. Staff E CNA will be in the kitchen cooking as well. Staff M indicated the Dietary Manager will send her texts asking her to work as a dietary aide or a cook but that's not her job. She is not certified to do any of that. The others that have assisted in the kitchen are also not certified to do what they do. The Administrator will tell them they need to go in the kitchen to help. Staff M acknowledged she knows she can help pass meals to the residents but knows she is not to help in the kitchen. On 6/21/24 at 12:47 PM Staff R previous [NAME] stated they have had CNAs and nurses help in the kitchen with no training. Those staff people don't know what they are doing as they cooked or did dietary aide stuff. They had to help because the facility could not keep kitchen staff, the whole facility can't keep help. On 6/21/24 at 12:54 PM Staff N CNA stated if there are enough CNAs she will help the kitchen staff, if there is not enough CNAs she will not help. When asked what kind of things she does to help the kitchen staff she stated she will get drinks ready, wrap silverware, serve food, and get room trays ready. She has noticed Staff P in the kitchen cooking after she is done with her nursing staff. Staff N is not sure if Staff P has been trained or certified but has cooked a few times. On 6/21/24 at 1:05 PM Staff O CNA stated they have asked her to help in the kitchen but when they have asked her she has been in rooms doing cares. A couple weeks ago, she noticed a nurse had been in the kitchen serving food and CNAs acting as dietary aides. On 6/21/24 at 3:32 PM Staff E CNA stated she has helped in the kitchen as a dietary aide and a cook a few times. When asked if she has been trained or had any dietary certification she denied having been trained or having any certifications. This did not happen very often within a week's time. She complained about helping and they took her out of the kitchen. During a follow-up interview on 6/25/24 at 10:01 AM Staff E was asked how she knew what to do when making the mechanical soft and puree meals when she helped in the kitchen. She stated she looked at a chart that's in the kitchen. She added she previously worked at an adult day care center where she cooked, so she knew the different diets and how to do the different consistencies. On 6/23/24 at 6:00 PM Staff B [NAME] stated kitchen staffing had been rough for a bit because herself and the Dietary Manager were off at the same time due to medical reasons. On 6/27/24 at 12:24 PM Staff P LPN stated she has worked in the kitchen before. The Dietary Manager had prepped the food, sat right there as Staff P served the meals. She would follow their slips when serving the meals. Staff P denied cooking, she only plated the food. When asked why the Dietary Manager watched her serve instead of serving herself, she stated because she just had surgery so she sat in a chair and watched her. Staff P denied having training from staff but worked in another facility's kitchen so she knew how to use the dishwasher and knew certain diets. Staff P stated she does not have any certifications or trainings to work in the kitchen. The Dietary Manager did show her how to obtain food temperatures, makes sure it was hot and how to keep it hot. On 6/27/24 at 12:12 PM the Activities Coordinator indicated she was asked to work in the kitchen for kitchen staff but out on the floor was just passing out trays and drinks. She denied ever going into the kitchen to cook. She provided that Staff E CNA did work as a cook one day as she passed out drinks to the residents. She added all the kitchen staff called in that day so they had no choice but to go back there to work as kitchen staff. This was roughly two months ago. On 7/1/24 at 2:01 PM the Director of Nursing (DON) laughed when asked if nursing staff had assisted in the kitchen. She stated it was accurate but not recently, in the last two months. The DM had to go on medical leave abruptly, had staffing issues with call-ins along with vacancies. When nursing staff was overstaffed Staff E and Staff P would go help in the kitchen. The DON indicated the DM completed orientation checklists with them but is unsure of the entire protocol for this. She knows staff have to complete serve safe training. When asked if Staff E and Staff P got all the training a normal dietary staff would do, she stated no. She acknowledged she has helped as a dietary assistant before. Review of the job description for a cook listed the purpose of this position under general supervision of the Dietary Services Manager, the cook position assures the resident meals and other nourishments are properly prepared/cook and apportioned according to authorized menus and individual care plans, and are served according to established schedules, consistent with regulations and starts of practice. Functions within strictly defined procedures with little latitude for variation or change. Under the qualifications portion of the job description there is a section for education/certifications/license: staff must be willing to complete the following during new hire orientation: food, safety, and sanitation study courses and modified diet training. Experience needed for this position includes demonstrating skills in quantity food preparation and service. Review of the job description for a CNA listed the purpose of this position under on-site supervision of the charge nurse, the CNA provides personal care and supervision to residents in a manner conductive to their safety, comfort, security and the greatest degree of independence possible. Operates within the parameters of each resident's care plan and daily schedule as determined by the interdisciplinary team and within the practice of limitations of certification. The primary functions and responsibilities of this position are as follows: additional duties may be added as necessary to meet the needs of the facility. Staff will be evaluated on their ability to perform these functions competently with minimal supervision and/or reminders. Review of the essential functions section revealed it did not list kitchen duties or responsibilities. Review of the general functions section revealed it did not list kitchen duties or responsibilities.

Based on observations, staff interviews, and facility policy review the facility failed to store and serve food in a sanitary manner. The facility also failed to maintain infection control practices while in the dish area when going from the dirty area to the clean area. The facility reported a census of 30 residents. Findings include: On 6/18/24 at 10:23 AM observed three tubes of hamburger meat in a gray hard plastic bin with a tape label that indicated the hamburger was for Thursday 6/19/24 (Thursday was actually 6/20/24). Red, bloody looking, fluid gathered at the bottom of the gray hard plastic bin. This bin sat on the second to last shelf in the walk-in cooler with two cardboard boxes of stripped bacon on the shelf below. Also noted in the walk-in cooler, a box that contained 4 green peppers with what appeared mold on them (black and white fuzzy areas throughout). While speaking with the Dietary Manager, Staff A Dietary Aide, had gloved hands while in the dish area. With gloved hands he moved a trash can closer to the dish room, removed dishes (bowls, cups, small plates) from the clean area of the dish room and placed them in their proper areas in the kitchen. With the same gloved hands, he began cleaning the dirty side with a squeegy. He then opened the dishwasher, removed more clean dishes with the same gloved hands. He took those clean dishes (bowls and cups) to their proper place. On 6/20/24 at 11:17 AM observed two tubes of hamburger meat in a gray hard plastic bin. The bin also had an opened zip lock bag that contained one raw hamburger patty. The zip lock bag was not labeled and opened to air. The zip lock bag and two tubes of hamburger rested in red, bloody looking, fluid at the bottom of the gray hard plastic bin. This plastic bin now rested on the bottom self in the walk-in cooler. The four moldy looking green peppers remained in a card board box in the walk-in cooler. On 6/23/24 at 5:08 PM Staff B [NAME] was in the kitchen behind the food service window holding a cell phone with both hands. Observed Staff B plating sandwiches with her bare hands for 16 residents. During the meal service she would handle the meal tickets that are filled out by the residents, plates, individual ice cream containers, a bag of chips, and soup bowls. Observed Staff B scratching her hair line with her index finger on her right hand and pull at her t-shirt. The same ungloved hand she used to plate the sandwiches. At 5:21 PM Staff B walked by the service area where the food was and coughed into the area without covering her mouth. On 6/20/24 at 11:19 AM the Dietary Manager (DM) was made aware of the raw hamburger patty in an opened zip-lock, she indicated she would throw it away. When informed the gray hard plastic bin that had the raw hamburger in it was on a shelf above two boxes of stripped bacon on 6/18/24, she stated it shouldn't have been. She was also shown the four green peppers that contained what looked like mold (black and white fuzzy areas throughout) had been in there since 6/18/24 she again indicated she would get rid of them. On 6/23/24 at 6:00 PM Staff B was asked why she handled the ready to eat sandwiches with her bare hands, she indicated she was taught she had to wear gloves while making them. As long as she washed her hands before services and did not leave the service line she could serve the sandwiches with her bare hands. So, she always stays at the service line until all meals are served. To clarify, asked Staff B if she did not have to wear gloves when touching ready to eat food as long as she washed her hands and stayed in the service area. She acknowledged that was accurate. On 6/25/24 at 1:22 PM the DM stated Staff B said something to her about touching ready to eat foods. Staff B told her she had gloves on when she made the sandwiches but did not wear them when she served them. The DM told her she has to wear them when serving ready to eat food or use tongs to serve the item. The DM indicated Staff B has been working at the facility for two years and should have known this. The DM was made aware of Staff A in the dish room completing dirty and clean tasks with the same gloved hands. She stated he should be washing his hands between tasks. Staff C [NAME] added that's why it's nice to have extra people working in the kitchen. They will have one staff member on the dirty side of the dish area and one on the clean side. Review of the Job Description for a cook listed the purpose of this position under general supervision of the Dietary Services Manager, the cook position assures the resident meals and other nourishments are properly prepared/cook and apportioned according to authorized menus and individual care plans, and are served according to established schedules, consistent with regulations and starts of practice. Essential functions include to handle and prepare food in a sanitary manner. The facility provided a document titled Food Receiving and Storage with a revision date of 10/2017 documented foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 13. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods. The facility provided a document titled Food Storage-Refrigerated Foods, February 2016 edition. The policy statement read, perishable foods shall be refrigerated in a manner which optimizes food safety, nutrient retention and aesthetic quality. The facility provided a document titled Generalized Food Preparation and Service, February 2016 edition. The policy statement read the facility shall provide each resident with foods prepared and served by methods that conserve nutritive value and flavor. The food should also be palatable, attractive and at the proper temperature. Procedure 3. Food Storage a. Food is covered/sealed. 4. Food Preparation i. Bare hands should never touch ready to eat food directly. 5. Food Service f. Never touch food directly with bare hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident interview, staff interviews, and facility policy review the facility failed to ensure that residents have the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 of 5 residents reviewed (Resident #37). The facility reported a census of 40 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE], documented Resident #37 had a Brief Interview for Mental Status (BIMS) score of 15 (no cognitive impairment). The MDS documented the resident required substantial assistance for toileting hygiene, personal hygiene, footwear, and functional transfers. Resident #37 completed transfers with the use of dependent weight bearing lift. The MDS documented Resident #37 had diagnoses including: chronic diastolic (congestive) heart failure, anxiety disorder, gastro-esophageal reflux disease without esophagitis, chronic kidney disease stage 3, hypertensive chronic kidney disease, other specified hypothyroidism, polyarthritis unspecified, venous insufficiency (chronic peripheral), morbid (severe) obesity, personal history of pulmonary embolism. Resident #37 was on supplemental oxygen therapy via nasal cannula with the use of a concentrator. On 01/29/24 at 03:14 PM Resident #37 stated she was somewhat comfortable and had privacy and her own room until this date. The resident stated she had a roommate move in and was not notified until the roommate's belongings were moved in. On 1/29/24 at 3:15 PM observation of the room found a double occupancy room with resident #37 occupying one half of the room. Resident #37 had a hospital bed, recliner (primary position of choice), television, dresser, bedside table, oxygen concentrator and personal belongings. The roommate had a hospital bed, dresser, television, bedside table, wheelchair, and personal belongings. On 01/31/24 at 08:26 AM Resident #37 stated she did not like how the roommate was moved in and now has decreased personal space. Resident #37 stated her new roommate stayed up late at night listening to music, while she preferred quiet. Resident #37 stated the room is packed with stuff and her wheelchair is parked in the hallway as there is no room. On 01/31/24 at 08:30 AM observed Resident #37's wheelchair in the hallway. On 01/31/24 at 10:24 AM Resident #37 stated she had never had a roommate, and was told she was getting a roommate. However she wasn't told when, and then staff began moving the roommate's items in. 01/31/24 at 10:33 AM Staff M, Social Worker, stated she did not recall Resident #37 ever having a roommate prior to the current roommate. Staff M stated she believed Resident #37 was provided a 48 hour notice prior to the new roommate moving in. Staff M stated the current room occupant will not have documentation to sign but would have a progress note stating notification of new roommate. Staff M was unable to locate documentation in the EHR indicating notification had been provided to Resident #37. Staff M was unable to recollect if a conversation had been held with Resident #37, but stated the facility is not required to notify the current occupant of the room prior to new roommate. Review of the document titled, Room Change/Roommate Assignement, with revised date March 2021, documented: Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives) are given an advance written notice of such change. On 02/01/24 at 08:33 AM Staff L, Facility Administrator, stated it is the expectation that residents should be notified prior to moving or having a new roommate move in. Typically the facility notified the person receiving a new roommate within the same 48 hours period as the person moving into the room. A signature of acknowledgement is not required of the current room occupant. Staff I stated the facility does not typically notify the Power of Attorney (POA).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family interviews, staff interviews, and policy review, the facility failed to provide timely notification to the physician or family when changes occurred in the resident's physical or mental condition for 2 of 2 residents reviewed (Resident #15 & #17). The facility reported a census of 40 residents. Findings include: 1. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 08 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of inflammatory bowel disease, retinal vascular occlusion (an eye condition that causes blurred vision), and right eye glaucoma. It also revealed she had not had a poor appetite during the previous seven (7) day look-back period but required only setup assistance with eating. The Care Plan dated 10/13/23 indicated the resident was at risk for altered nutrition and weight loss and directed staff to monitor her diet tolerance. The Progress Note dated 11/13/23 at 9:11 pm, documented by Staff I, Licensed Practical Nurse (LPN) indicated the resident experienced confusion during the shift and required cueing and prompting to eat. The Electronic Health Record (EHR) Weight Summary revealed the resident weighed 137.8 lbs. on 10/13/23 and 125.2 lbs. on 12/18/23; a -9.14 % weight loss. On 1/30/24 at 2:56 PM, Resident #15's family member indicated the resident had not received assistance with meals. On 1/31/24 at 2:45 PM, Staff I (LPN) stated she did not notify the physician or family because she thought this was an isolated episode. The EHR Progress Notes lacked documentation the physician nor the family was notified of the change in the resident's eating assistance nor the significant weight loss. 2. The quarterly MDS dated [DATE] revealed Resident #17 had a BIMS score of 03 of 15, indicating severe cognitive impairment. The MDS included diagnoses of Non-Alzheimer's dementia, malnutrition, dyskinesia of esophagus (involuntary movement of the muscles in the throat), and cataracts. It also revealed she had not had a poor appetite nor swallowing difficulty during the previous seven (7) day look-back period but indicated she required supervision or touching assistance with eating. The Care Plan revised 12/12/23 indicated the resident was able to eat only ½ of her meals and included a no significant weight change resident goal. The EHR Weight Summary for Resident #17 revealed the resident weighed 130 lbs. on 12/13/23 and 122 lbs. on 1/06/24; a 6.15% weight loss. The EHR Progress Notes revealed the Dietician failed to follow up on the weight loss until 1/11/24 at 1:21 pm and the family not notified until 1/12/24 at 1:29 am. On 2/01/24 at 12:07 PM, the Director of Nursing (DON) stated the dietician, physician, and family should be notified for a resident's excessive weight loss and the physician and family should be notified of changes in the resident's level of function. A policy titled Change in a Resident's Condition or Status revised 2/2021 indicated the nursing staff would notify the resident's attending physician or physician-on-call for a significant change in the resident's physical/emotional/mental condition. It also indicated a nurse would notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status; unless otherwise instructed by the resident. The policy defined a significant change of condition as a major decline or improvement in