Based on interviews, clinical record review, facility investigation, and facility policy review, the facility failed to protect resident's right to privacy for 1 of 3 residents reviewed for resident rights when staff took video of a resident and posted it to social media (Resident #1). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 10/23/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Resident #1's diagnoses included Schizophrenia, moderate intellectual disability, and depression. The Care Plan, initiated 7/09/24, revealed Resident #1 had impaired cognition related to moderate intellectual disability, Schizophrenia, and Major Depressive Disorder. The facility submitted a self-reported incident on 11/12/24 at 10:58 to the Department of Inspections, Appeals, and Licensing (DIAL) for video of Resident #1, taken by Staff A, Certified Nursing Assistant (CNA) on 11/11/24, and posted to a social media platform (Snapchat). Review of the facility internal investigation revealed a statement of incident, signed and dated on 11/12/24 by Staff A. Staff A wrote that on 11/11/24, they were joking with resident while eating an ice cream cone and had asked if it was good and how he was eating it. Staff A's statement informed the video was taken at approximately 4:30 PM and the resident was joking saying no as he smiled and showed his teeth. Staff A's statement revealed the video was posted to their private Snapchat story. Review of an 8 second video submitted by the facility showed Resident #1 holding an ice cream cone, he appeared to be sitting in a wheelchair in the hallway and was without dentures in place. A female voice said, let me see your teeth, Resident #1 responded no, and then smiled without teeth as a female voice laughed. Review of Staff A personnel file revealed a document titled Confidentiality Agreement, signed and dated by Staff A on 8/16/23 which agreed not to take any photographs or recordings of residents in any nature and not post any information resident's personal or health related information on any form of social media. Staff A personnel file additionally revealed a document titled, Dependent Adult Abuse Policy Review, which attested understanding of obligation to report to supervisor any potential abuse as defined in the Abuse Prevention, Identification, and Reporting Policy, signed by Staff A and dated 8/16/23. Disciplinary Report Form, dated 11/14/24, revealed termination of Staff A's employment due to video taken of resident and posted to Snapchat in violation of the facility's abuse policy for personal degradation signed by the Director of Nursing and Facility Administrator. On 1/08/25 at 3:50 PM, Staff B, former Director of Nursing (DON), stated that on 11/11/24 at approximately 8:00 PM she received a text message, with screen-shot of the video, from Staff C, former Assistant Director of Nursing (ADON) which informed her that Staff A had posted video of Resident #1 to their Snapchat story. Staff B stated that she showed this to the Facility Administrator the following day and that the facility decided to suspend Staff A while conducting an internal investigation. On 1/09/24 at 09:40 AM, Staff C, former ADON, stated she had witnessed the video of Resident #1 posted by Staff A on Staff A's Snapchat story and notified Staff B through a text message. Staff C informed that Staff A did not send video directly to Staff C, but posted it to a Snapchat story in which anyone on Staff A's friends list could have seen the video. On 1/09/25 at 10:45 AM, Facility Administrator stated she found out about video of Resident #1 posted by Staff A on 11/12/24 around 10:00 AM, when Staff B, notified her of the incident. Facility Administrator revealed she then reported incident to DIAL and began an internal investigation of the incident which included staff and resident interviews for potential abuse, disciplinary action of Staff A, and all staff education of the facility's abuse/personal degradation policy. The facility policy, titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated July 2024, revealed the prohibition of staff from taking part in acts that result in personal degradation, including the taking or using any type of equipment to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. The policy defined personal degradation as a willful act or statement by a caretaker intended to shame, degrade, humiliate, or otherwise harm, the personal dignity of a reasonable person and includes the taking, transmission, or display of an electronic image of a dependent adult by a caretaker, or where the caretaker knew or reasonably should have known the act would cause shame, degradation, humiliation, or harm to the personal dignity or a reasonable person.

Based on interviews, facility investigation review, and facility policy review, the facility failed to report to the state agency within 2 hours of knowledge of an abuse allegation for 1 of 3 residents reviewed for resident's rights (Resident #1). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 10/23/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Resident #1's diagnoses included Schizophrenia, moderate intellectual disability, and depression. The facility submitted a self-reported incident on 11/12/24 at 10:58 AM to the Department of Inspections, Appeals, and Licensing (DIAL) for video of Resident #1, taken by Staff A, Certified Nursing Assistant (CNA) on 11/11/24, and posted to a social media platform (Snapchat). Review of facility internal investigation revealed a statement of incident, signed and dated on 11/12/24 by Staff A. Staff A wrote that on 11/11/24, they were joking with a resident while eating an ice cream cone and had asked if it was good and how he was eating it. Staff A's statement informed the video was taken at approximately 4:30 PM and the resident was joking saying no as he smiled and showed his teeth. Staff A's statement revealed the video was posted to their private Snapchat story. Review of an 8 second video submitted by the facility showed Resident #1 holding an ice cream cone, he appeared to be sitting in a wheelchair in the hallway and was without dentures in place. A female voice said, let me see your teeth, Resident #1 responded no, and then smiled without teeth as a female voice laughed. On 1/08/25 at 3:50 PM, Staff B, former Director of Nursing (DON), stated that on 11/11/24 at approximately 8:00 PM she received a text message, with screen-shot of the video, from Staff C, former Assistant Director of Nursing (ADON) which informed her that Staff A had posted the video of Resident #1 to their Snapchat story. Staff B stated that she showed this to the Facility Administrator the following day and that the facility decided to suspend Staff A while conducting an internal investigation. On 1/09/24 at 09:40 AM, Staff C, former ADON, stated she had witnessed the video of Resident #1 posted by Staff A on Staff A's Snapchat story and notified Staff B through a text message. Staff C informed that Staff A did not send video directly to Staff C, but posted it to a Snapchat story in which anyone on Staff A's friends list could have seen the video. On 1/09/25 at 10:45 AM, Facility Administrator stated she found out about the video