the resident's status that required interdisciplinary review and/or revision to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and facility policy review the facility failed to ensure that residents' equipment was kept clean and in good repair for 1 of 5 residents reviewed (Resident #4). The facility census was 40 residents. Findings Include: Resident #4's Minimum Data Set (MDS) dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #4 required the use of a wheelchair (w/c), and required partial/moderate assistance for transfers. The MDS documented the Resident #4 had diagnoses of syncope and collapse, gastrointestinal hemorrhage, other secondary Parkinsons, chronic atrial fibrillation, essential (primary) hypertension, moderate protein-calorie malnutrition, metabolic disorder, hypothyroidism, allergy, depression, and melena. The Care Plan revised on 1/4/24 revealed that Resident #4 utilized a w/c for long distance mobility. Observations revealed the following: On 01/29/24 at 12:00 PM Resident #4's w/c with bilateral armrests torn with exposed foam. On 1/31/24 at 08:12 AM observation of Resident #4 in w/c with bilateral torn armrests. On 01/31/24 at 08:38 AM Staff B, CNA, stated if a repair is needed for a w/c contact is made with the therapy department. On 01/31/24 at 09:03 AM Staff J, CNA, stated if repairs required for a w/c it would be written in the maintenance repair book located at the nurses station. Staff J further stated the maintenance department checks the book daily. On 01/31/24 at 09:07 AM Staff C, LPN, stated if a w/c is in need of repairs contact is made with the maintenance staff. On 01/31/24 at 09:09 AM Staff D, maintenance, stated if repairs are needed they will be documented in the maintenance book located at the nurses station. The book is labeled and readily available to staff. Staff D stated he may also get referrals in a meeting. Staff G has implemented monthly checks on w/c's. The checks have started with the stock w/c's with re-building to prepare them for use. Staff D stated therapy is involved by writing referrals in the book. When repairs are completed, Staff D noted the completion with the date and time on the referral sheet. Review of the referral book revealed it had all the referrals for facility needs (beds, w/c, remotes, plumbing) in the documentation. Review of the book found entries back to July 2023 with no reference to Resident #4's armrests needing to be replaced. Repairs for w/c's (brakes, raising/lowering height) were completed within a couple of days. On 01/31/24 at 10:00 AM Staff H, Director of Nursing (DON), stated when a w/c's armrests are in disrepair, the maintenance department is alerted. She stated that any needs may also be made in the morning meeting. Staff H stated the expectation if anything is wrong with a w/c it is reported no matter the staff's title. On 01/31/24 at 10:08 AM Staff E, Physical Therapist Assistant, stated if she noted a w/c in disrepair she would notify the occupational therapist. Staff E further stated she had only been working in the facility for 4 days and was still learning the facility processes. On 01/31/24 at 10:09 AM Staff F, Occupational Therapist, stated w/c needs (brakes, height changes) are documented in the maintenance book. Staff F stated if she noticed something, even if the resident is not on her caseload, it would have been documented in the maintenance book. On 01/31/24 at 11:28 AM observation of Resident #4's w/c found tears to bilateral armrests. On 01/31/24 at 11:36 AM Resident #4 stated her w/c had torn armrests when she first received it upon admission. Resident #4 stated she required the w/c as she is unable to walk with a walker without staff assistance in her room. Resident #4 stated the seat of the w/c was horrible when she got it, and the seat was fixed. The resident stated she doesn't care if the armrests are torn or if they were fixed. On 01/31/24 at 01:14 PM observation of the wheelchair continued to have torn armrests. Photos taken of armrests. Review of the document Maintenance Service, revised December 2009, revealed the Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. The department should establish priorities in providing repair service, and provide routinely scheduled maintenance service to all areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family and staff interviews, and policy review, the facility failed to ensure each resident received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 1 of 12 residents (Resident #15) reviewed. The facility reported a census of 40 residents. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 08 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of unspecified injury of the head and disorders of the peripheral nervous system. It revealed the resident was dependent with toileting and personal hygiene but indicated the resident had not had a UTI in the last 30 days. On 1/30/24 at 2:56 PM, Resident #15's family member revealed the resident was treated for a Urinary Tract Infection (UTI) at the beginning of December 2023. The Electronic Health Record (EHR) physician orders indicated the resident received one (1) 300 mg Cefdinir Oral Capsule by mouth two times a day for UTI between 12/04/23 and 12/13/23. The Care Plan failed to include a UTI focus prior to 1/02/24. On 2/01/24 at 12:07 PM, the Regional Director of Clinical Services (RDCS) stated the MDS Coordinator was a hybrid employee and also covered another facility. The Director of Nursing (DON) stated the MDS was expected to be reflective of the resident's current status. A policy titled Certifying Accuracy of the Resident Assessment revised 11/2019 indicated any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. It also revealed the information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and policy review, the facility failed to implement a comprehensive, person-centered care plan for 3 of 3 residents reviewed (#15, #17, & #20). The facility reported a census of 40 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 06 of 15, indicating severe cognitive impairment. It included diagnoses of fractures other than her hip, disorders of the peripheral nervous system, and sprain of the ligaments of the lumbar spine (lower back). It also revealed the resident dependent for putting on and removing footwear and required a wheelchair for mobility. The Care Plan dated 12/22/23 directed staff to ensure the resident had moon boot heel protectors on the left lower extremity at all times. On 1/29/24 at 2:56 PM, Resident #15's family member indicated the resident should have moon boots (a device used to stabilize sprains, fractures, or ligament tears in the ankle or foot) on at all times. The resident observed not having any supportive devices on her feet or ankles. 2. The significant change MDS dated [DATE] indicated the resident had a BIMS score of 03 of 15, indicating severe cognitive impairment. It included diagnoses of Non-Alzheimer's dementia, cataracts, disorders of bone density and structure, and difficulty walking. It also revealed the resident wandered four (4) to six (6) days in the seven (7) day look-back period. The Care Plan dated 12/19/23 indicated the resident had a risk of unsafe wandering and directed staff to place the monitoring device on the resident that sounds alarms when she leaves the building. It also directed staff to check the placement and function of the bracelet every shift. An observation on 1/30/24 at 12:41 PM revealed Resident #17's wander-guard attached to her 4-wheeled walker while she was eating in the dining room. An observation on 1/31/23 at 8:09 AM revealed the resident's wander-guard was still attached to her 4-wheeled walker. 3. The MDS dated [DATE] indicated the resident had a BIMS score of 08 of 15, indicating moderate cognitive impairment. It included diagnoses of pneumonia, Coronary Artery Disease, Non-Alzheimer's dementia, and hypoxemia (low blood oxygen level). It also indicated the resident had not used oxygen in the seven (7) day look-back period. The Electronic Health Record (EHR) included a physician's order dated 1/14/24 directing staff to titrate oxygen to keep the resident's oxygen saturation (O2 sat) above 90%. On 1/29/24 at 12:51 PM, Resident #20 observed receiving nasal cannula oxygen while she slept in bed. The Care Plan did not include the resident's oxygen requirements or parameters. On 2/01/24 at 12:07 PM, the Regional Director of Clinical Services (RDCS) stated a wander-guard device should be placed on a resident's wrist or ankle but may be placed on a resident's mobility device if the resident was adamant on not wearing it but it should be included in the Care Plan. The Director of Nursing (DON) stated staff should follow the Care Plan interventions. A policy titled Care Plans, Comprehensive Person-Centered revised 12/2016 indicated the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. It identified the IDT members as: a. The Attending Physician; b. A registered nurse who has responsibility for the resident; c. A nurse aide who has responsibility for the resident; d. A member of the food and nutrition services staff; e. The resident and the resident's legal representative (to the extent practicable); and f. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and reviews of policy the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice regarding respiratory treatments, oxygen administration and insulin administration per orders for 2 of 3 residents reviewed. The facility census was 40. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE], documented that Resident #37 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The resident required substantial assistance for toileting hygiene, personal hygiene, footwear, and functional transfers. Resident #37 completed transfers with the use of dependent weight bearing lift. Resident #37 had diagnoses to include: chronic diastolic (congestive) heart failure, anxiety disorder, venous insufficiency (chronic peripheral), morbid (severe) obesity, and personal history of pulmonary embolism. Resident #37 was on supplemental oxygen therapy via nasal cannula with the use of a concentrator. A continuous observation on 01/30/24 for Resident #37 revealed the following: At 12:34 PM resident seated in her wheelchair (w/c), head tilted fully back sleeping with a nebulizer on. At 12:37 PM Staff A, Licensed Practical Nurse (LPN), walked by and did not look in the resident's room. At 12:44 PM Staff A walked by and did not do a visual assessment of resident #37. During this time period Staff G, Certified Nurse Assistant (CNA)/Certified Medication Assistant (CMA) walked by Resident #37's room without looking in. At 12:48 PM Staff A walked by the resident's room twice. Resident #37's nebulizer can be heard from the resident's room with the television on. At 12:57 PM Staff G and Staff B, Certified Nurse Assistant (CNA),walked past Resident #37's room to check on another resident and returned back within 1 minute without visual assessment of the resident. At 12:58 PM Resident #37 woke up and looked around the room. The resident then dozed back off as demonstrated by head tilting backwards and eyes closing. At 01:10 PM Staff A stated a breathing treatment is supposed to last 10 minutes. Staff A questioned if she had forgot to take off the nebulizer or if Resident #37 had removed it herself. Staff A removed the nebulizer mask and placed the oxygen nasal cannula on Resident #37 with the concentrator set at 3 Liters (3 L). On 01/30/24 at 04:34 PM observed Resident #37's oxygen concentrator set at 3 L with the resident seated in her recliner. On 01/31/24 at 08:24 AM observed Resident #37 seated in her recliner with a nasal cannula in place with the oxygen concentrator set at 3 L. On 02/01/24 at 08:01 AM observed Resident #37 seated in her recliner with oxygen via nasal cannula with her legs elevated and the concentrator set at 3 L. On 02/01/24 at 08:09 AM Staff G stated she did not know what Resident #37's oxygen rate was supposed to be set at. On 02/01/24 at 08:11 AM Staff N, (RN) confirmed that Resident #37's oxygen orders are supposed to be at 2 Liters (2 L) as needed (PRN) to keep oxygen saturations above 90%. Staff N stated the order was written on 12/4/23. Staff N did state Resident #37 started on Z-Pac and was ill the previous week when she last worked. Staff N unsure if the oxygen was increased at that time. On 02/01/24 request from facility for a document regarding physician orders and expectations, however a document with this information was not made available. On 02/01/24 at 08:46 AM Staff H, Director of Nursing (DON), stated that it is expected that physician orders are to be followed as they are written. Staff H stated PRN orders are written with needed parameters for keeping oxygen saturations above a certain percentage. Staff H stated if oxygen was being used continuously at a higher concentration, a new order must be requested for a change. 2. The MDS dated [DATE], documented Resident #16 had a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment. The resident required supervision or touching assistance for self cares and functional mobility using a wheeled walker. Resident #16 had diagnoses to include: essential (primary) hypertension, anxiety disorder (unspecified), type 2 diabetes mellitus (DM), and obesity. Review of the Treatment Administration Record (TAR) report for 1/24 showed lack of documentation for Insulin Deem Subcutaneous Solution Pen-injector 100 unit/milliliter (ml) inject 20 units subcutaneous 2 times a day related to type 2 DM. Documentation of missing signatures on 1/7 /24 PM, and 1/13/24 PM. The TAR for 1/24 revealed an order for insulin Lispro subcutaneous solution pen-injector 200 unit/ml. Inject per sliding scale parameters 4 times a day related to type 2 DM documentation of missing signatures on 1/7/24 PM, 1/8/24 mid AM, and 1/13/24 PM. On 01/31/24 at 10:00 AM Staff H stated it is the expectation in the Medication Administration Record (MAR) or TAR there is documentation when medications are given, held, or refused. Medications that are held or refused should have a progress note entered to indicate why the medication was held or refused. There should not be holes in the MAR or TAR when medications are scheduled. On 01/31/24 at 02:56 PM Staff A unaware of a reason why there would be missing documentation in the MAR or TAR for scheduled medications, unless the medication was not administered. Staff A stated if a medication is held or not given, it would be documented as such on the MAR/TAR. Review of the document titled, Administering Medication, updated April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. It further stated that PRN medications frequently used shall be reviewed by the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist, as needed to determine if there is a clinical reason for the frequent PRN use, and consider whether a standing order is clinically indicated. The document further provided for the expectations for documentation if a medication is withheld, refused, or given at a time other than the scheduled time; as well as expectations for general documentation in the medication records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review, the facility failed to provide restorative activities for 2 of 2 residents reviewed (#15 & #23). The facility reported a census of 40 residents. Findings include: 1. On 1/29/24 at 2:56 PM, Resident #15's family member stated the resident had declined in her functional abilities and was no longer receiving therapy. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 08 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of inflammatory bowel disease, retinal vascular occlusion (an eye condition that causes blurred vision), and right eye glaucoma. The MDS indicated the resident was independent with mobility, required moderate assistance with toilet and shower transfers, and substantial assistance with ambulating 10 feet. She also required setup or supervision assistance for Activities of Daily Living (ADLs) and moderate assistance with putting on or taking off footwear. The MDS included the resident began Physical Therapy (PT) and Occupational Therapy (OT) on 10/18/23 and Speech Therapy (ST) on 10/18/23. The Care Plan dated 10/13/23 included a focus of therapy services, acknowledged orders for PT/OT/ST, and set a resident goal of continued work with therapy as the doctor ordered but did not include restorative program recommendations. The Electronic Health Record (EHR) included physician order for PT/OT/ST to evaluate and treat the resident as indicated. The EHR also contained a Notice of Medicare Non-Coverage (NOMNC) that indicated therapy services would end on 12/22/23. The PT Discharge summary dated [DATE] included restorative program recommendations of lower extremity passive range exercises. On 1/31/23 at 11:33 AM, Staff S, Occupational Therapist (OT) stated therapy discharged the resident due to on-going knee pain, decreased appetite, and plateau of progress, and declining engagement. She indicated the resident was referred for restorative nurse program and no evidence of implementation. The EHR task list did not include restorative program exercises or directives. 2. The quarterly MDS dated [DATE] revealed Resident #23 had a BIMS score of 15 of 15, indicating a complete intact cognition. It included diagnoses of Neurogenic bladder, Diabetes Mellitus, Multiple Sclerosis, and paraplegia. It also indicated the resident had functional limitation in her lower extremities and was dependent or required maximum assistance with all ADLs involving lower extremities. The MDS included the resident began PT and OT on 5/26/23 and ST on 5/30/23 and services ended on 6/02/23 and 6/01/23, respectively. The Care Plan revised 10/04/23 included a focus of therapy services, acknowledged orders for PT/OT/ST, and set a resident goal of continued work with therapy as the doctor ordered but restorative program recommendations. On 1/30/24 at 9:40 AM, observed Resident #23 lying in bed and had difficulty repositioning herself. The resident stated she used to be able to walk but had not received restorative care. The Electronic Health Record (EHR) included a physician order dated 5/26/23 for PT/OT/ST to evaluate and treat the resident as indicated. On 1/31/24 at 8:13 AM, Staff S, OT stated insurance denied the resident's therapy. She indicated the Physical Therapist entered restorative program recommendations for bilateral lower extremity, passive range-of-motion exercises but did not include the frequency. The PT Discharge summary dated [DATE] included restorative program recommendations of lower extremity passive range exercises. The EHR task list did not include restorative program exercises or directives. On 2/01/24 at 12:07 PM, the Director of Nursing stated residents should receive the recommendations from restorative documented in Point-of-Care. A policy titled Restorative Nursing Services revised 7/2017 revealed residents would receive restorative nursing care as needed to help promote optimal safety and independence. It indicated residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care and included restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care.

Based on clinical record review, resident interview, staff interview, and policy review the facility failed to provide an opportunity for bath or shower to 1 of 5 residents (Residents #3) reviewed. The facility reported a census of 40 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #3 dated 11/22/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnosis of diabetes mellitus, hyperlipidemia, and hemiplegia. Review of the Electronic Healthcare Record (EHR) document labeled Plan of Care (POC) Response History for 1/1/24 through 1/29/24 revealed Resident #3 had been given a bath/shower on 1/6/24 and 1/8/24. This document further revealed that Resident #3 refused bath/shower on the 4th, 18th, and 22nd of January. During an observation 1/29/24 at 12:55 PM of Resident #3 revealed her hair uncombed and disheveled. During an interview 1/30/24 at 1:42 PM with Staff J Certified Nurse Assistant (CNA) revealed baths and showers will be documented in the EHR if a resident refused and she would let the nurse know. Staff J further revealed that bath sheets are filled out as well on paper for resident's bath days. During an interview 1/30/24 at 1:52 PM with Staff K CNA revealed she would tell the nurse if a resident refused a bath and then the nurse would then document in the EHR. Staf K further revealed she might try and go look at where to document it as well. Staff K then revealed if baths are refused she would go back and ask again. Staff K further revealed that baths have been missed due to staffing or things coming up in the day and being unable to give baths/showers. During an interview 1/30/24 at 2:19 PM with Staff C Licensed Practical Nurse (LPN) revealed that staff don't always tell her when baths are refused, but if she is told then she would document the refusal in the EHR. Staff C then revealed there are bath sheets that are filled out daily by the CNA's. During an interview 1/30/24 at 2:21 PM with Staff B CNA revealed a bath sheet with green highlighting of baths that are being completed. Staff B then revealed that baths have been overlapped into Tuesday from Monday and some baths from Tuesday will be overlapped into the next day. Staff B further revealed that sometimes baths don't get completed as they only have 2 cna's on the floor and they just don't have time to complete all the baths. During an interview 1/30/24 at 3:21 PM with Resident #3 revealed she does not always get her baths, and would like them more. During an interview 1/30/24 at 3:47 PM with Staff H Director of Nursing (DON) and Staff L Administrator revealed their expectation was for baths/showers to be given at a minimum of 2 times a week or as ordered. Staff H further revealed there was no policy to review on bathing frequency. Review of the facility provided policy titled Bath, Shower/Tub with a revision date of February 2018 revealed: a. Notify the supervisor if the resident refuses the shower/tub bath.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview, and policy review, the facility failed to prevent a resident from developing a preventable pressure ulcer for 1 of 1 resident reviewed (Resident #15). The facility reported a census of 40 residents. Findings include: On 1/29/24 at 2:56 PM, Resident #15's family member indicated the resident had multiple pressure ulcers that were not present upon admission. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 8 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of inflammatory bowel disease, retinal vascular occlusion (an eye condition that causes blurred vision), and right eye glaucoma. It also indicated the resident did not have any pressure ulcers but was at risk of developing them. The Care Plan dated 10/13/23 indicated the resident was at risk for altered nutrition and weight loss and directed staff to monitor her diet tolerance. The Braden Scale for Predicting Pressure Sore Risk dated 10/13/23 revealed the resident scored a 20, indicating the resident was not at risk for the development of pressure ulcers. A score of 9 or less indicates a very high risk. A score of 10-12 indicates a high risk. A score of 13-14 indicates a moderate risk. A score of 15-18 indicates at risk. A score of 19 or higher indicates a resident is not considered at risk for pressure ulcer development. The Electronic Health Record (EHR) Weight Summary revealed the resident weighed 137.8 lbs. on 10/13/23 and 125.2 lbs. on 12/18/23; a -9.14 % weight loss. It also included a dietary progress note that indicated the resident's weight loss was likely due to having not met nutritional needs. The Braden Scale for Predicting Pressure Sore Risk dated 12/23/23 revealed the resident scored a 15, indicating the resident was at risk for the development of pressure ulcers. An emergency room Discharge Summary revealed the resident was diagnosed with dehydration on 12/29/23, received Lactated Ringers and Sodium Chloride IV fluids, and returned to the facility on [DATE]. The Skin and Wound Evaluation sheet dated 12/30/23 revealed the resident had a 1cm x 1.9cm x 1cm, in-house acquired, stage 1 pressure ulcer to her coccyx (the upper center of the buttocks). The Skin and Wound Evaluation sheet dated 1/22/24 revealed the resident had a 13.7cm x 3.1cm x 4.2cm, in-house acquired, stage 1 pressure ulcer to her right trochanter (hip). The comprehensive care plan, revised 1/02/24, included an added focus for the resident's coccyx and hip ulcers. The care plan instructed staff to provide Juven and house supplement per MD order. On 1/31/24 at 2:45 PM, Staff I, Licensed Practical Nurse (LPN) confirmed the pressure ulcers were acquired at the facility. On 2/01/24 at 12:07 PM, the Director of Nursing (DON) stated staff should follow the care plan for high risk residents with interventions. The facility did not provide a policy on the prevention of wounds or pressure ulcers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, clinical record review, staff interview and policy review, the facility failed to maintain acceptable parameters of nutritional and hydration status by failing to prevent excessive weight loss and dehydration for 1 of 1 resident (#15). The facility reported a census of 40 residents. Findings include: On 1/30/24 at 2:56 PM, Resident #15's family member indicated the resident had not received assistance with meals and she was transported to the Emergency Department and received intravenous (IV) fluids. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 8 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of inflammatory bowel disease, retinal vascular occlusion (an eye condition that causes blurred vision), and right eye glaucoma. It also revealed she had not had a poor appetite during the previous seven (7) day look-back period but required only setup assistance with eating. The Care Plan dated 10/13/23 indicated the resident was at risk for altered nutrition and weight loss and directed staff to monitor her diet tolerance. The Electronic Health Record (EHR) Weight Summary revealed the resident weighed 137.8 lbs. on 10/13/23 and 125.2 lbs. on 12/18/23; a -9.14 % weight loss. It also included a dietary progress note that indicated the resident's weight loss was likely due to having not met nutritional needs. An emergency room discharge summary revealed the resident was diagnosed with dehydration on 12/29/23, received Lactated Ringers and Sodium Chloride IV fluids, and returned to the facility on [DATE]. On 2/01/24 at 12:07 PM, the Director of Nursing (DON) stated staff are expected to provide residents nutrition to maintain healthy weight to prevent weight loss or hydration. A policy titled Food and Nutrition Services revised 10/2017 indicated nursing personnel, with the assistance of the food and nutrition services staff, will evaluate food and fluid intake of residents with, or at risk for, significant nutritional problems.

Based on clinical record review, observation, staff interviews, and policy review the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by not verifying gastrostomy tube (G-tube) is functioning properly before administering medications for 1 of 1 residents (Resident #18) reviewed. The facility reported a census of 40 residents. Findings include: Record review of the Minimum Data Set (MDS) for Resident #18 dated 12/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Further review of the MDS revealed diagnosis of quadriplegia, anoxic brain damage, seizure disorder, dysphagia, and need for assistance with personal care. Review of the Electronic Healthcare Record (EHR) tab labeled orders revealed physician orders for 18 french g-tube, three times a day verify tube placement every shift for AM, Midday, and bedtime, three times a day check residual every shift if less than 30mL (milliliters) note in progress note, and every 4 hours Jevity 1.5 formula with a flow rate of 50 ml per hour x 4 hours off for 1 hour and a water flow rate of 45 ml per hour x 4 hours and off for 1 hour. During an observation on 1/31/24 at 12:13 PM Staff C Licensed Practical Nurse (LPN) washed her hands and donned gloves. Staff C placed Resident #18's feeding pump on hold and flushed it with 240 mL of water via piston syringe utilizing a slow push method with no residual check before the water flush. Staff C mixed the crushed medication with 10 mL of water, placed it into the g-tube and then flushed it with another 120 mL of water. Staff C then placed another 10 mL into the med cup to rinse medication residue and drew up into the piston syringe. This was then placed into the g-tube and flushed with another 60 mL of water. Staff C reattached Resident #18's feeding tube to his g-tube and doffed her gloves. Staff C then resumed the feeding on the pump and completed hand hygiene. During an interview on 1/31/24 at 12:22 PM with Staff C LPN revealed that residuals are only checked on nights if she recalled correctly. Staff C revealed that she could not let the water flushes flow via gravity related to Resident #18's g-tube getting clogged easily. Staff C further revealed she was unaware she was supposed to be checking residuals at this time of day. During an interview on 1/31/24 at 12:47 PM with Staff H Director of Nursing (DON) revealed her expectations were for medications to be administered via gravity and residuals to be obtained per the physician's orders. Review of a facility provided policy titled, Administering Medications through an Enteral Tube with a revision date of November 2018 revealed: a. Verify placement of feeding tube. b. Administer medication by gravity flow.

Based on clinical record review, staff interviews, and policy review the facility failed to provide dialysis services consistent with professional standards by not completing a pre and post dialysis assessments for 1 of 1 residents (Resident #30) reviewed. The facility reported a census of 40 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #30 dated 11/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Further review of the MDS revealed diagnosis of end-stage renal disease, and dependence on renal dialysis. Review of the Electronic Healthcare Record (EHR) document titled Clinical Physician Orders revealed orders for pre-dialysis and post-dialysis evaluations on Monday, Wednesday, and Fridays related to dependence on renal dialysis. Further review revealed an order for non-dialysis day evaluation every day shift on Tuesdays, Thursdays, Saturdays, and Sundays related to end stage renal disease. Review of the EHR document titled Clinical-Assessment from 1/1/24 through 1/29/24 revealed pre-dialysis assessments were missed on 4 of the 29 days reviewed, post-dialysis assessments were missed 8 of the 29 days reviewed, and non-dialysis day assessments were not completed on 3 of 29 days reviewed. During an interview on 1/31/24 at 10:37 AM with Staff C Licensed Practical Nurse (LPN) revealed dialysis assessments are to be completed twice daily on dialysis days and once a day on off days. During an interview on 1/31/24 at 10:40 AM Staff A LPN revealed dialysis assessments are to be completed pre and post dialysis. Staff B revealed that Resident #30 is usually gone before she gets here so she usually gets the post assessments completed. Staff B then revealed that she is unsure if dialysis assessments are completed on off days when there are no dialysis treatments. During an interview on 1/31/24 at 10:51 AM with Staff H Director of Nursing (DON) revealed her expectations would be for pre and post assessments for dialysis to be completed as ordered and an assessment to be completed on non-dialysis days. Review of a facility provided policy titled, End-Stage Renal Disease, Care of a Resident with, with a revision date of September 2010 revealed: a. The type of assessment data that is to be gathered about the resident ' s condition on a daily or per shift basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and facility policy review the facility failed to ensure medication error rates are not 5 percent or greater by having a medication error rate of 7.41%. The facility reported a census of 40 residents. Finding include: The Minimum Data Set, dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Observation completed of 26 medications administered and 1 medication ordered but not administered. A total of 27 medication administration opportunities for error. Observation of 2 medication administration errors when Staff A had intention on giving 6 units of Insulin Glargine (long acting insulin) when 6 units of Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) was ordered. This revealed a medication error rate of 7.41%. Review of Resident #37's physician orders revealed an order for Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) inject 25 unit subcutaneously at bedtime for diabetes and an order for Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) inject 6 units under the skin three times daily before meals. Observation on 1/31/24 at 8:30 AM revealed Staff A, Licensed Practical Nurse (LPN), drew up 6 units of Insulin Glargine (long acting insulin). Staff A entered Resident #37's room with the insulin. On 1/31/24 at 8:39 AM Staff A stated her intention was to give the insulin. Medication administration stopped by the surveyor at that time. Staff A returned to the medication cart and drew up 6 units of Insulin Aspart returned to Resident #37 and administered insulin. Review of policy titled, Administering Medications revealed that medications would be administered in accordance with prescriber orders, including any required time frame. The individual that administered medications verified the resident ' s identity before giving the resident his/her medications. Methods of identifying the resident include: Check identification band, Check photograph attached to medical record, and If necessary, verify resident identification with other facility personnel. The individual that administered the medication checked the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. On 1/31/24 at 10:19 AM Resident #37's Nurse Practitioner stated that giving long acting insulin would have peaked about 12 hours later than expected peak. Resident #37's Nurse Practitioner stated she did not think that would lead to serious harm or death. Resident #37's Nurse Practitioner stated the facility would have needed to ensure Resident #37 had eaten food throughout the day to ensure her blood sugar would not drop. On 1/31/24 at 9:25 AM the DON stated the facility's expectation was the nurse would follow the 6 rights to medication administration and would have thoroughly checked that the medication is correct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy review the facility failed to ensure the residents were free of significant medication errors to 1 of 4 residents reviewed (Resident #37). The facility reported a census of 40 residents. Finding include: The Minimum Data Set, dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) of 6 indicating severe cognitive impairment. Review of Resident #37's physician orders revealed an order for Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) inject 25 unit subcutaneously at bedtime for diabetes and an order for Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) inject 6 units under the skin three times daily before meals. During an observation on 1/31/24 at 8:30 AM of insulin administration observed Staff A, Licensed Practical Nurse (LPN), draw up 6 units of Insulin Glargine (long acting insulin) and enter Resident #37's room with the insulin. On 1/31/24 at 8:39 AM Staff A stated her intention was to give the insulin. Insulin administration stopped by the surveyor at that time. Staff A returned to the medication cart and drew up 6 units of Insulin Aspart, returned to Resident #37 and administered the insulin. Review of policy titled, Administering Medications revealed that medications would be administered in accordance with prescriber orders, including any required time frame. The individual that administered medications verified the resident ' s identity before giving the resident his/her medications. Methods of identifying the resident include: Check identification band, Check photograph attached to medical record, and If necessary, verify resident identification with other facility personnel. The individual that administered the medication checked the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. On 1/31/24 at 10:19 AM Resident #37's Nurse Practitioner stated that giving long acting insulin would have peaked about 12 hours later than expected peak. The Nurse Practitioner stated she did not think that would lead to serious harm or death. She stated the facility would have needed to ensure Resident #37 had eaten food throughout the day to ensure her blood sugar would not drop. On 1/31/24 at 9:25 AM the DON stated the facility's expectation was that the nurse would follow the 6 rights to medication administration and would have thoroughly checked that the medication is correct.