of Resident #1 posted by Staff A on 11/12/24 around 10:00 AM, when Staff B, notified her of the incident. Facility Administrator revealed she then reported incident to the state agency and began internal investigation of incident, which included staff and resident interviews for potential abuse, disciplinary action of Staff A, and all staff education of the facility ' s abuse/personal degradation policy. The facility policy, titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated July 2024, revealed the prohibition of staff from taking part in acts that result in personal degradation, including the taking or using any type of equipment to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. The policy instructed that all allegations of resident abuse shall be reported to the Department of Inspections, Appeals, and Licensing (D.I.A.L), not later than 2 hours after the allegation is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, policy review, and staff interview the facility failed to maintain accurate advance directive records based on resident preference for 1 of 8 residents reviewed (Resident #4). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) for Resident #4 dated [DATE] documented the resident scored 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. It further revealed diagnoses of coronary artery disease, chronic respiratory failure with hypoxia (not enough oxygen in the blood), and asthma. On [DATE] at 9:50 AM a document titled Policy for Resuscitative Services/Cardiopulmonary Resuscitation (CPR) dated [DATE] was located in front of the resident's chart. It documented that in the event respirations or pulse would cease for Resident #4, she requested CPR be performed. During the same chart review the resident's Iowa Physician's Orders for Scope of Treatment (IPOST), signed [DATE] and located in the resident's chart behind the Resuscitative Services document, indicated if the resident did not have a pulse and was not breathing, staff should not attempt CPR. An entry in the electronic health record (EHR) dated [DATE] at 17:43 titled Health Status Note revealed the care provider called Resident #4's daughter to update her about changing the IPOST to a code status of DNR, comfort measures only, with no feeding tube and she was in agreement with the change. On [DATE] at 2:00 PM when asked about code status Staff A, Licensed Practical Nurse (LPN) stated he would look for it in the front of the resident's chart. He reported there was not a code status book or other location for advance directive information. Observed Staff A look in the front of Resident #4's chart, where he pointed at the request for CPR to be performed. When showed the discrepancy between that document and the IPOST behind it, Staff A indicated he would have looked at the first form and was not aware they were different. At 12:11 PM on [DATE] a follow up with Staff A determined the facility was working to ensure the correct document was in the resident's file. A policy, titled Advanced Directives Policy and dated [DATE], documented the intent of the facility to implement the terms of resident Advanced Directives in accordance with the appropriate direction of the resident, Power of Attorney, or resident's physician. The procedure included information that revoked advance directives should be removed from the resident's medical record and placed in an administrative file to avoid any misunderstanding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and policy review the facility failed to address the resident's goals for discharge for 1 of 1 residents reviewed (Resident #52). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) report dated 8/08/24 for Resident #52 indicated a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderate cognitive impairment. The MDS further indicated diagnoses including: alcohol cirrhosis of the liver with ascites (scar and fluid buildup), non-Alzheimer's dementia, and Diabetes Mellitus. The Care Plan for Resident #52 updated 7/11/22 noted the resident needed 24-hour care related to cognitive loss. It instructed staff to arrange for care conferences and review discharge plans quarterly and as needed. It further encouraged the resident/family/POA to share concerns. A review of the clinical record and Electronic Health Record revealed they lacked documentation pertaining to Durable Power of Attorney or mental capacity documents to indicate the resident was unable to make his own medical decisions. The Discharge Planning Review- v2 dated 6/28/24 documented Resident #52's family goal was to have the resident stay in the facility long term. It further documented the resident had alcohol-induced dementia diagnosed which impairs judgment and safety awareness. It indicated the need for supervision for Activities of Daily Living along with medication management. It reported the resident was unable to meet basic and critical care needs in a lower level of care setting. The Nursing Communication note dated 7/22/24 documented the resident verbalized wanting to get out of here saying he's too young to be here, he wants to work, [NAME] the lawn, have a beer, and is too self-sufficient to be here. The Psychosocial Note dated 8/12/24 reported the resident went to the Social Services office and wanted to know about discharge. The social worker suggested the resident speak to his family as staff was not in the position to make that decision. The note dated 9/06/24 documented a case consultation with the Managed Care Organization caseworker in which discharge plans were reviewed and no changes were made. In an interview on 9/16/24 at 1:29 PM Resident #52 noted he wanted to go home and had not seen the social worker to discuss this. In an interview on 9/17/24 at 9:42 AM the Social Worker explained he encouraged the resident to speak to his family as they would need to have a big part in his leaving and they said he can't return home. He acknowledged the resident does not have a guardian or designated decision maker. Thus far he had only encouraged the resident to talk to family about this; he did not start any other discharge planning. He confirmed the resident was not evaluated for his mental capacity to make decisions. In an interview on 9/18/24 at 2:57 PM the Administrator explained Resident #52 had a BIMS of 12 and his family was involved with his Plan of Care but was now non-responsive. She noted the facility collaborated as a team to determine if a discharge plan was appropriate or not, and relied on the medical provider's input as well. If they think someone will eventually not be capable of making decisions they have the resident designate who they want to be DPOA. If they come in already compromised they work with family to try and get a guardian appointed. Non-relatives who are willing to take guardianship usually have a full caseload. She acknowledged she was not sure if guardianship was attempted for the resident, and that the Social Worker would know for sure. The facility policy titled Transfer/Discharge Criteria, revised 2/01/20 lacked any direction regarding discharge planning according to resident goals or determination of medial decision-making capacity as it relates to discharge planning.