Based on clinical record review, observations, resident interviews, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 5 residents ( Residents #6, #8, and #9) reviewed. The facility reported a census of 40 residents. Findings include: 1. Review of the Minimum Data Set (MDS) for Resident #6 dated 12/27/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. During an interview on 1/29/24 at 2:45 PM Resident #6 revealed that sometimes food is cold when it should be hot. 2. Review of the MDS for Resident #9 dated 12/23/23 revealed a BIMS score of 15 indicating intact cognition. During an interview on 1/29/24 at 3:13 PM Resident #9 revealed that the food is sometimes cold when it should be hot. 3. On 1/30/24 at 1:36 PM a sample tray taken to the residents rooms. On 1/30/24 01:38 PM the sample tray returned to the kitchen and the temperature of the food obtained. The temperature of the rice registered 101.9 degrees, the Dorito chicken 122.4 degrees, and the corn 103.7 degrees. On 1/30/24 at 1:39 PM Resident #8's room tray returned to the kitchen. The temperature of the pureed Dorito chicken registered 102.1 when returned. Resident #8 informed the staff she returned the tray due to the food not warm enough. Review of policy titled, Food and Nutrition Services revealed that food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. On 1/30/24 at 5:30 PM the Administrator stated food temperatures should meet the federal regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the MDS for Resident #3 dated 11/22/23 revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed diagnosis of diabetes mellitus, hyperlipidemia, and hemiplegia. Review of Resident #3's Care Plan revealed an initiation date of 1/23/24 for assistance to the bathroom with the EZ stand and 2 assist. During an interview with Staff H Director of Nursing (DON) she stated Resident #3 is a Hoyer lift and has been only a Hoyer lift. During an observation 1/31/24 Resident #3 refused observation of Hoyer lift transfer. During a follow up interview 1/31/24 with Staff H revealed her expectation is for care plans to be updated and correct when there are changes. Review of a facility provided policy titled, Care Plans, Comprehensive Person-Centered with a revision date of December 2016 revealed: a. The Interdisciplinary Team must review and update the care plan. On 2/01/24 at 12:07 PM, the Director of Nursing stated care plans should be reviewed and revised with different interventions. She also indicated histories of multiple UTI's, required oxygen therapy, and restorative program recommendations should be included in the resident's care plan. She further added resident representatives for residents with a BIMS of 08 should be invited to participate in the resident's care conference but the care conference should not be delayed if the representative doesn't attend. A policy titled Care Plans, Comprehensive Person-Centered revised 12/2016 indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. Based on observation, clinical record review, staff interviews, and policy review, the facility failed to fully review and revise the comprehensive care plan for 4 of 4 residents reviewed (#3, #15, #20, & #23) and failed to include family representatives of 1 of 1 resident reviewed (#15). The facility reported a census of 40 residents. Findings include: 1. On 1/30/24 at 2:56 PM, Resident #15's family member revealed the resident was treated for a Urinary Tract Infection (UTI) at the beginning of December 2023 and the resident declined in her functional abilities and was no longer receiving therapy. The family member also indicated the resident had no representative present for the initial care conference. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 08 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of unspecified injury of the head, disorders of the peripheral nervous system, inflammatory bowel disease, retinal vascular occlusion (an eye condition that causes blurred vision), and right eye glaucoma. It revealed the resident was dependent with toileting and personal hygiene but indicated the resident had not had a UTI in the last 30 days. The Electronic Health Record (EHR) physician orders indicated the resident received one (1) 300 mg Cefdinir Oral Capsule by mouth two times a day for UTI between 12/04/23 and 12/13/23. The Care Plan lacked a UTI focus prior to 1/02/24. The MDS indicated the resident independent with mobility, required moderate assistance with toilet and shower transfers, and substantial assistance with ambulating 10 feet. She also required setup or supervision assistance for Activities of Daily Living (ADLs) and moderate assistance with putting on or taking off footwear. The MDS included the resident began Physical Therapy (PT) and Occupational Therapy (OT) on 10/18/23 and Speech Therapy (ST) on 10/18/23. The Care Plan dated 10/13/23 included a focus of therapy services, acknowledged orders for PT/OT/ST, and set a resident goal of continued work with therapy as the doctor ordered. The Electronic Health Record (EHR) included physician order for PT/OT/ST to evaluate and treat the resident as indicated. The EHR also contained a Notice of Medicare Non-Coverage (NOMNC) that indicated therapy services would end on 12/22/23. On 1/31/23 at 11:33 AM, Staff S, Occupational Therapist (OT) stated therapy discharged the resident due to on-going knee pain, decreased appetite, and plateau of progress, and declining engagement. She indicated the resident was referred for restorative nurse program and no evidence of implementation. The PT Discharge summary dated [DATE] included restorative program recommendations of lower extremity passive range exercises. The EHR task list did not include restorative program exercises or directives. The Care Plan lacked restorative program recommendations. 2. The MDS dated [DATE] indicated the resident had a BIMS score of 08 of 15, indicating a moderate cognitive impairment. It included diagnoses of pneumonia, Coronary Artery Disease, Non-Alzheimer's dementia, and hypoxemia (low blood oxygen level). It also indicated the resident had not used oxygen in the seven (7) day look-back period. The Electronic Health Record (EHR) included a physician's order dated 1/14/24 directing staff to titrate oxygen to keep the resident's oxygen saturation (O2 sat) above 90%. On 1/29/24 at 12:51 PM, Resident #20 observed receiving nasal cannula oxygen while she slept in bed. The Care Plan lacked the resident's oxygen requirements and parameters. 3. On 1/30/24 at 9:40 AM, Resident #23 was observed lying in bed and had difficulty repositioning herself. The resident stated she used to be able to walk but was had not received restorative care. The quarterly MDS dated [DATE] revealed Resident #23 had a BIMS score of 15 of 15, indicating a complete intact cognition. It included diagnoses of Neurogenic bladder, Diabetes Mellitus, Multiple Sclerosis, and paraplegia. It also indicated the resident had functional limitation in her lower extremities and was dependent or required maximum assistance with all ADLs involving lower extremities. The MDS included the resident began PT and OT on 5/26/23 and ST on 5/30/23 and services ended on 6/02/23 and 6/01/23, respectively. The Care Plan revised 10/04/23 included a focus of therapy services, acknowledged orders for PT/OT/ST, and set a resident goal of continued work with therapy as the doctor ordered but restorative program recommendations. The Electronic Health Record (EHR) included physician order for PT/OT/ST to evaluate and treat the resident as indicated. On 1/31/24 at 8:13 AM, Staff S, OT stated insurance denied the resident's therapy. She indicated the Physical Therapist entered restorative program recommendations for bilateral lower extremity, passive range-of-motion exercises but did not include the frequency. The PT Discharge summary dated [DATE] included restorative program recommendations of lower extremity passive range exercises. The EHR task list did not include restorative program exercises or directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document review, and staff interview the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets by not having a staff on duty at the facility trained in cardiopulmonary resuscitation (CPR) for 5 days in the month of [DATE]. The facility reported a census of 40 residents. Findings include: Review of documents titled, Daily Staffing Sheets for the month of [DATE] revealed the facility had no staff trained in cardiopulmonary resuscitation on [DATE] from 6 PM till 6 AM, [DATE] from 6 PM till 6 AM, [DATE] from 6 PM till 10 PM, [DATE] from 10 PM till 6 AM, and [DATE] from 6 PM till 6 AM. On [DATE] at 9:00 AM the Administrator acknowledged on [DATE] 6 PM till 6 AM, [DATE] 6 PM till 6 AM, [DATE] 6 PM till 10 PM, [DATE] 10 PM till 6 AM, and [DATE] 6 PM till 6 AM there was not a CPR certified staff present at the facility. The Administrator stated the facility's expectation was that a staff member trained in providing CPR would be working at the facility 24 hours a day. The Administrator stated the facility had no policy on the 24 hour need for CPR certified staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, policy review, and staff interviews, the facility failed to secure medications in a locked compartment for to 1 of 3 residents reviewed (Residents #33). The facility also failed to label open medication with the date the medication was opened for 27 of 30 medications reviewed. The facility reported a census of 40 residents. Findings include: The Minimum Data Set, dated [DATE] documented Resident #33 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Review of physician orders for Resident #33's revealed a discontinued order for Lorazepam Intensol 2 mg/mL. Orders to give 0.25 mL by mouth as needed for restlessness. On 2/1/24 at 10:45 AM an observation of both medication carts and treatment cart revealed Vitamin D-3 2000 IU, Bisacodyl 5 mg, Vitamin E 180 mg, Vit D 1000 IU, Magnesium Oxide 400 mg, Multi-Vitamin, Cranberry 450 mg, B-12 500 mg, Folic Acid 400 mcg, Calcium 500 mg, Aleve 220 mg, Loratadine 10 mg, Vitamin B-12 1000 mcg, Timolol date open sticker no date, Prednisolone date open sticker no date, Lidocaine, Rena Vite, Acetaminophen 500 mg, Melatonin 5 mg, Lactulose liquid 10 mg/15 mL, Levetiracetam liquid 100 mg/mL, Milk of Magnesia, Metoclopramide liquid 5 mg/5 mL, Lidocaine and Prilocaine Cream 2.5%, Triamcinolone Ointment 0.1%, Pain relief cream, and BioFreeze open and undated. On 2/1/24 at 11:00 AM an observation of the medication storage room revealed the door to the medication refrigerator unlocked with a lock hanging on the door. Observed Resident #33's Lorazepam Intensol in the door of the refrigerator with the door to the medication storage room unlocked. On 2/1/24 at 11:26 AM Staff G Certified Medication Assistant (CMA), stated the facility's expectation was that all medications would be labeled with the date the medication opened. Review of policy titled, Storage of Medications revealed schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. On 2/1/24 at 11:15 AM the Director of Nursing (DON) stated the facility's expectation was that all medication would be dated when they are opened. The DON stated it was the facility's expectation that the Lorazepam would be locked up behind 2 locks.

Based on observations, facility document review and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs of the resident for 1 of 19 residents reviewed (Resident #9). The facility reported a census of 19 residents. Findings include: On 1/30/24 at 12:56 PM a continuous observation of lunch service revealed a #10 white handled scoop used for the service of Spanish rice to all residents that requested the regular lunch except to residents with a pureed diet. Review of scoop sizes revealed a #10 scoop was 3 ¼ oz. Review of document titled, Therapeutic Spread report - Fall and Winter regular menu revealed #8 scoop, 4 oz. or ½ cup of Spanish rice to be served to all diets. An observation on 1/30/24 at 1:41 PM revealed Staff P [NAME] using a spatula to empty pureed Doritos chicken from the food processor into 2 bowls. 1/4 cup pureed mix left in the food processor. On 1/30/24 at 1:41 PM Staff P stated she eyeballed the size and made the bowls level with each other when splitting the portions of the pureed meal. Staff P stated she usually just decides the scoops on her own. Staff P stated would usually use a gray scoop for the main course. Staff P stated she did not have anything to tell her the appropriate scoop sizes. Staff P stated she just decides the scoop sizes herself. Review of policy titled, Food and Nutrition Services revealed that each resident would be provided with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. On 1/30/24 at 5:30 PM the Administrator stated that she had spoken to the dietary department about scoop sizes in the past and would rather the food over-serve than under-serve for portion sizes. The Administrator stated the facility's expectation was to follow the scoop sizes as ordered on the menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Review of physician orders for Resident #1 revealed an order for regular/NAS diet, mechanical soft texture, level 0. An observation on 1/30/24 at 12:56 PM of lunch service revealed Staff O serving all residents on a mechanical soft diet, Dorito chicken with the same consistency as regular diet residents. Staff O used a scoop spoon to cut the larger pieces of chicken. 3. The MDS dated [DATE] documented Resident #10 had a BIMS of 14 indicating no cognitive impairment. MDS also documented a diagnosis of dysphagia. Review of physician orders for Resident #10 revealed an order for regular/NAS diet, mechanical soft texture, level 0. An observation on 1/30/24 at 12:56 PM of lunch service revealed Staff O serving all residents on a mechanical soft diet, Dorito chicken with the same consistency as regular diet residents. Staff O used a scoop spoon to cut the larger pieces of chicken. An observation on 1/30/24 at 1:20 PM of Resident #10 ' s plate with a piece of chicken an inch in length. 4. The MDS dated [DATE] documented Resident #11 had a BIMS of 13 indicating no cognitive impairment. Review of physician orders for Resident #11 revealed an order for regular/NAS diet, mechanical soft texture, level 0. An observation on 1/30/24 at 12:56 PM of lunch service revealed Staff O serving all residents on a mechanical soft diet, Dorito chicken with the same consistency as regular diet residents. Staff O used a scoop spoon to cut the larger pieces of chicken. On 1/30/24 at 3:42 PM Staff P, [NAME] stated the mechanically soft diet should be ground meats. Staff P stated that she thought the food for lunch on 1/30/24 should have been ground but Staff O, Dietary Manager told her that it was acceptable to serve in the form it was in. Staff P stated Staff O said the meat was soft enough that the food would fall apart and the residents on mechanical soft diets would be able to chew it. Staff P stated she would not expect to see pieces of anything in a pureed diet. Staff P stated the pureed food should not have any shape that are identifiable. On 1/30/24 at 3:51 PM Staff R Registered Dietitian stated she would expect that the chicken should have been ground in the Dorito chicken. Staff R stated there should not be any chunks in the pureed food and should not be able to identify the food by the shape of the food. On 1/30/24 at 5:30 PM the Administrator stated the facility's expectation was the modified diets would be followed when served to residents. On 2/01/24 at 12:07 PM, the Director of Nursing (DON) stated residents should receive the correct ordered diet. A policy titled Therapeutic Diets revised 10/2017 indicated therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. A policy titled Food and Nutrition Services revised 10/2017 directed food and nutrition staff to inspect food trays to ensure that the correct meal is provided to each resident. Based on observation, clinical record review, resident interview, staff interviews, and policy review, the facility failed to serve the appropriate diet type to 4 of 4 resident reviewed (#1, #8, #10, & #11). The facility reported a census of 40 residents. Findings include: 1. During an observation on 1/29/24 at 1:14 PM observed Resident #8 eating amd she spit out chunks of food in a napkin on her bedside table. She stated she had difficulty swallowing the food and indicated her diet was supposed to be pureed. She confirmed the chunks of food were carrots and potatoes. Her tray included a cookie and a slice of bread. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating completely intact cognition. It included diagnoses of retromolar cancer (area directly behind the last teeth), hyponatremia (low salt levels in the blood), malnutrition, sialoadenitis (inflamed salivary glands), and Chronic Obstructive Pulmonary Disease (COPD). It also indicated the resident received a mechanically altered diet (includes pureed) as a resident and required setup assistance for eating. The Care Plan revised 5/9/23 indicated the resident was ordered a pureed diet due to swallowing problems and directed staff to provide her with pureed textured, regular diet. The Electronic Health Record (EHR) included a pureed diet order dated 2/4/22. On 1/31/24 at 9:02 AM, Resident #8 stated she received the wrong textured diet before but denied she ever choked on any food. She stated she was able to feel it with her tongue and spit it out.

Based on observation, staff interview, and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal preparation and service of a meal. The facility reported a census of 40 residents. Findings include: An observation on 1/30/24 at 11:45 AM revealed Staff O, Dietary manager scooping ice from the ice machine and supporting the bottom front lip of the ice scoop with a bare hand and pouring it into tubs to keep liquids cold. Observed this repeated 6 times. An observation on 1/30/24 at 11:47 AM revealed Staff P [NAME] removed an entire loaf of bread from the sack with gloves on. Staff P placed the bread on the cooking sheet, used her right hand to butter the bread and left hand to hold the bread. Staff P obtained a bag of cheese from across the kitchen in a refrigerator, opened the bag and removed a stack of cheese from the bag of cheese. Staff P placed the cheese on the bread, placed the leftover cheese back into the bag and zipped the bag shut. Staff P obtained foil to cover the cooking sheet, put oven mitts on with gloves on, moved oven rack in oven, removed oven mitts, obtained sealed bag of ham, and obtained new cooking sheet. Staff P placed 16 pieces of bread on a cooking sheet, obtained bread, used left hand to hold the bread and right hand to butter the bread. Staff P removed a stack of Swiss cheese from a bag of Swiss cheese, applied cheese to the bread, and placed the leftover cheese back into the bag. Staff P obtained a knife to open the ham from the drawer, and removed a stack of ham from the bag. Staff P then applied ham to the bread using both hands and placed leftover ham back into the bag. Staff P utilized the knife used to open ham to cut sandwiches and removed her gloves. Staff P obtained a pan and a liner applied to the pan. Staff P pressed the pan liner into the pan with bare hands and poured Spanish rice into the pan with the liner. Staff P applied gloves, obtained a second pan, applied liner, pressed liner in with gloved hands and separated the Doritos chicken into 2 separate pans. Review of policy titled, Food Preparation Service revealed that bare hand contact with food was prohibited. Gloves were worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. On 1/30/24 at 5:30 PM the Administrator stated the expectation is that hand hygiene would be completed and gloves would be changed during any sort of cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices when providing blood glucose sampling for 4 of 4 residents reviewed (Resident #21, #29, #31 and #37). The facility reported a census of 40 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #21 had a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. MDS also documented a diagnosis of diabetes. 2. The MDS dated [DATE] documented Resident #29 had a BIMS of 13 indicating no cognitive impairment. The MDS also documented a diagnosis of diabetes. 3. The MDS dated [DATE] documented Resident #31 had a BIMS of 15 indicating no cognitive impairment. The MDS also documented a diagnosis of diabetes. 4. The MDS dated [DATE] documented Resident #37 had a BIMS of 6 indicating severe cognitive impairment. Review of physician orders for Resident #37 revealed an order to check blood sugar 4 times daily and as needed. On 1/31/24 at 7:30 AM an observation revealed Staff C entered Resident #21's room and obtained a sample of blood. Blood glucose at that time was 138. Staff C returned to the medication cart and completed hand hygiene. Staff C then walked down the hall to Resident #31's room and obtained a sample of blood. Blood glucose at that time was 155. Staff C returned to the medication cart and completed hand hygiene. One blood glucose machine was used between both residents. Staff C then wiped the blood glucose machine down with an alcohol wipe. On 1/31/24 at 7:51 AM Staff C stated she did not know the procedure for sanitizing the blood glucose monitoring machine between residents. On 1/31/24 at 7:57 AM an observation revealed Staff A entered Resident #29's room and obtained a sample of blood. Blood glucose at that time was 133. Staff A returned to the medication cart and completed hand hygiene. Staff A then walked down the hall to Resident #37's room and obtained a sample of blood. Blood glucose at that time was 151. Staff A returned to the medication cart and completed hand hygiene. One blood glucose machine used between both residents. Staff A returned the blood glucose monitor to the drawer in the medication cart. Review of a policy titled, Blood Sampling revealed the purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Single-resident use fingerstick devices (pen-like devices) should never be used by more than one resident. On 1/31/24 at 9:25 AM the Director of Nursing (DON) stated she did not realize each resident did not have their own blood glucose monitor. The DON stated the nurses should be utilizing appropriate sanitizing wipes. The DON stated the blood glucose monitor should have been sanitized and wrapped for 3 minutes. The DON stated the facility's expectation was that appropriate sanitization would have been completed between all residents. Based on observations, clinical record review, staff interviews, and policy review the facility failed to implement appropriate infection control practices to prevent infection and/or cross contamination. The facility reported a census of 40 residents. Findings include: 1. On 1/29/24 at 12:51 PM, Resident #20 observed receiving nasal cannula oxygen while she slept in bed. The tubing labeled with an orange sticker and dated 1/28/24. The Minimum Data Set, dated [DATE] indicated the resident had a BIMS score of 8 out of 15, indicating a moderate cognitive impairment. It included diagnoses of pneumonia, Coronary Artery Disease, Non-Alzheimer's dementia, and hypoxemia (low blood oxygen level). The Electronic Health Record (EHR) included a physician's order dated 1/14/24 directing staff to titrate oxygen to keep the resident's oxygen saturation (O2 sat) above 90%. The Care Plan lacked documentation of the use of oxygen therapy. On 1/29/24 at 1:41 PM, observed the resident lying in the same position with her blanket and oxygen tubing lying on the floor. At 3:10 PM, observed the resident covered with the same blanket and the same oxygen tubing placed back on her face. The oxygen tubing's orange label still dated 1/28/24. On 1/30/24 at 1:55 PM, Staff K, Certified Nursing Assistant (CNA) stated she put Resident #20's blanket and oxygen back on her on 1/29/24. 2. An observation on 2/01/24 at 8:52 AM, revealed Staff K, Activities staff, brought the resident's water pitcher out of room [ROOM NUMBER] and used a scoop to fill it with ice stored in a bin on a cart in the hallway. She returned the pitcher to the resident in room [ROOM NUMBER], exited the room, and entered room [ROOM NUMBER]. She repeated that process for rooms [ROOM NUMBER]. Staff K failed to wear gloves and failed to perform hand hygiene during the pitcher filling process. On 2/01/24 at 2:56 PM, the Director of Nursing (DON) stated the oxygen tubing should have been replaced with new tubing and staff should adhere to Infection Control policies. A policy titled Departmental (Respiratory Therapy) - Prevention of Infection revised 11/2011 directed staff to change the oxygen cannula and tubing every seven (7) days, or as needed. A policy titled Standard Precautions revised 10/2018 indicated hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub (ABHR), which does not require access to water and directed staff to perform hand-hygiene after contact with items in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, visitor interview, and facility policy review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility reported a census of 40 residents. Findings include: Observation on 1/29/24 at 12:45 PM of the facility resident halls revealed a pungent odor of urine noted primarily in front of room [ROOM NUMBER] and extended past room [ROOM NUMBER]. The same odor noted upon entry of the 200 hallway and noted primarily around rooms [ROOM NUMBERS]. On 2/01/24 at 10:45 AM, Staff T, Housekeeping Aide (HA) stated the facility is cleaned on a routine schedule and housekeeping relied on nursing staff for notification of subsequent cleaning needs. She stated the toilet in room [ROOM NUMBER] leaked within the last year and staff have not been able to rid the facility of the urine odor. Subsequent observations on 1/30/24, 1/31/24, and 2/01/24 revealed the odor not as pungent but could still be noted in both resident hallways. On 2/01/24 at 12:07 PM, the Director of Nursing (DON) stated the facility should be cleaned daily and staff should remove trash containing body-fluid soiled items from each resident room to minimize odors. Review of the facility provided policy titled Floors revised on 12/2009 documented: Floors shall be maintained in a clean, safe and sanitary manner. The facility did not provide a policy specific to odors.

Based on personnel document review, staff interviews and facility policy review the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 40 residents. Findings include: On 1/30/24 a request for documentation from Staff O Dietary Manager, of qualifications for dietary manager revealed no certification or documentation. Interview on 1/30/24 at 9:02 AM, with Staff O revealed she was currently in charge of running the kitchen. Staff O stated she was not a certified dietary manager, a certified food service manager, does not have a certification for food service management and safety, does not have associate's or higher degree in food service, and does not have 2 or more years worth of experience in the position. Review of policy titled, Dietitian revealed that if a dietitian is not employed full time (35 or more hours per week) a director of food service management will be designated. This individual will be a certified dietary manager, be a certified food service manager, be nationally certified in food service management and safety, have an associate ' s (or higher) degree in food service management or hospitality (must be from an accredited institution and include courses in food service or restaurant management), or meet any state requirements for food service or dietary managers. On 1/30/24 at 10:05 AM the Administrator stated stated Staff O had completed the class but had to take the test still. The Administrator stated she thought that the CDM had 6 months to get into a class after being hired.

Based on facility document review, policy review and staff interview the facility failed to have the minimum members of the quality assessment and assurance committee meet quarterly. The facility reported a census of 40 residents. Findings include: Review of documents titled, Quality Assurance Committee Meeting sign-in from 2/23 through 1/24 revealed 3/23 no DON or Infection Preventionist present, 4/23 no DON present, 5/23 no DON present, 7/23 no DON present, 8/23 no DON or Infection Preventionist present, 9/23 no DON or Infection Preventionist present, 10/23 no Infection Preventionist and only 5 members, and 1/24 only 5 members present for meetings. Review of the policy titled, QAPI Program Governance and Leadership revealed the following individuals serve on the committee: Administrator, or a designee who is in a leadership role, Director of Nursing Services, Medical Director, and Infection Preventionist. Also representatives of the following departments, as requested by the Administrator: Pharmacy, Social Services, Activity Services, Environmental Services, Human Resources, and Medical Records. The committee meets at least quarterly (or more often as necessary). Committee members are reminded of meeting day, time and location via e-mail at least two business days prior to the meeting. On 2/1/24 at 12:14 PM the Administrator stated she did not realize there had to be 6 members. The Administrator stated she thought there only had to be the DON, Medical director and the Administrator. The Administrator stated moving forward the facility's expectation would be what regulations require.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to treat 2 of 13 residents with dignity and respect. Resident #6 was found to be soaked with urine in the morning and she told the staff that she had been instructed to urinate in her brief. Resident #6 was told to decrease his fluid intake so he didn't have to be taken to the restroom so often. The facility reported a census of 36 residents. Findings include: 1) According to theadmission Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive skills. The resident required extensive assistance with the help of 2 staff for bed mobility, transfers and toileting. The resident was occasionally incontinent of urine and always continent of bowel. The Care Plan initially dated on 3/29/23 showed that the resident had acute pain related to cervical vertebrae fracture and she was on an antibiotic for a urinary tract infection. On 8/1/23 at 9:42 AM, Family Member (FM) #1 said that Resident #6 was continent but needed help getting to the bathroom. She was often soaked in urine when he would visit because she couldn't get staff to answer the call light to take her to the bathroom. On 8/1/23 at 2:15 PM, FM #2 said that she would visit the nursing home every other day. One morning when she came in, the resident had been soaked in urine in her bed. The Social Worker (SW) and the Administrator pulled her aside and told her that the overnight aide, Certified Nurse Aide (CNA) Staff C told the resident that she should just pee in her brief, and they would come and change her in the morning. Staff C had been terminated shortly thereafter. On 8/2/23 at 6:30 AM, CNA Staff A, said she was the aide on the morning shift when Resident #6 was soaking wet with urine. She reported it to the Director of Nursing (DON). When Resident #6 was first admitted to the facility she was very cognizant and she would ask to be taken to the bathroom or use the bedpan. She went downhill fast, quit eating and drinking. On 8/1/23 at 3:58 PM, CNA Staff B, said that she came in the morning that Resident #6 had been soaked in urine. She said that they would normally do change of shift rounds where they go from room to room with the outgoing staff. The night shift was in a hurry to leave and they didn't do rounds that morning. At about 6:30 AM she went to check on the resident and found her wet, she asked what happened and the resident told her that a night shift staff person told her not to put on her call light to use the bathroom and to just urinate in her brief. On 8/2/23 at 9:40 AM the Director of Nursing (DON) said that the aides that were working on 5/17/23 when the resident was found soaked in urine, were disciplined and Staff C had been terminated. They both denied having told the resident to urinate in her brief. 