Based on record review, staff and resident interviews, and policy review the facility failed to implement its policy to ensure the safety of both smoking and non-smoking residents (Resident #65). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) report dated 6/26/24 for Resident #65 indicated a Brief Interview for Mental Status (BIMS) score of 14/15 indicating no cognitive impairment. The MDS further indicated diagnoses including: Wernicke's Encephalopathy (difficulty waking, abnormal eye movements, confusion), bipolar disorder, and tremor. The Smoking Safety Screen dated 8/27/24 documented Resident #65 was able to smoke without supervision off campus. It indicated the need for the facility to store his lighter and cigarettes for safety. In an interview on 9/16/24 at 10:40 AM the resident reported he buys and keeps his own cigarettes and lighter in his room. He confirmed he smokes by himself whenever he wants. In an interview on 9/17/24 at 11:08 AM Staff A, Licensed Practical Nurse (LPN) explained most times residents keep their smoking supplies with them, not at the nurse's station. He confirmed they do not keep Resident #65's smoking supplies. In an interview on 9/17/24 at 11:18 AM Staff B, LPN explained nurses don't really control resident smoking supplies. They are not kept on the medication carts or in the medication rooms. Residents keep the supplies in their rooms. In an interview on 9/17/24 at 11:10 AM the MDS coordinator explained the smoking safety screening is done quarterly. Nurses are to keep the lighters and cigarettes in their cart. There shouldn't be any residents keeping their own supplies. It be should either at the nurse's station or the locked medication room. In an interview on 9/18/24 at 2:53 PM the Administrator explained the smoking residents were told they needed to keep their materials with the nurse in the lock box. Safety risks for other confused residents were explained and education was provided to families as well. Residents have been non-compliant so they discussed getting lock boxes for resident rooms. They have not gotten them because the residents again agreed to keep their supplies with the nurses. It is technically a non-smoking facility but if they are alert and oriented, and have the assessment to be safe to do so, they are allowed to smoke off campus. The facility policy titled Smoking, revised 8/30/23 instructed residents choosing to leave the premises to smoke to store smoking materials in an area not easily accessible to others.

Based on interviews, clinical record review, and facility policy review the facility failed to complete pre and post dialysis assessments that included site assessment for 1 of 1 dialysis residents reviewed (Resident #16). The facility reported a census of 66 residents. Findings include: The Medication Administration Record (MAR) for Resident #16 dated 7/2024, listed a diagnosis of chronic kidney disease, stage 4 (SEVERE) end stage renal disease. The MAR directed vital signs (VS) before and after dialysis every Monday, Wednesday, Friday. The MAR failed to direct staff to assess the dialysis site after return from dialysis. The Medication Administration Record (MAR) for Resident #16 dated 8/2024, directed vital signs before and after dialysis every Monday, Wednesday, Friday. The MAR failed to direct staff to assess the dialysis site after she returned from dialysis. The Medication Administration Record (MAR) for Resident #16 dated 9/2024, the MAR directed vital signs before and after dialysis every Monday, Wednesday, Friday. The MAR failed to direct staff to assess the dialysis site after she returned from dialysis. The Care Plan dated 1/9/24, addressed Resident#16 needed hemodialysis related to end stage renal disease. The Care Plan directed assess access site (right upper extremity) as ordered. The Psychosocial Note dated 9/12/2024 at 2 PM, revealed a Brief Interview for Mental Status score of 11, mild cognitive impairments. The Nurses Progress Note dated 9/6/24, at 6:04 PM, 9/4/24 at 6:04 PM, 8/30/24 at 2:54 PM, 7/26/24 at 10:26 PM, 7/24/24 at 12:05 PM, and 7/17/24 at 12:39 PM, lacked an assessment of the dialysis site. The facility lacked documentation of the Hemodialysis Communication form's dated 7/10/24, 8/2/24, 8/12/24, 8/23/24, 8/26/24, 8/28/24, 9/2/24, 9/9/24, 9/11/24, 9/13/24, and 9/16/24. The Order Review dated 9/19/24, identified the location of dialysis every Monday, Wednesdays, Fridays with a Pick up time at 05:45 AM. The orders lacked direction to assess the site post dialysis. 09/18/24 01:44 PM Staff C, Registered Nurse (RN) revealed upon Resident#16's return from dialysis she checked her vitals and documents on the Dialysis Communication form and looked at the sheet they send with her to see if they changed anything. On 09/18/24 at 2:03 PM the Restorative Licensed Practical Nurse (LPN) reported when a resident comes back and before they go to dialysis the nurses check vitals and the bruit and thrill and doc in the MAR. On 9/18/24 at 2:27 PM the Assistant Director of Nursing (ADON) reported the nurses need to check the vitals when a resident comes back from dialysis and put them on the sheet or could be on the MAR. On 9/19/24 at 8:10 AM the Director of Nursing (DON) reported the nurses are expected to check residents vitals before and after dialysis and check the bruit and thrill before dialysis. She said the don't listen after dialysis due to the bandage. The DON reported they look at the dressing when they come back but the don't document that anywhere. 09/19/24 10:15 AM the ADON reported that staff are expected to document vitals pre and post dialysis in the MAR and on the sheet and some note in the Progress Note. The facility Dialysis Binder held a document titled Binder Expectations undated that directed: All Hemodialysis forms will remain inside the binder. All Hemodialysis forms will be completed in full (no blanks). Management team will audit binder for completion. Only management team will remove Hemodialysis forms to file in Pt chart. Process: The nurse: 1. Pre-treatment (Tx) VS assessment (Complete the entire facility section except post vitals, Print your name and date/time of completion) 2. Include appointment packet with facesheet and medication list. 3. Post Tx VS/assessment when resident returns 4. Enter VS assessment in MAR and chart in Progress notes. The facility policy titled Dialysis Care dated 2/2/17, directed nursing shall provide direct visual monitoring of the access site before and after dialysis. Nursing shall provide ongoing monitoring and care of the resident's vascular access site.

Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, the facility Quality Assessment and Performance improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance (QA) activities to ensure effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. The facility reported a census of 66 residents. Findings include: The CMS 2567, dated 1/18/24 listed, in part, the following concerns: F689, F698 The current survey, conducted 9/16/24-9/19/24 also identified the above concerns. In an interview on 9/19/24 at 12:27 PM the Administrator explained she did not know if the facility put plans in place to address the deficiencies from the previous survey. There was nothing handed off when the previous administrator left. A review of the facility QAPI Program Policies and Procedures, undated revealed the following: The QAA Committee functions under the facility's governing body and is responsible for developing and implementing appropriate plans of action to correct deficiencies identified, regularly review, and analyze data under QAPI and drug regimen review, and act on available data to make improvements. To ensure the planned changes/interventions are implemented and effective in achieving and sustaining improvements, our organization chooses indicators/measures that tie directly to the new action and conducts ongoing periodic measurement and review to ensure that the new action has been adopted and is performed consistently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, policy review, and staff interviews, the facility failed to ensure privacy by leaving a resident exposed for several minutes during incontinence cares for 1 of 7 residents reviewed for dignity (Resident #6). The facility reported a census of 74 residents. Findings: Resident #6 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #6 required total assistance from staff for toileting hygiene. The MDS included diagnoses of anxiety disorder, depression, and weakness. The Care Plan Focus, dated 4/8/24, indicated Resident #6 experienced bladder incontinence related to impaired mobility, obesity, and overactive bladder. The Interventions directed the staff to use incontinence products to promote hygiene and dignity. On 7/23/24 at 1:25 PM, Staff E, Certified Nursing Assistant (CNA), and Staff F, CNA, transferred Resident #6 to the bed with a mechanical lift, as the Director of Nursing (DON) observed. Staff E and Staff F pulled down Resident #6's pants. Staff E unfastened her incontinent brief and pulled the brief down in front, exposing Resident #6's frontal perineal area (referring to the frontal genital area). Staff F stated she would go and find a large sized brief. Staff F and the DON left the room. Staff E waited for approximately 2 minutes and then proceeded to clean Resident #6's frontal perineal area. Approximately 2 minutes later, the DON returned to the room, and reported Staff F would be back with a few more items. Approximately 2 minutes later, Staff F returned with a pan of water on a rolling bedside table. Staff E utilized the pan of water and the cloths to complete Resident #6's perineal cleansing. Several minutes elapsed from the time Staff F and the DON left the room until Staff E completed the remainder of Resident #6's perineal cares. During this time, Resident #10 laid in bed without a drape with her frontal perineal area exposed. The facility policy Residents' [NAME] of Rights revised December 2023, stated residents had the right to personal privacy during personal care. On 7/29/24 at 1:14 PM Staff G, Licensed Practical Nurse (LPN), stated if staff stepped away from a resident for a few moments they should drape them for privacy. On 7/29/24 at 1:30 PM the Director of Nursing (DON) stated if staff stepped away from an exposed resident, they should cover the resident up. She stated she thought the staff member waited to perform cares because the facility directed staff when the facility had State Surveyors in the building, the needed to wait for a member of administration to proceed with cares. She stated if the staff waited, they should cover the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview, the facility failed to follow the care plan to provide a pressure reducing cushion for 1 of 3 residents reviewed with a pressure ulcer (Resident #11). The facility reported a census of 74 residents. Findings: 1. Resident #11 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of arthritis, non Alzheimer's dementia, and weakness. The MDS stated Resident #10 required partial to moderate assistance for rolling right to left, substantial to maximum assistance for showering and transfers, and was dependent of staff for toileting hygiene. The MDS listed a Brief Interview for Mental Status (BIMS) score as 5 out of 15, indicating severely impaired cognition. The Care Plan Focus dated 6/27/23, reflected Resident #11 had a risk for skin breakdown related to impaired mobility, incontinence, and weakness. The Care Plan Focus, dated 6/12/24, indicated Resident #11 had a pressure reducing cushion to the chair. The Braden Scale for Predicting Pressure Sore Risk, dated 7/18/24, identified Resident #11 at risk for the development of pressure sores. The Wound/Skin Healing Records revealed Resident #11 had a Stage 2 (partial thickness loss of skin) pressure ulcer on the coccyx (tailbone) with an onset date of 6/11/24 which measured 0.5 centimeters (cm) x 0.2 cm x 0.1 cm. (length x width x depth). The Subsequent Wound/Skin Health Record measurements included: a. 6/17/24 0.8 cm x 0.5 cm x 0.1 cm b. 6/24/24 0.5 cm x 0.4 cm x 0.1 cm c. 7/1/24 0.8 cm x 0.4 cm x 0.2 cm d. 7/8/24 0.6 cm x 0.3 cm x 0.2 cm e. 7/15/24 0.5 cm x 0.3 cm x 0.1 cm f. 7/22/24 0.5 cm x 0.2 cm x 0.1 cm Observations on the following dates/times revealed Resident #11 in her wheelchair with no cushion under her: 7/23/24 at 8:44 AM, 12:16 PM and 12:41 PM 7/24/24 at 8:10 AM On 7/24/24 at 2:38 PM, Staff G, Licensed Practical Nurse (LPN), measured a wound on Resident #11's coccyx as 0.5 cm x 0.3 cm x 0.2 cm. The wound had a yellow center and red edges. On 7/29/24 at 1:14 PM Staff G stated Resident #11 should always have a cushion in her chair, she had an incontinent episode and they had to switch it out. She stated the staff should replace the cushion in the chair in a timely manner. On 7/29/24 at 1:30 PM the Director of Nursing (DON) stated Resident #11 had a cushion in her wheelchair but stated she didn't know why she didn't have it the week before. She stated they could be cleaning it or the staff could have failed to place it in the chair. She stated they had extra cushions (if one became soiled). The facility policy Pressure Ulcer Prevention Program, effective 6/7/17, directed the facility would provide care to promote the prevention and healing of pressure ulcers. The policy indicated the most effective means of preventing skin breakdown included relief of pressure on the skin and directed staff to utilize pressure redistribution devices.