2. According to the Qauarterly MDS dated [DATE], Resident #4 required extensive assistance with the help of 2 staff for bed mobility, transfers, dressing and toileting. His diagnosis included hemiparesis (paralysis of one side of the body), cerebral infarction (stroke), pain in the left hip, history of falls, anxiety and benign prostrate hyperplasia (enlarged prostate). A Brief Interview for Mental Status (BIMS), dated 6/14/23, showed that the resident had a score of 15, which indicated intact cognitive ability. A Care Plan dated 12/7/22, showed the resident had diagnoses that included neuropathy and chronic low back pain. Staff were directed to anticipate his needs, approach and speak in calm manor, and to have a urinal available for him to use independently. On 8/1/23 at 11:01 AM Resident #4 was sitting in a recliner in his room. He responded to questions by shaking his head no and said that he was in a lot pain and wanted to be adjusted in his chair. When requested to assist, CNA, Staff F stated I literally just adjusted him in his chair. She went into the room and while the resident was using the urinal, she left the door open where he could be seen in the hallway. A Nurses Note dated 4/25/23 at 8:25 PM written by Licensed Practical Nurse (LPN) Staff D, showed that Resident #4 had been using his call light requesting assistance to the bathroom. Staff D indicated that he had been to the bathroom just 20 minutes prior and he refused to use the urinal. She then instructed him to limit his fluid intake. A Nurses Note dated 7/31/23 at 8:58 PM written by Staff D, indicated that the resident was repeatedly on call light and demanded Milk of Magnesia because he felt constipated. The nurse responded to his request with a comment that his demands would not get a response any sooner. A facility policy titled; Dignity, and dated 2021. Showed that each resident would be cared for in a manner that promoted and enhanced his or her sense of well-being, and feelings of self-worth and self-esteem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with family, record and policy review the facility failed to notify family of an emergency transfer for 1 of 3 resident reviewed. When Resident #6 was sent to the hospital, staff failed to contact the family. The facility reported a census of 36 residents. Findings include: According to the admission Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15. She required extensive assistance with the help of 2 staff for bed mobility, transfers and toileting. She was occasionally incontinent of urine and always continent of bowel. The Care Plan initially dated on 3/29/23 showed that the resident had acute pain related to cervical vertebrae fracture and she was on an antibiotic for a urinary tract infection. A Nurses Note dated 6/3/23 at 4:24 PM, showed that Resident #6 was sent to the hospital that afternoon and the primary care physician and the Director of Nursing (DON) were notified. The nurse was later told that the resident had passed away at the hospital On 8/1/23 at 2:15 PM a family member for Resident #6 said that she would visit the facility every other day. The resident had a change in condition and had quit eating and drinking. On 6/3/23 the family had been called by hospital staff and told that the resident was in the emergency room. She passed away shortly thereafter. During an interview on 8/1/23 at 2:15 p.m. a family member said that the facility had not contacted them to let them know that she was being transferred. On 8/3/23 at 4:00 PM the DON said that the nurse should have contacted the family and informed them that the resident had been transferred to the hospital. According to a facility policy titled; Transfer or Discharge, Emergency, dated 2016. If it was necessary to make an emergency transfer to the hospital, staff were expected to notify the representative or other family member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to provide comprehensive care plans for 3 of 13 residents reviewed. Resident #9 was admitted with a chronic heel ulcer the care plan lacked goals and interventions to prevent worsening of pressures. Resident #11 had a suprapubic urinary catheter, the care plan lacked details on specific catheter cares. Resident #7 was admitted to the facility with a diagnosis of Human Immunodeficiency Virus (HIV) the care plan lacked notice of the virus and any special precautions for staff to take. The facility reported a census of 36 residents. Findings include: 1. Observation on [DATE] at 7:55 AM, revealed Resident #9 in his bed on his back, wearing gripper socks and his heels rested on the bed. The resident reported a sore on his left heel. According to the admission Minimum Data Set (MDS) dated [DATE], Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He required extensive assistance with the help of 2 staff for bed mobility, transfers and toileting. The MDS indicated that the resident did not have any pressure ulcers at the time of admission. An After-Visit Summary faxed from the hospital on [DATE] at 8:25 AM contained admission orders to the nursing home that included direction to staff to apply Alevyn dressing (foam dressing used for fluid absorption and management of partial full-thickness wounds) to the left foot every 5 days. The electronic chart lacked documentation of this order. A facility skin observation dated [DATE] at 10:41 AM, showed that Resident #9 did not have any skin issues. Skin and Wound Observation documentation included the following: a. On [DATE] at 7:48 PM. Injury to the left heel, said to be present upon admission, scabbed with no drainage. Foam dressing intact. Area measured 5.5 centimeters (cm) total area x 3.1 cm (length) x 2.9 cm (width). b. On [DATE] at 3:22 PM, Injury to left heel measured 8.5 cm x 2.6 cm x 5.0 cm. No dressing in place at time of assessment. c. On [DATE] at 3:45 PM, a fax was sent to the doctor and indicated previous area to left heel had an open area and Mepilex (absorbent foam wound dressing) was applied with weekly monitoring. The doctor signed on [DATE]. The electronic chart lacked an order entry for the treatment. The Care Plan lacked goals and interventions related to the wound issues on the resident's left heel until [DATE]. The interventions/tasks column of the Care Plan for Resident #9, dated [DATE], showed three different transfer directions: a. required a mechanical lift for all transfers, b. required one-person assistance with all transfers, c. required 2-person assistance with all transfers. 2. According to the Quarterly MDS dated [DATE], Resident #11 required extensive assistance with the help of two staff for bed mobility, transfers, dressing and toileting. A BIMS assessment dated [DATE] showed a score of 14 (intact cognitive ability). The resident had an indwelling catheter and diagnosis included; renal insufficiency, benign prostate hyperplasia. Observation on [DATE] at 7:15 AM revealed the resident in bed with catheter hooked onto the bed frame. The residents Electronic Health Record (EHR) documented an order as follows; change suprapubic catheter every month and as needed with start date of [DATE]. The Care Plan lacked information regarding current catheter in place. The Care Plan included the following Focus Areas; advanced directive wishes for Do Not Resuscitate (DNR) order with initiated date of [DATE]. At risk for falls, related to double amputee with initated date of [DATE]. Resident was frequently to totally incontinent of urine with initated date of [DATE]. An order dated [DATE] in the electronic chart, indicated that the residents wishes were to have cardiopulmonary resuscitation (CPR) initiated if he were in cardiac arrest. 3. According to the MDS dated [DATE], Resident #3 was admitted on [DATE] with BIMS score of 14 (intact cognitive ability). He required limited assistance with the help of one for transfers, walking, dressing, toileting. The diagnosis tab of the electronic chart included a diagnosis of Human Immunodeficiency virus (HIV). The Care Plan lacked indications of this diagnosis or infection control interventions that should be implemented. The care plan lacked goals or interventions related to his HIV status. On [DATE] at 4:00 PM, The Director of Nursing (DON) agreed that the HIV, catheter cares and transfer techniques and code status should have been added to care plans, and or documented correctly. A facility policy titled: Care Plans, Comprehensive, Person Centered, dated 2001, indicated that a comprehensive, person-centered care plan should include measurable objectives related to the resident's individual needs. Assessments of the residents were to be ongoing and revised as conditions changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow up with physician orders for 3 of 13 residents reviewed. Resident #9 had an order for wound care on a chronic heel ulcer. The order did not get entered into the electronic chart. Upon admission, Resident #7 had an order for daily weights and orthostatic blood pressures, the facility failed to follow through with this order. Resident #6 developed a pressure sore and the dietician recommended some supplements. Staff failed to make sure the doctor received the recommendations and wrote an order. The facility reported a census of 36 residents. Findings include: 1. In an observation on 8/1/23 at 7:55 AM, Resident #9 was in his bed on his back, wearing gripper socks and his heels were resting on the bed. The resident said he had a sore on his left heel. According to the admission Minimum Data Set (MDS) dated [DATE], Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He required extensive assistance with the help of 2 staff for bed mobility, transfers and toileting. The MDS indicated that the resident did not have any pressure ulcers at the time of admission. An After-Visit Summary faxed from the hospital on 6/12/23 at 8:25 AM contained admission orders to the nursing home that included direction to staff to apply Alevyn dressing (foam dressing used for fluid absorption and management of partial full-thickness wounds) to the left foot every 5 days. The electronic chart lacked documentation of this order. A facility skin observation dated 6/18/23 at 10:41 AM, showed that Resident #9 did not have any skin issues. Skin and Wound Observation documentation included the following: a. On 6/20/23 at 7:48 PM. Injury to the left heel, said to be present upon admission, scabbed with no drainage. Foam dressing intact. Area measured 5.5 centimeters (cm) total area x 3.1 cm (length) x 2.9 cm (width). b. On 7/7/23 at 3:22 PM, Injury to left heel measured 8.5 cm x 2.6 cm x 5.0 cm. No dressing in place at time of assessment. c. On 7/7/23 at 3:45 PM, a fax was sent to the doctor and indicated previous area to left heel had an open area and Mepilex (absorbent foam wound dressing) was applied with weekly monitoring. The doctor signed on 7/10/23. The electronic chart lacked an order entry for the treatment. 2. According to the admission Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15. She required extensive assistance with the help of 2 staff for bed mobility, transfers and toileting. She was occasionally incontinent of urine and always continent of bowel. The Care Plan documented the resident had the following focus area; provide the resident a regular diet, with regular texture, and thin liquid consistency. The Care Plan directed staff to monitor tolerance of the diet that was ordered with initiated date of 3/29/23. A nursing note dated 4/27/23 at 10:19 AM showed that Resident #6 had a pressure injury on her coccyx and the dietician recommended Liquicel (liquid protein) 1 ounce (oz) once a day and Arginaid (nutritional supplement) once a day mixed with 4 oz of yogurt. The documentation was passed onto nursing and the chart lacked documentation that the doctor had been notified of the recommendation. The electronic chart lacked orders for the Liquicel and Arginaid. On 8/9/23 at 2:45 PM the Dietician reported that when she made a recommendation for nursing to communicate to the doctor, if she's not in the facility she will send an email to the Director of Nursing (DON) to put the recommendation in the binder for the doctor to sign off when he is in the building doing rounds. 3. The Quarterly MDS dated [DATE], showed that Resident #7 had a BIMS score of 14 (intact cognitive ability) He was admitted on [DATE] after an acute hospitalization. He required limited assistance with the help of one staff for transfers, walking, dressing and toileting. The MDS documented that the resident had diagnoses including high blood pressure, alcoholic cirrhosis of liver with ascities (liver disorder with complications of fluid retention and abnormal blood pressure), and cornary artery disease. A Clinical Physician Order dated 4/17/23 directed staff to complete orthostatic blood pressures daily for 5 days, and daily weights for 5 days. The electronic chart showed that the orthostatic blood pressures were completed on the 19th only and one weight was taken only on the 21st. On 8/2/23 at 1:15 PM, Resident #7 said the during his time at the facility, the staff was mostly agency and they weren't familiar with his needs. He said he was having dizzy spells and the staff were supposed to take his orthostatic blood pressures daily and that did not happen. Facility policy titled; admission Orders dated 2005, indicated that residents would receive appropriate treatment and services starting upon admission. Essential information for new admission or readmission would include frequency of monitoring, medications and treatments and appropriate infection control measures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to use safe transfer techniques for 2 of 3 residents, and failed to implement an intervention to prevent falls for 1 of 3 residents. (Resident#3, #2, #13). The facility reported a census of 36 residents. Findings include: 1. According to the Quarterly Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He required extensive assistance with the help of 2 for bed mobility, transfers, dressing and toileting. The Care Plan for Resident #3 indicated that he had a suprapubic catheter (date initiated 8/6/19) and required a mechanical lift for transfers (date initiated 9/16/22). Diagnosis included; acquired absence of the right great toe, anxiety disorder, cellulitis and obesity. On 7/31/23 at 7:57 AM Resident #3 sat on the edge of the bed as Certified Nurse Aide (CNA), Staff F, and CNA, Staff A, pushed the EZ Stand mechanical lift in front of him and applied the sling. They buckled the strap in the front and raised him up to the standing position. When he was in the standing position, they transferred him to the recliner chair but failed to tighten the strap once he was standing. 2. According to the MDS dated [DATE], Resident #2 had a BIMS score of 14 (intact cognitive ability). He was totally dependent on two staff for bed mobility and toileting. Diagnoses included; wedge fracture of 4th lumbar vertebra, osteoporosis, and chronic obstructive pulmonary disease. The Care Plan for Resident#2 with initiated date of 7/24/23 directed staff to use two staff for all transfers. On 7/31/23 at 3:13 PM, a family member for Resident #2 said that over the previous weekend, a couple of CNA's were moving the resident up in bed and rather than use the sheets to adjust him, they put their arms under his armpits and pulled him up and it hurt his shoulders. The resident said that both of his shoulders hurt after they tried to move him in the bed. On 8/1/23 at 1:43 PM, Registered Nurse (RN) Staff J said that the resident's sister came and told her that an aid hurt him when they moved him but the resident hadn't said anything to her about an incident. On 8/1/23 at 3:14 PM, CNA, Staff K acknowledged that he and another aide did not know that there was a mat on his bed with handles that they could use to scoot the resident up in bed. He said that and they may have hurt his shoulder but pulling him up by the upper arms. On 8/1/23 at 1:45 PM, CNA Staff L said that the resident told her that 2 aides had hurt his shoulders when they moved him in bed. 3. According to the Annual MDS dated [DATE], Resident #13 had a BIMS score of 7 (moderate cognitive deficits). She required limited assistance with the help of 2 staff for bed mobility, transfers, dressing and toileting. She used a wheel chair for mobility and was occasionally incontinent of urine. The Care Plan documented on initiated date 3/29/23 that the resident tended to refuse to allow staff to provide cares and preferred to sleep during the day. The Care Plan focus area with initiated date of 9/16/23 documented the resident an actual fall with no injury, and directed two staff to assist the resident with a gait belt for all transfers and used wheel chair for mobility. Staff were directed to use Dyscem (anti-slip material) to wheelchair to prevent her from sliding from the chair. On 8/3/23 at 8:43 the residents wheel chair (WC) was across the room and she was in bed. There was no Dycem material on the seat. On 8/8/23 at 8:59 AM the resident had just been transferred to her bed from the wheel chair. The wheel chair had a protective pad on the seat but no Dycem material. On 8/3/23 at 4:00 PM the Director of Nursing (DON) said that Resident #13 should have the Dycem in her WC to prevent her from sliding out and that she would follow up and educate the staff that moved Resident #2 using unsafe techniques. A facility policy titled: Safe Lifting and Movement of Residents 2017, showed that in order to protect the safety and well-being of staff and residents, and to promote quality care, the facility used appropriate techniques and devices to lift and move residents. According to the manufacturer guide titled; EZ Way Smart Stand dated 7/30/18, page 6, As the patient is being raised simultaneously tighten the safety strap buckled around the torso.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide adequate urinary catheter care for 1 of 3 residents reviewed. After surgery for a suprapubic catheter, Resident #11 continued to have leakage and staff failed to notify the urologist. The resident was found to have the catheter bag on the bed next to him and not hung lower than the bladder. The facility reported a census of 36 residents. Findings include: According to the Quarterly MDS dated [DATE], Resident #11 required extensive assistance with the help of two staff for bed mobility, transfers, dressing and toileting. A BIMS assessment dated [DATE] showed a score of 14 (intact cognitive ability). The resident had an indwelling catheter and diagnosis included; renal insufficiency, benign prostate hyperplasia, The Care Plan updated on 11/27/22 showed that the resident was frequently incontinent of urine with history of catheter use. The care plan lacked information regarding the suprapubic catheter. A review of the clinical record revealed that from July 5th through the 13th, the resident did not have any output from the catheter on 7 days, and 2 days had just 100 milliliters of output. On 8/3/23 at 1:00 PM, Staff I Certified Nurse Aide (CNA), reported that sometimes Resident #11 would urinate and his brief would be wet. She was not sure what the situation was with him and if that was normal for him. On 8/3/23 at 2:40 PM Staff D Licensed Practical Nurse (LPN) reported that Resident #11 was leaking from the suprapubic catheter and from the penis. She said that another nurse had contacted the urologist and they weren't concerned as long as he had some urine output. On 8/3/23 at 12:28 PM, a nurse for the urologist said that they had only gotten calls from the facility a couple of times, once was on 6/21/23 when they gave an order to flush the catheter and on 7/5/23 when they gave an order for Ditropan 10 milligrams (mg) 1x daily for bladder spasms. She said that they would assume that the medication was working if the facility didn't call them back. They would have liked to know if there were further problems. A Nurses Note dated 7/13/23 at 9:41 PM showed that the catheter had been changed on that date and the urine that returned upon insertion had been thick with a strong odor. The chart lacked documentation that the doctor had been contacted regarding abnormal urine. On 8/8/23 at 7:59 AM the resident was in bed sleeping. His catheter bag was on the bed beside him, not lower than the bladder. 8/3/23 at 4:00 PM DON said that they had been in communication with the urologist, and he hadn't been too concerned about the leakage as long as there was some output. A facility policy titled; Catheter Care, Urinary, revised 2014 stated that staff should observe the resident's urine level for noticeable increases or decreases and report it to the physician or supervisor. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to implement infection control practices for 1 of 13 residents reviewed. Resident #3 had a urinary catheter and staff hooked the bag on the trash can while he was in his recliner during the day. The facility reported a census of 36 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He required extensive assistance with the help of 2 for bed mobility, transfers, dressing and toileting. The care plan for Resident #3 indicated that he had a suprapubic catheter and required a mechanical lift for transfers. Diagnosis included; acquired absence of the right great toe, anxiety disorder, cellulitis and obesity. On 7/31/23 at 2:16, Resident #3 was sitting in his recliner chair with the catheter bag hooked on the trashcan next to the chair. He said that he stayed in his recliner chair all day and he would let the staff know when his catheter bag was full so they could empty it. He said that he could tell when the bag was full because sometimes, the trash can would tip over from the weight of all the urine. On 8/2/23 at 2:29 PM the administrator stated that it was not acceptable to have a catheter bag hanging on the trash can. A facility policy titled; Infection Control 2018 facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Maintain a safe, sanitary, and comfortable environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with family and staff, and record review the facility failed to maintain a clean, homelike environment and failed to alleviate offense odors throughout the facility. The facility reported a census of 36 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He required extensive assistance with the help of 2 for bed mobility, transfers, dressing and toileting. The care plan for Resident #3 indicated that he had a suprapubic catheter and required a mechanical lift for transfers. Diagnosis included; acquired absence of the right great toe, anxiety disorder, cellulitis and obesity. Observation on 7/31/23 at 7:30 AM it was noted that there was a heavy urine smell around the nurse's station. The smell became increasingly stronger down the 200 hallway and in the room of Resident #3. Certified Nurse Aide (CNA), Staff M, was emptying the catheter bag the was hanging from the bedframe. The floor inside the doorway of the resident's room, and near the resident's bed was sticky and dirty. On 7/31/23 at 2:16 PM, Resident #3 was sitting in his recliner and his catheter bag was hooked to the trashcan next to his chair. He said he would let the staff know when his catheter bag was full and needed to be changed and sometimes he could tell when the bag was full because the trash would tip over from the weight of all the urine. On 7/31 at 9:27 AM, the floor just inside the doorway of Resident #13's room and in the bathroom was very dirty and sticky. On 7/31/23 at 3:13 PM, a family member for Resident #2 said that the family noticed the heavy odor throughout the facility. She brought in their own Clorox wipes to clean areas around in the room and in the bathroom. The floor was dirty and sicky at the entrance to the room and in the bathroom. On 7/31/23 at 8:09 AM Environmental Services (ES) aide, Staff G said that they did not have a manager in ES and the floors were sticky because of the cleaners and wax that the previous ES staff had been using. On 8/1/23 at 2:15 PM a family member for Resident #6 said that she would visit the nursing home every other day and the facility smelled so bad that it would make her nauseous. On 8/2/23 at 2:29 PM, the Administrator walked down the 200 hallway and acknowledged the heavy musky smell. She said that much of the smell was coming from the old carpet, and they had plans to tear it out and replace it with a laminate surface in November. She went into the room of Resident #13 and acknowledged the stickiness and grime on the floors. She said this was from the previous cleaning company that was maintaining the floors and the current ES staff were trying to get to every room, strip off the old wax, but it was very time consuming. A facility policy titled; Homelike Environment dated 2021, indicated that the staff would provide a clean, sanitary environment comfortable and free from institutional odors. 2) According to the MDS dated [DATE] Resident #13 had a BIMS score of 7 (moderate cognitive deficits). She required limited assistance with the help of two staff for bed mobility, transfers and dressing. The care plan updated on 3/29/23 showed that the resident became agitated when woken up from sleep and would refuse to allow staff to provide cares. Needed set-up assistance with eating. Assist of 2 with a gait belt for all transfers and used wheel chair for mobility. On 8/2/23 at 1:00 the resident was sleeping in bed and her lunch meal was on the bedside table. At 4:10 PM the lunch was half eaten and still on bedside table. On 8/3/23 at 8:00 AM a breakfast tray was on the bedside table, at 11:34 AM, the breakfast was still on bedside table half eaten. 3) According to the MDS dated [DATE], Resident #5 required limited assistance with the help of one staff for mobility, transfers, dressing, toileting and hygiene. Diagnosis included hemiparesis, major depressive disorder, anxiety, dysphasia, aphasia and vascular dementia. The care plan updated on 4/17/23 showed that Resident #5 would self-isolate and refused cares at times. He was unable to dress independently and preferred to wear the same clothes even when they were soiled. In ongoing observation on 7/31/23, at 7:15 AM the resident was sleeping and did not get out of bed or wake up when his lunch was served at 12:30PM. At 2:43 PM he was still in bed and his lunch was still sitting on the bedside table untouched. On 8/1/23 at 12:30 PM, the resident's lunch was on the bedside table and the resident was sleeping. At 4:15 PM the lunch tray was still on the bedside table and the food was uneaten. According to a facility policy titled; Pest Control 2008, garbage and trash were not permitted to accumulate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of hospital reports, clinical record review and interview the facility failed to include a diagnosis of Type II Diabetes Mellitus and interventions for monitoring on a residents' care plan. The facility reported a census of 32 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required extensive assistance with the help of 2 staff from bed mobility, dressing, toilet use and hygiene needs. According to the diagnosis tab in the electronic chart, Resident #12 had a diagnosis of Type II Diabetes Mellitus on 8/6/19. According to the orders tab, the resident had an order dated 8/6/19 for staff to monitor for signs and symptoms or hypo/hyperglycemia related to Type II Diabetes mellitus. The care plan for Resident #12 last updated on 11/16/22 lacked information regarding the resident's diagnosis of Type II Diabetes and the need to monitor for signs and symptoms of hyper/hypoglycemia. On 12/22/22 at 3:24 PM, the Nurse Consultant verified staff should have added Type II diabetes mellitus and monitoring for pertinent side effects to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure staff followed physician medication orders. The physician decreased Resident #27's daily Sertraline and Trazadone doses in November 2022. However, staff failed to transcribe the order into the electronic record. The facility reported a census of 32 resident. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The MDS revealed the resident was independent with bed mobility, transfers and toilet use. Resident #27's care plan, updated on 04/07/22, directed staff to administer medications as ordered and also to attempt gradual dose reductions. The care plan revealed the resident had a diagnosis of major depressive disorder. In an observation on 12/20/22 at 7:10 AM, Staff C, Certified Medication Aide administered 100 milligrams (mg) of Sertraline to Resident #27 during the morning medication pass. Review of the resident's clinical record revealed a physician's order dated 8/11/22 at 7:00 AM, that directed staff to administer Sertraline 200 mg daily and a physician order dated 2/3/22 at 8:00 PM that directed staff to administer Trazadone 150 mg at night. In an interview on 12/21/22 at 8:08 AM, the pharmacist stated that they had made a mistake in filling the prescription and there should have been two, 100 mg Sertraline tabs in each daily dose. A review of the scanned documents revealed an order dated 11/10/22 that directed staff decrease the resident's Sertraline to 150 mg daily and reduce Trazadone to 125 mg at night. However, staff had failed to note the order or enter it into the electronic chart to reflect the change in orders. On 12/22/22 at 3:24 PM, the Nurse Consultant said she expected the nurses to enter new orders as soon as they are received and sign the document when the order is entered. A policy titled Medication Orders updated in November of 2014 indicated that a current list of orders must be maintained in the Electronic Medication Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interviews and record review the facility failed to provide timely baths and showers for 3 of 12 residents reviewed (Residents #12, #31, and #11). The facility reported a census of 32 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment tool dated 9/19/22, Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required extensive assist of 2 staff for bed mobility, dressing, toilet use, and personal hygiene. Resident #12's care plan updated 11/16/22 documented Resident #12 had a suprapubic catheter and required frequent monitoring for urinary tract infections. The care plan also documents he had an abrasion to the testicle/scrotum and a rash on his right abdominal fold. The care plan directed staff to monitor for skin issues and notify the doctor of changes. On 12/19/22 at 12:11 PM, Resident #12 sat in his recliner chair and reported he had not had a bath or shower for a couple of weeks. He said that every time he got a bath the staff would also shave him as he had long facial hair. He said that the staff tell him that they don't have enough help to get the task completed - he would only refuse a bath or shower if he were not feeling well. Review of the Bathing Assistance sheet from 11/21 - 12/19/22 revealed the resident had only one bath which staff provided on 12/05/22. 2) The MDS dated [DATE] did not contain a BIMS score. The MDS documented Resident #31 required limited assist of 1 staff for mobility and toilet use. The care plan updated on 12/7/22 documented Resident #31 had chronic back pain and required staff assist due to diagnoses of left-sided hemiplegia and neuropathy. On 12/19/22 at 12:13 PM, Resident #31 reported staff gave him a shower about once a week, but he would like to have showers more often. Bath documentation showed Resident #31 had one shower in a 30 day timeframe. 3) The MDS dated [DATE] did not contain a BIMS score. The MDS revealed Resident #11 required limited assist of 1 staff for toilet use and personal hygiene. The care plan updated on 8/25/22 documented the resident received kidney dialysis services three times weekly. On 12/21/22 at 9:00 AM the dialysis nurse reported Resident #11 told her he believed that staff did not like him and did not provide showers or baths. Review of the facility's bath documentation reveled staff gave Resident #11 within a 30 day timeframe. On 12/22/22 at 3:24 PM, the Nurse Consultant confirmed the standard of practice was for resident to be offered a bath or showers at least twice a week. The administrator stated that they did not have a policy on offering residents baths and showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review that facility failed to prevent accidents and hazards related to a Sit to Stand mechanical lift transfer. While Resident #31 was standing on the platform on the Sit-to-Stand lift, the platform disengaged and it fell to the floor. The facility reported a census of 32 residents. Findings include: According to the MDS dated [DATE] Resident #31 did not have a BIMS score. The resident required limited assistance with the help of one staff for mobility and toilet use. The care plan updated on 12/7/22 showed that Resident #31 had chronic back pain and required staff assistance due to left sided hemiplegia and neuropathy. In an observation on 12/20/22 08:46 AM Certified Nursing Assistant (CNA) Staff I and CNA Staff J positioned the Sit to Stand mechanical lift in front of Resident #13 to transfer him from the chair to the toilet. They strapped legs to the platform and adjusted the sling around his chest. As they lifted him up and he began to stand, the platform became unhooked from the lift and the platform fell to the floor. The resident was unharmed and said it startled him. On 12/22/22 at 3:30 PM the nurse consultant said that she would not expect that staff would check the platform of the EZ Stand before every transfer. This was an unusual situation and may have been that someone adjusted the platform previously and did not double check to make sure that it was locked into place.

Based on record review, staff interviews, and procedure review the facility failed to complete and/or maintain records of pre-dialysis assessments/evaluation and post-dialysis assessments/evaluation for 1 of 1 residents reviewed (Resident #11), that required and received dialysis services at the local dialysis center. The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) documented diagnosis of Diabetes mellitus (DM), and Heart failure. The MDS also documented the resident's need for dialysis. Record review on 12/21/22 of Resident #11 evaluations/assessments completed in the facility's Electronic Health Record (EHR) from 11/28/22 to 12/20/22 revealed the following: No pre-dialysis evaluations/assessments were completed on 11/30/22, 12/2/22, 12/5/22, 12/7/22, 12/14/22, and 12/16/22. No post-dialysis evaluations/assessments were completed on 12/12/22, 12/14/22, 12/16/22 and 12/20/22. Only one dialysis evaluation/assessment was completed on 12/9/22. Interview on 12/22/22 at 11:16 am with RN staff F revealed she would expect a pre-dialysis and post-dialysis assessment completed every day before and after resident attended dialysis. Review of the Dialysis Communication facility policy dated May, 2022 directed staff to complete a pre and post dialysis evaluation/assessment.

Based on observation, record review, and staff interview the facility failed to implement a resident centered care plan with resident specific interventions for 1 of 1 residents reviewed (Resident #7) that routinely yelled or screamed. The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 11/01/22 documented Resident #7 scored 15 of 15 possible points on the Brief Interview Mental Status test, which meant the resident demonstrated intact cognitive abilities. The MDS also documented diagnoses that included non-traumatic brain dysfunction, anxiety disorder, and bipolar disorder. The MDS identified Resident #7 required extensive assist of 2 staff for bed mobility and toilet use. Observation on 12/20/22 from 08:30 AM to 09:30 AM revealed staff provided 1 to 1 care and support for Resident #7 due to her yelling. The Director of Nursing also provided 1 to 1 assistance and support for Resident #7 by pushing her around in the hallway. Resident #7's Progress Notes for November 2022 documented the resident exhibited behaviors such as yelling and screaming on the 1st, 7th, 13th-16th, and the 22nd. Resident #7's Progress Notes for December 2022 documented the resident exhibited behaviors such as yelling and screaming on the 5th, 7th, 13th, 15th, 16th, 20th, and 21st. Resident #7's current Care Plan failed to contain resident-centered interventions to direct staff how to intervene or what care to provide if the resident displays behaviors such as yelling or screaming. The care plan also did not detail likes or dislikes or activities the resident enjoys to redirect or support her when she exhibited behaviors. During an interview on 12/22/22 at 3:53 PM, Staff F, Registered Nurse (RN) stated she expected care plans to address behaviors and contain specific resident interventions for that resident, not a generic care plan.