Based on review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance (QA) activities to obtain feedback, use data, and act to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 74 residents. Findings: The Centers for Medicare and Medicaid Services (CMS) 2567, dated 1/18/24, listed, in part, the following concerns: F550, F600 The CMS 2567, dated 6/6/24, listed, in part, the following concerns: F550 The current survey, conducted 7/22/24 7/29/24, also identified the above concerns. A 1/17/24 Performance Improvement Project (PIP) Inventory document stated all staff would complete abuse prevention training and the current phase of the PIP was monitoring. The document listed the indicators and measures tracked to show improvement to include better treatment noted to residents by family, staff, and residents. The facility In Service Agenda for 5/21/24 included the topics of resident rights and the abuse policy/procedures. The QA Committee Meeting Sign in, dated 6/19/24, listed a PIP Team Report for Abuse. The facility lacked further documentation of QAPI/QA program activities related to resident treatment or abuse prevention. The facility lacked evidence of an ongoing QAPI program related to the above areas including a process of addressing how the committee would conduct the activities necessary to identify and correct quality deficiencies. The facility lacked do documentation of monitoring or evaluating the effectiveness of corrective action/ performance improvement activities and revision as needed. On 7/29/24 at 4:09 PM, when queried about QA activities from January to June 2024 which addressed dignity or abuse prevention, the Administrator stated they all had staff abuse training which had a completion deadline of 2/1/24. In February 2024, they educated all staff regarding de escalation techniques and resident rights. She stated in May, they talked to staff regarding resident rights, grievances, and conducted abuse education on 6/10/24. The Administrator stated she would email all QA activities related to dignity and abuse prevention to the survey team. The facility's QAPI Plan, updated 7/19/18, indicated the plan provided guidance for the overall quality improvement program . The plan reflected the facility utilized a systematic approach to determine when they needed an in depth analysis to fully understand identified problems, causes of the problems, and implications of a change. The facility would implement the plan, evaluate the results, and analyze the outcome.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and policy review the facility failed to ensure catheter care orders were in place for 1 of 3 residents reviewed for catheter care (Resident #1). The facility reported a census of 83 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 required supervision or touch assistance with transfers, standing up from bed, and mobility. The MDS reflected diagnoses of benign prostatic hyperplasia, chronic kidney disease, and respiratory failure. The Care Plan Focus dated 4/29/24 indicated Resident #1 had a urinary catheter. The Focus lacked interventions for cleaning the catheter site, changing the catheter bag, or changing the catheter. Neither the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) documented an order to change the indwelling urinary catheter on a schedule or as needed before 5/13/24, (27 days after admission). The MAR and TAR printed at 9:58 AM on 5/28/24 lacked documentation of orders to change the catheter bag. The Order Note dated 5/13/24 at 2:42 PM indicated Resident #1 didn't have orders entered for care of the indwelling urinary catheter. The nurse contacted the Nurse Practitioner for orders at that time. On 5/28/24 at 5:59 PM the Administrator stated the only time the facility monitored fluid intake or urine output for residents with a catheter was if there was a provider's order. On 5/29/24 at 1:55 PM the Director of Nursing stated the facility entered orders at admission and found an RN to do the admission assessment. Sometimes that was her or the Assistant Director of Nursing, or the charge nurse. She further stated that there was no documentation of emptying the bags, tracking fluid intake, or measuring urine output that might have caught missing orders. An interview with Staff K, Licensed Practical Nurse (LPN) on 5/30/24 at 10:18 AM revealed there were no orders in place for catheter care or maintenance when the resident began complaining of pain on 5/13/24, so he had to call the nurse practitioner to establish care. He had to find supplies, put together a makeshift catheter kit, and was able to get it changed later that day. He stated someone dropped the ball on making sure the orders were in place at admission. A policy titled Catheter Care effective 10/1/18 documented the procedure for catheter site care. It lacked policy or procedure regarding catheter orders, bag replacement, catheter replacement, assessment for care or removal, or documentation of input/output.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and policy review the facility failed to provide wound care as ordered for 1 of 3 residents (Resident #2) In addition, the facility failed to complete skin assessments for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 83 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #2 required substantial to maximal assistance with rolling in bed, they required total assistance with sitting up and transfers. The MDS included diagnoses of diabetes mellitus, paraplegia (inability to move from the waist down), stage IV (4) pressure ulcer of unspecified buttock, and non pressure chronic ulcer of skin of sites with fat layer exposed. The Care Plan Focus initiated 3/6/23 reflected Resident #2 had skin breakdown. The Interventions directed the following: a. Assess Resident #2 for risk factors b. Assist with repositioning, keeping skin as clean and dry as possible c. Minimize skin exposure to moisture d. Monitor skin during care e. Skin treatments as ordered for areas of impaired skin integrity. A document titled Treatment Administration Record (TAR) listed the following treatments as not completed in May 2024: a. 5/1/24: i. Gentamicin 480mg in Saline Solution Use 60 ml via irrigation every evening shift for Bladder irrigation Instill 60mL into bladder via catheter. Clamp for 30min, then drain. ii. Calamine External Lotion 8 8 % Apply to Affected Area topically every day and evening shift for Itching due to shingles. iii. Calmoseptine External Ointment 0.44 20.6 % Apply to Left groin topically every day and evening shift for MASD wound until healed. iv. Dakin's (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to Coccyx topically every day and evening shift for Coccyx/sacral wound Dampen kerlix with Dakin's solution and pack into wound base. Cover with dry ABD and secure with Medipore tape. v. Dakin's (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to right ischium topically every day and evening shift for right ischium pressure ulcer Cleanse wound, pat dry. Apply skin prep to the intact skin around the wound (peri wound) and at the location of the adhesive application. Lightly moisten gauze, pack lightly into wound bed, cover with silicone border or ABD PAD & paper tape (DUODERM ANCHORS IN PLACE FOR TAPE) BID and PRN vi. Miconazole Powder (Miconazole) Apply to ABDOMINAL SKIN FOLDS topically every day and evening shift for MASD Cleanse skin with soap and water, rinse well, pat dry, sprinkle powder lightly until healed vii. Miconazole Powder (Miconazole) Apply to Bilateral groin topically every day and evening shift for MASD Cleanse skin with soap and water, rinse well, pat dry, sprinkle powder lightly until healed viii. Miconazole Powder (Miconazole) Apply to Neck folds topically every day and evening shift for MASD Cleanse skin with soap and water, rinse well, pat dry, sprinkle powder lightly until healed ix. Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to penis topically every day and evening shift for Pressure ulcer, penis Cleanse open area, pat dry. Apply triad paste and cover w/ gauze. BID and PRN x. Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to Right Posterior Thigh topically every day and evening shift for Shearing b. 5/6/24: i. Mepilex Border Flex External Pad Apply to Umbilicus topically every day shift for Hernia Change mepilex dressing daily and as needed. ii. Mepilex External Pad Apply to Bilateral Heels topically every day shift for Bilateral heal callous A document titled Medication Administration Audit Report documented that in the week prior to Resident #2's discharge to the hospital, the facility provided 101 out of 113 treatments outside of their scheduled time frames. A progress note dated 5/20/24 at 10:34 AM titled SBAR Summary for Providers documented a change of condition for the resident. It included respiratory changes, abdominal pain and tenderness, pain, and pressure ulcer/injury wound. The recommendation was to send Resident #2 to the emergency department (ED) for further investigation, recommendation, treatment. A document titled ED Triage Notes dated 5/20/24 at 12:50 PM documented Resident #2 transferred to a different healthcare facility with a pressure injury to the sacral region with necrotizing fasciitis (bacterial infection causing soft tissue death). On 5/28/24 at 5:00 PM Staff E, Registered Nurse (RN), stated she was very aware of residents complaining about missing wound treatments and indicated management was aware of it as well. She stated the problem was inconsistency in staffing and heavy levels of care along with poor communication. On 5/29/24 at 1:29 PM the Assistant Director of Nursing confirmed she was aware of 3 residents with concerns about missing wound treatments, including Resident #2. She stated it was the Director of Nursing's (DON) responsibility to order supplies and she did that monthly. There was a way to order emergency supplies if needed. On 5/29/24 at 1:55 PM the DON stated she was not aware of any resident complaints about missing wound treatments. She tried to figure out the resident's needs and ordered supplies once a month. The DON stated a lot of high acuity had put a strain on their supplies. She indicated that insurance only allowed for specific amounts so she tried to order more stock supplies. On 6/5/24 at 10:19 AM Staff H, Licensed Practical Nurse (LPN), explained they had difficulty making sure the facility had enough dressings in place for Resident #2. He stated he planned 5 days ahead for catheter care to make sure he had all of the supplies, but sometimes, the dressings just ran out. Staff take things from an area they shouldn't without telling someone. He said they just need to know the supplies are available to do their job. Staff H also reported that Resident #2 told him the weekend agency staff were not completing all of the treatments they marked. On 6/6/24 at 2:06 PM the Administrator stated that if a box didn't have documentation on the TAR, ideally the nurse did the treatment, but missed documenting it happening. However, nursing 101 is that if no one documented it, it didn't happen. She didn't know the TAR reflected time of the completed treatments. The Pressure Ulcer Prevention Program policy, effective 6/7/17, instructed to complete assessments in a timely manner; implement interventions, monitor, and revise as appropriate; and recognize, evaluate, and report changes in condition to the resident's attending practitioner. The program shall include implementing individualized comprehensive plans of care (interventions). The procedure included following physician's orders for treatment. 2. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #6 required total staff assistance with sitting up in bed and all transfers. The MDS reflected diagnoses of morbid obesity, anxiety and depression, and need for assistance with personal care. The Care Plan Focus dated 4/8/24 indicated Resident #6 had chronic pain and ADL deterioration. The Interventions directed the following: a. Assess the effects of pain b. Monitor for complaints and non verbal signs of pain c. Don't rush the resident allowing for extra time to complete ADLs. On 5/23/24 at 2:50 PM observed Resident #6 lying in her bed, covers on, propped up with pillows, watching television. She stated that on or around the week of 5/19/24, as Staff A went too fast with her cares, she grabbed her right arm to turn her. Resident #6 showed a bruise on the inside of her arm and reported it as a result of that repositioning. The observation revealed no additional bruises next to or on the other side of her arm. Resident #6's progress notes lacked documentation of a skin assessment or the origin of the original bruise. The facility lacked documentation of completed skin assessments with Resident #6's showers on 5/9/24, 5/13/24, 5/16/24, 5/20/24, 5/23/24, 5/27/24, or 5/30/24. On 5/31/24 at 4:29 PM the Administrator provided an incomplete Daily Bath Tracking Log by email. She wrote CNAs/Bath Aides completed the bath sheets that identified new skin areas, and then gave the sheets to the nurse to address if the resident had any areas noted. If no areas noted they gave the sheets to the DON to file. On 6/3/24 at 8:17 AM in a follow-up email, the Administrator reported they recently implemented the tracking logs and they didn't have any available for the month of May. On 6/5/24 at 10:19 AM Staff H, Licensed Practical Nurse (LPN), reported he didn't know of Resident #6's bruise until the Assistant DON came to investigate the cause.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, clinical record review, and policy review the facility failed to treat residents with dignity and respect while providing cares for 5 of 7 residents reviewed for resident rights (Residents #3, #6, #7, #8, #9). The facility reported a census of 83 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated Resident #3 required total assistance with toilet use, transfers, and sitting up in bed. The MDS reflected diagnoses of anxiety and depression, obesity, and respiratory failure. The Care Plan Focus dated 2/27/23 reflected Resident #3 had a decline in activities of daily living (ADL). The Intervention directed to not rush the resident and allow extra time for ADLs. On 5/23/24 at 2:36 PM observed Resident #3 laying on her left side in bed with her right arm over her forehead. As she slowly rolled to her right to lay on her back, her face reflected a slight grimace. She stated she had a leg that didn't work very well anymore. Resident #3 described Staff A, Certified Nurse Aide (CNA), as rough when providing care on the overnight shift from 5/21/24 to 5/22/24. Resident #3 elaborated rough meant rushed and maybe angry. In addition, if she didn't move fast enough Staff A pulled on her leg to position her. Resident #3 said she couldn't report the CNA as mean, but just in a hurry. She shouldn't have to fear putting the call light on at night because she didn't know who was going to answer. Resident #3 stated the CNA 'runs hot and cold' and she never knew what she was going to get. On 5/28/24 at 4:45 PM Staff D, Certified Nursing Assistant (CNA), stated that some CNAs can be 'stern.' She reported resident needs were