Based on record review, staff interview, and policy review the facility failed to ensure an as needed anti-anxiety medication classification drug was limited to a 14 day use period without physician written rationale to continue for 1 of 3 residents (Resident #25) reviewed. The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated 11/19/2022 documented Resident #25 scored 15 of 15 possible points on the Brief Interview of Mental Status (BIMS) test, which indicated the resident displayed intact cognitive abilities. The MDS documented the resident had diagnoses of anxiety and depression. Resident #25's Discharge Documents from the hospital dated 11/15/22 contained an order that directed staff to continue Clonazepam (anti-anxiety medication) one tablet twice daily as needed. Resident #25's November 2022 Medication Administration Record (MAR) documented staff administered the as needed Clonazepam 12 times during the resident's 15 day stay that month. Resident #25's December 2022 MAR documented staff administered the as needed Clonazepam 18 times during the resident's 22 day stay that month. Review of Resident #25's Progress Notes revealed an entry on 12/19/22 that showed the Pharmacy Consultant completed a Drug Regimen Review for the resident and was looking for a stop date on the as need Clonazepam order. Further review revealed the Progress Notes failed to contain the stop date. Resident #25's Care Plan documented anti-anxiety medication (Clonazepam) use and instructed staff to review the medication monthly and complete Gradual Dose Reductions (GDR) as needed per facility protocol. During an interview on 12/22/22 at 3:53 PM, Staff F, Registered Nurse (RN) verified the facility expectation that staff request an as needed anti-anxiety medication for only 14 days, have the physician re-evaluate, and then not continue past the 14 days. The Tapering Medications and Gradual Drug Dose Reduction facility policy revised in April, 2007 lacked direction to staff on how to complete GDR's for anti-anxiety classification medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to maintain accurate resident records for 1 of 12 residents reviewed. Resident #19 had an order for a dressing change every three days. On 12/21/22, the bandage that covered her wound contained a date of 12/12/22, although the clinical record documented staff last changed it on 12/18/22. The facility reported a census of 32 residents. Findings include: According to the MDS dated [DATE] Resident #19 had a BIMS score of 13 (moderate cognitive deficit). The MDS listed diagnoses that included kidney failure and colostomy malfunctions and identified the resident required extensive assist of 1 staff for dressing and toilet use. The MDS documented the resident had an indwelling urinary catheter and an ostomy of the bowel. The care plan updated on 11/10/22 identified the resident as at risk for skin impairment and directed staff to observe the skin daily and monitor for issues. The electronic medical record contained an order dated 12/9/22 at 6:00 AM, which directed staff to cleanse the wound on the right abdomen and cover it with Allevyn bandage - change every 3 days. Observation on 12/21/22 at 6:29 AM revealed Staff E, Registered Nurse (RN) changed the dressing on the resident's right flank. Closer observation revealed the bandage she removed contained a last changed date of 12/12/22. The Treatment Administration Record (TAR) lacked documentation to indicate staff changed the resident's right flank bandage 12/15/22, but did document that staff had changed the dressing on 12/18/22. On 12/22/22 at 3:24 PM, the nurse consultant confirmed she expected staff to change dressings as ordered and document the changes accurately. The Charting and Documentation facility policy dated July 2017 directed staff to document in the medical record in a complete and accurate manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Based on observation, record review, staff interviews, and facility policy review, the facility failed to provide timely assessments and implement adequate interventions for 3 of 7 residents reviewed (Residents #10, #12, #19). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 11/24/22 identified Resident #10 had diagnoses of cancer, anemia, malnutrition, and hyponatremia. Resident #10's medical record contained the following information: On 12/14/22 at 11:02 AM, the Progress Notes showed Resident #10's Lasix (diuretic medication) dosage increased to 60 milligrams (mg) twice daily. Review of the Progress Notes from 12/15/22 to 12/22/22 revealed a lack of documentation related to the efficacy of the Lasix increase or whether or not the resident experienced side effects. Review of Resident #10's Evaluations from 12/12/22 - 12/22/22 revealed no documented assessments. Review of Resident #10's Weights from 11/14/22 - 12/22/22 revealed no weights documented. During an interview on 12/22/22 at 3:57 PM, Staff F, Registered Nurse (RN) reported she would expect staff to document follow-up information after order changes in the Progress Notes regarding the effectiveness of medication changes. 2) A Minimum Data Set (MDS) assessment tool dated 9/19/22, showed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required extensive assistance with the help of 2 staff from bed mobility, dressing, toilet use and personal hygiene needs. The care plan for Resident #12 last updated on 11/16/22 showed that he had a suprapubic catheter and required frequent monitoring for urinary tract infections. He had an abrasion to the testicle/scrotum and a rash on the right abdominal fold. Staff were instructed to monitor for skin issues and to notify the doctor of changes. On 12/20/22 at 9:38 AM Resident #12 was in bed on his back and he said that it felt good to be able to sleep bed. He said that it had been at least one week since staff had gotten him into bed for the night so he had been sleeping in his recliner. Resident #12 said that it wasn't very comfortable to sleep in his recliner and he could tell that he was developing a sore on his scrotum. The resident said that at night the staff would tell him they didn't have enough help to get him into bed so he had to stay in his recliner to sleep. The recliner did not have a pressure reducing cushion. On 12/20/22 at 11:32 AM, Licensed Practicing Nurse (LPN) Staff A and Certified Nursing Assistant (CNA) Staff B provided incontinence cares to Resident #12. As they cleaned bowel movement from under the scrotum the resident reported that it was sore in that area. He had a red open sore under his scrotum and there was no treatment or barrier on the spot. On 12/21/22 at 9:10 AM CNA Staff D acknowledged that at times, they had told Resident #12 that they could not get him into bed because they didn't have enough help to transfer him from the recliner to the bed. On 12/22/22 at 3:30 PM the nurse consultant said that at night they always have at least 2 staff available so they should be able to put the resident to bed if that was what he wanted. 3) According to the MDS dated [DATE] Resident #19 had a BIMS score of 13 (moderate cognitive deficit). The resident had diagnosis that include kidney failure and colostomy malfunctions and required extensive assistance with the help of one staff for dressing and toilet use. She had an indwelling urinary catheter and an ostomy of the bowel. The care plan updated on 11/10/22 the resident was at risk for skin impairment and staff were directed to observe the skin daily and monitor for issues. The electronic medical record included an order dated 12/9/22 at 6:00 AM to cleanse the wound on her right abdomen and to cover it with Allevyn bandage every 3 days. In an observation on 12/21/22 at 6:29 AM RN Staff E brought into room Allevyn pad to change the dressing on the right flank. Staff E removed the pad that was over the sore. The bandage was dated 12/12/22. A review of the Treatment Administration Record (TAR) showed that staff had documented that the dressing had been changed on 12/18/22. According to a facility policy dated April 2020, and titled: Prevention of Pressure Injury, staff were directed to review the resident care plan and identify at risk factors and intervention designed to eliminate skin breakdown. Staff were to inspect skin on daily basis, reposition the resident with risk of pressure injuries, evaluate, report and document potential changes in skin. On 12/22/22 at 3:24 PM the nurse consultant said that she would expect that wound changes were performed as ordered. I. Based on observation, interviews and record review the facility failed to accurately monitor and report blood glucose levels for 3 of 5 residents reviewed and identified as at risk for side effects of hyperglycemia or hypoglycemia (Residents #12, #31, #4). On 09/4/22, the facility sent Resident #12 to the hospital with an elevated blood sugar. Facility staff failed to adequately monitor his blood glucose levels when he had symptoms of hyperglycemia. Residents #31 & #4 had multiple episodes of unstable blood glucose levels and staff failed to contact the physician as ordered. The facility reported a census of 32 residents. Findings include: According to the American Diabetes Association (ADA), the diabetic blood sugar level before taking a meal should be between 80-130 milligrams per deciliter (mg/dl). One to two hours after a meal, the blood sugar level should be less than 180 mg/dl. 1. A Minimum Data Set (MDS) assessment tool dated 9/19/22, showed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required extensive assistance with the help of 2 staff from bed mobility, dressing, toilet use and personal hygiene needs. The care plan for Resident #12 last updated on 11/16/22 showed that he had a suprapubic catheter and required frequent monitoring for urinary tract infections. The care plan lacked information regarding the resident's diagnosis of Type II Diabetes and the need to monitor for signs and symptoms of hyper/hypoglycemia. The Medication Administration Record (MAR) and the Treatment Administration Record (TAR) revealed a physician's order entered on 8/6/19 at 3:30 PM that directed staff to monitor for signs and symptoms of hypo/hyperglycemia related to Type II diabetes mellitus and check the blood glucose levels as needed (PRN). A review of the MAR/TAR revealed that staff did not use this PRN order in the months of August or September. The Progress Notes contained the following entries: - On 8/28/22 at 11:26 PM, the resident reported that he felt like he was getting sick and complained of a head ache. - On 8/31/22 at 9:20 PM, the resident refused melatonin because he felt sick. - On 8/31/22 at 11:45 PM, the resident had nausea with projectile vomiting. The doctor was called and a new order for ondansetron for nausea. - On 9/1/22 at 1:12 PM, the resident complained of head ache. - On 9/2/22 at 9:24 PM, the resident experienced nausea and staff administered ondansetron - On 9/3/22 - no documentation - On 9/4/22 at 5:39 PM, the resident had chills and pale skin and asked staff to send him to the emergency room. A hospital History and Physical (H&P) report dated 09/5/22 at 9:56 AM revealed Resident #12 presented to the emergency room with chills and weakness. The resident was said to be a good historian and reported that he had nausea and vomiting for a weak. The resident had a diagnosis of Type II Diabetes and complained of thirst and poor appetite. His blood glucose reading was 397 mg/dl. The report showed that the primary problem identified was diabetic ketoacidosis. Diabetic ketoacidosis is a serious complication of diabetes. The signs and symptoms include thirst, nausea and vomiting, stomach pain and weakness. Retrieved on 12/27/22 from: Diabetic ketoacidosis - Symptoms and causes - Mayo Clinic In an interview on 12/20/22 at 1:26 PM, Resident #12 reported he had a blood infection, urinary infection, and pneumonia back in September when he went to the hospital. He said he had been throwing up and passing out, was drowsy and thirsty and told the nursing staff he was sick and wanted to go to the hospital. He commented he kept telling staff he did not feel well for a couple days before he finally went to the hospital. He added one nurse suggested they could just do some blood work at the facility, but the resident told them that he wanted to go to hospital. He could not remember exactly what his blood glucose number was when he went to the emergency room, but thought it was above 500. On 12/21/22 at 11:25 AM the Primary Care Physician (PCP) for Resident #12 said that given the symptoms that the resident was experiencing in the days leading up to his hospitalization in September, it would have been helpful to have had a blood glucose test completed before the hospitalization. He said that they had started to do daily glucose monitoring in October. He stated that they may need to get more aggressive with the resident's diabetic care and monitoring. 2. Resident #31's MDS dated [DATE] did not include a BIMS score and identified the resident required limited assistance of 1 staff for bed mobility and toilet use. The care plan updated on 12/7/22 documented the resident had chronic back pain and required staff assistance due to left-sided hemiplegia and neuropathy. The diagnosis tab in the electronic chart included adult failure to thrive and type II diabetes. According to the MAR/TAR in October the resident had a blood glucose level of 544 mg/dl. The resident was in the hospital through November. On December 8 he had a glucose level of 402 and on 12/11/22 it was 412. The chart lacked documentation that the doctor had been contacted about these levels. On 12/20/22 at 1:10 PM Licensed Practical Nurse (LPN) Staff A said that signs and symptoms of hypoglycemia were sweating or clammy. Signs of hyperglycemia were lethargy, confused or hot. She said that if she noticed symptoms she would check the resident's blood sugar. If there was any lower than 60 or above 400 she would notify doctor or follow orders. On 12/20/22 at 1:21 PM Certified Medication Aide (CMA) Staff C said the signs of hypoglycemia include cold and clammy but she was unsure of hyperglycemia signs and symptom. If symptoms would be present she would notify nurse and give orange juice if she thought the resident had a low blood glucose level. 3. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented diagnosis's of diabetes mellitus, malnutrition, schizophrenia, and depression. The MDS documented the need for limited assistance of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the October 2022 Medication Administration Record (MAR) for Resident #4 documented an order for sliding scale insulin to be given depending on the residents blood sugar reading and if over 400 recheck the blood sugars after two (2) hours and contact the physician if not lower. The following dates document when the blood sugar was over 400 and needed to be reassessed. 10/08/22 - 586 Review of the November 2022 Medication Administration Record (MAR) for Resident #4 documented an order for sliding scale insulin to be given depending on the residents blood sugar reading and if over 400 recheck the blood sugars after two (2) hours and contact the physician if not lower. The following dates document when the blood sugar was over 400 and needed to be reassessed. 11/04/22 - 509 11/20/22 - 504 Review of the December 2022 Medication Administration Record (MAR) for Resident #4 documented an order for sliding scale insulin to be given depending on the residents blood sugar reading and if over 400 recheck the blood sugars after two (2) hours and contact the physician if not lower. The following dates document when the blood sugar was over 400 and needed to be reassessed. 12/01/22 - 546 12/02/22 - 420 12/08/22 - 484 12/10/22 - 426 Review of Resident #4's Blood Sugar Summary on 12/22/22 for October, November, and December documented the following blood sugars over 400 and the length of time it took for the reading to be rechecked: 10/08/22 at 08:56 AM - 535 10/08/22 at 11:27 AM - 586 10/08/22 at 02:00 PM - 148 11/04/22 at 07:08 AM - 509 11/04/22 at 11:58 AM - 183 11/20/22 at 08:39 AM - 504 11/20/22 at 11:51 AM - 206 11/30/22 at 09:30 PM - 412 12/01/22 at 08:47 AM - 546 12/01/22 at 11:35 AM - 158 12/02/22 at 04:49 PM - 420 12/02/22 at 08:25 PM - 93 12/08/22 at 07:33 AM - 484 12/08/22 at 11:27 AM - 368 12/10/22 at 05:19 PM - 426 12/10/22 at 10:06 PM - 202 Record review of Resident #4 Progress Notes on 12/22/22 lacked documentation to the physician on the following dates the blood sugar was found to be over 400 and and rechecks were not completed after 2 hours. 10/08/22 11/04/22 11/30/22 12/01/22 12/02/22 12/08/22 12/10/22 According to a facility policy titled: Diabetes, dated September 2017. A physician shall help manage individuals with diabetes appropriately and effectively. The markers of diabetic control would be optimized in the context of individual resident circumstances. The physician and staff would establish notification of parameters related to diabetic monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record, facility policy, and Centers for Disease Control and Prevention (CDC) guideline review and staff interview,the facility failed to ensure staff completed hand hygiene after they provided incontinence care for 1 of 2 residents observed for personal care (Resident #12). The facility reported a census of 32 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The MDS documented the resident required extensive assist of 2 staff with bed mobility, dressing, toilet use and personal hygiene. Resident #12's care plan updated on 11/16/22 documented the resident used a suprapubic catheter and required frequent monitoring for urinary tract infections. The care plan also documented Resident #12 had an abrasion to the testicle/scrotum and a rash on right abdominal fold, and directed staff to monitor for skin issues. On 12/20/22 at 11:32 AM, Staff A, Licensed Practical Nurse (LPN) and Staff B, Certified Nursing Assistant (CNA) provided bowel incontinence cares For Resident #12. With ungloved hands, Staff A grasped the resident's thigh and rolled him on his side while Staff B cleaned the stool from the buttocks and surrounding area, positioned him on his back, and then Staff A moved the urinary catheter bag to the opposite side of the bed. Without performing hand hygiene, Staff A proceeded to adjust her pants and surgical mask, touch her face and the blankets on the bed, and exit the resident's room to enter the code on the keypad to the shower room. She then went to another room punched in the numbers to that door keypad. The Hand Hygiene facility policy revised on August 2019 directed staff to utilize alcohol based hand rub or soap and water before and after direct contact with a resident or their skin. On 12/22/22 at 3:24 PM the Nurse Consultant verified staff should always wash their hands after resident contact and when entering or exiting a room.