extensive and the CNAs had to do their work to move on to assist other residents. Staff D stated Resident #3 reported Staff A rolled her too hard or too rough. On 5/28/24 at 5:00 PM Staff E, Registered Nurse (RN), stated she observed some CNAs work in a way resident might feel is too fast. She stated residents had complained to her about 3rd shift working with them too fast. On 5/29/24 at 5:24 AM Staff B, CNA, stated maybe some staff do work too fast. Residents want staff to spend a lot of time with them, but they had to get to the next resident to provide care. Staff B stated some staff approaches were hard for residents. She heard residents complain about rude attitudes. That included Staff A. On 5/29/24 at 6:25 AM Staff C, RN, said the facility staffed by budget, not acuity, and some residents didn't sleep through the night. On 5/29/24 at 1:29 PM the Assistant Director of Nursing (ADON) stated residents at night reported they didn't get the care they deserved. On 6/4/24 at 9:50 AM Staff G, CNA, reported Resident #3 told her she tried to be nice to Staff A because she knew she got upset. An interview with Staff A, CNA, on 6/4/24 at 1:09 PM revealed she would go to the nurse if Resident #3 reported pain. She said she didn't think she was rough providing cares. Staff A thought residents might view rough as carelessness, moving too fast, or rushed cares. She stated she could tell maybe by the look on their face or what they said. Staff A confirmed she told other CNAs not to go in the resident's room unless her call light was on. She thought Resident #3 didn't want anyone in there because she was upset when she first arrived that they woke her up multiple times at night. Staff A didn't ask the resident if this was what she wanted. A document titled Resident's [NAME] of Rights, revised 12/2023, documented the resident had a right to a dignified existence and self determination. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of quality of life. The facility must protect and promote the rights of the resident. The Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated October 2022, indicated the facility would provide a supportive and safe environment for all residents. 2. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #6 required total staff assistance with sitting up in bed and all transfers. The MDS reflected diagnoses of morbid obesity, anxiety and depression, and need for assistance with personal care. The Care Plan Focus dated 4/8/24 indicated Resident #6 had chronic pain and ADL deterioration. The Interventions directed the following: a. Assess the effects of pain b. Monitor for complaints and non verbal signs of pain c. Don't rush the resident allowing for extra time to complete ADLs. An interview with Resident #6 on 5/23/24 at 2:50 PM stated on or around the week of 5/19/24 Staff A was going too fast and grabbed her arm to turn her. Resident #6 further stated there have been other times Staff A has been rude or rushed during care. That included: 1. Yelling from the doorway when the call light was on 'what do you want' even though she had to come in to turn the light off 2. Ignoring her when coming in to assist her roommate 3. Making her feel like a nuisance if she needed her, like she shouldn't be here 4. Moving her too fast and rolling her on her arm 5. Making rough, growling sounds while turning her, 'bullish like a drill sergeant ' 6. Telling other CNAs not to come in her room unless the call light was on An interview with Resident #6's roommate on 6/3/24 at 10:00 AM revealed that Staff A is 'hard on' Resident #6. She was 'pretty rough' on her, she heard it. She explained she heard Resident #6 groan and Staff A said she had to roll over and just moved her fast. The resident asked for pillows and Staff A dropped them on the bed without helping her use them as support. Resident #6's roommate added Staff A regularly worked 16 hour shifts, it affected her mood and the way she treated them. On 6/5/24 at 10:19 AM Staff H, Licensed Practical Nurse (LPN), stated he couldn't deny if residents described Staff A as rushed or frustrated, she had a routine and didn't want it messed with. It wouldn't surprise him if there was a complaint; if they called her and she helped. Then they called again, changing her routine and she didn't like that. On 6/5/24 at 2:23 Staff I, CNA, stated residents can misinterpret Staff A and she can misinterpret them. She didn't think that happened with the other staff. Staff A could get anxious and was matter of fact. She had a routine that she stuck to. Some of the residents missed that when she was not there, some didn't. 3. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #7 required substantial to maximal assistance with bed mobility and total assistance from staff to stand from sitting and chair to bed transfers. The MDS reflected diagnoses of chronic pain, obesity, and polyneuropathy. On 5/28/24 at 4:14 PM Resident #7 revealed he felt some of the staff on the overnight shift were 'not so good.' He stated around 9:00 PM or 10:00 PM he didn't like to put his call light on because of who might walk through the door. He said there were 7nights a week that he lived there and he knew all of them were not going to be good because of certain staff. 'It isn't right.' He mentioned his medications needed to be on time and staff should not talk down to residents. He should not have to worry about who was coming to take care of him. Resident #7 explained joking back and forth with two CNAs who told him he was the boss because he was the resident. When he shared that visit with a nurse and another CNA who came in, he said the nurse told him she was the boss around here and he felt she wasn't joking. This made him feel more anxious. 4. Resident #8's Care Plan listed an admission date of 5/24/24 and diagnoses of diabetes mellitus, Parkinson's disease, and unsteadiness on feet. The Care Plan Focus dated 5/30/24 reflected Resident #8 had a deterioration in ability to complete ADLs. The Interventions instructed to not rush Resident #8, allow extra time, help with morning and evening cares. The admission Record listed Resident #8 as his own responsible party. A progress note dated 5/29/24 at 13:04 documented Resident #8 reported to the facility's nurse practitioner about a CNA being rough with him last night. On 5/30/24 at 1:50 PM observed Resident #8 resting on his back in bed, on the top of his sheets. Resident #8 described himself as tired due to having difficulty sleeping the night before. He couldn't find his call light and had to get up to use the bathroom. He stated one of the facility's staff came into his room and told him to get back in bed. Resident #8 demonstrated how the CNA put her hands on his back, pushed him, and then he indicated he stumbled. He said he felt helpless and scared because it was dark, and he didn't know who it as he was new to the facility. He asked me to leave the door open so someone could see him. A document titled interview with (Staff J, RN) on 5/29/24 described Resident #8 got up and down a lot that night, used his call light a lot, and that she didn't have concerns with his care. An interview with Staff J on 6/4/24 at 11:39 AM revealed that she didn't know who the CNA was and therefore not able to discuss the care provided. On 6/4/24 at 8:12 AM Staff B recalled working with Resident #8. That night she checked in on the residents at least every 2 hours, completed check and change as needed, and assisted with toileting. She stated this resident was up and down all night and she redirected him to bed, offered the recliner, offered the common area, and took him to the bathroom or provided his urinal at least 4 times. She believed a resident who was being very vocal that night triggered and upset him. She denied physical contact other than putting her hand on his shoulder to guide him back to bed. Staff B indicated he also needed assistance with pivoting and that could be what he was thinking of. She stated there were no other staff in the room while she provided redirection, and they could have prevented this situation if they had enough staff at night to calm the other resident and Resident #8 at the same time. A follow up interview with Resident #8 on 6/3/24 at 10:20 AM determined the resident didn't have concerns over the weekend other than help being slow to come Sunday night. He reported that he remained worried, and watched the hallway outside of his room during the interview. 5. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #9 required partial to moderate assistance with bed mobility and needed total assistance from staff for transfers. The MDS reflected diagnoses of benign prostatic hyperplasia, chronic pain, and a fracture. A progress note dated 4/26/24 at 14:31 labeled Behavior Note documented Resident #9 complained 3 times that week of staff rolling him too rough during cares and being rude. He didn't think they were trying to hurt him but did say they needed to be gentler. The Progress Notes lacked follow-up documentation with Resident #9 about the status of the situation. On 6/3/24 at 3:12 PM Resident #9 reported he didn't think staff were rough any more, but mostly too fast. They could still slow down a little and talk to him. He said some staff are more respectful than others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, interviews, and policy review the facility failed to accurately and thoroughly assess patterns in fluid intake, voiding patterns, cleaning care, or symptoms associated with long term catheter use for 3 of 3 residents reviewed for catheters and for 12 of 12 residents in the facility using catheters as part of their care. The facility reported a census of 83 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 required supervision or touch assistance with transfers, standing up from bed, and mobility. The MDS reflected diagnoses of benign prostatic hyperplasia, chronic kidney disease, and respiratory failure. Resident #1's Care Plan included a focus area dated 4/29/24 documenting the use of the indwelling catheter related to urinary retention and a failed voiding trial. Interventions included catheter care BID and PRN (twice a day and as needed), reporting urinary tract infection symptoms, labs as ordered, and assessing for continued need of the catheter quarterly. The Care Plan lacked interventions regarding resident specific catheter site cleaning and care, changing the catheter bag, changing the catheter, fluid intake or urinary output guidelines, or symptoms to monitor for a change in condition. The MDS Observation Tasks documented continence for 29 of 41 possible shifts from 5/1/24 to 5/14/24 with 12 shifts not documented. 2 of 29 reflected Resident as continent, 11 of 29 as incontinent, 2 of 29 not rated due to a condom catheter, and the remaining 14 identified Resident #1's indwelling catheter. The document lacked evidence the staff provided catheter or catheter bag care on any shift. Progress notes, task sheets, electronic health records, and paper charts lacked documentation regarding patterns in fluid intake, voiding patterns, cleaning care, or symptoms associated with long term catheter use. 2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #2 required substantial to maximal assistance with rolling in bed, they required total assistance with sitting up and transfers. The MDS included diagnoses of diabetes mellitus, paraplegia (inability to move from the waist down), stage IV (4) pressure ulcer of unspecified buttock, and non-pressure chronic ulcer of skin of sites with fat layer exposed. Resident #2's Progress notes, task sheets, electronic health records, and paper charts lacked documentation regarding patterns in fluid intake, voiding patterns, cleaning care, or symptoms associated with long term catheter use. 3. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #9 required partial to moderate assistance with bed mobility and needed total assistance from staff for transfers. The MDS reflected diagnoses of benign prostatic hyperplasia, chronic pain, and a fracture. Progress notes, task sheets, electronic health records, and paper charts lacked documentation regarding patterns in fluid intake, voiding patterns, cleaning care, or symptoms associated with long term catheter use. Observation of catheter bag care for Resident #9 on 6/3/24 at 1:49 PM revealed staff pulled the curtain, practiced hand hygiene, wore appropriate PPE, and cleaned the tubing. Staff didn't discuss fluid intake with the resident, ask about catheter associated pain, or document urine output. An interview with Staff L, Licensed Practical Nurse (LPN) on 5/28/24 at 4:34 PM revealed orders for changing bags and the catheter should be in the electronic health record. She stated sometimes she doesn't have the right supplies for catheter care. She didn't think the facility measured fluid intake or urine output for any residents unless there was a specific order. On 5/28/24 at 4:45 PM Staff D, Certified Nursing Assistant (CNA) stated they have never had to document catheter care, input, or output for. They told the nurse what they observed and the nurse documented. On 5/28/24 at 5:00 PM Staff E, Registered Nurse (RN), stated they didn't document outputs at the facility. The CNAs emptied catheter bags at the end of every shift, but, didn't document either. She indicated there were residents currently in the facility on fluid restrictions and dialysis who should have this monitored. She thought it should be in the electronic health record under the task section. During an interview at 5:59 PM on 5/28/24 the Administrator stated the only time the facility monitored intake and output for catheters was if the doctor wrote an order for it. During an interview on 5/29/24 at 6:25 AM Staff C, RN stated she experienced poor communication in the facility. She indicated there was information she felt she should have about residents that she didn't get. She didn't know about documenting urine output, as the CNAs didn't have a place to record quantity or quality. She said notifying the providers of decreased output is difficult, because they don't have data to report. On 5/29/24 at 1:29 PM the Assistant Director of Nursing (ADON) stated the facility didn't currently document fluid intake or urine output unless they had an order from the provider. The order from the provider only included fluid restriction, not how much input to allow or to monitor for output. She reported she expected the staff to document the information. On 5/29/24 at 1:55 PM the DON explained they didn't have catheter care documentation. A follow up interview on 6/6/24 at 12:01 verified catheter care didn't get documented. The DON couldn't report how they verified the completion of catheter care. A policy titled Comprehensive Assessment and Reassessment, effective 5/10/17, documented the assessment of the care or treatment required to meet the needs of the resident shall be ongoing throughout the resident's stay, with the assessment process individualized to meet the needs of the resident population. It listed symptoms that might be associated with a disease, condition, or treatment, continence, and special treatments and procedures as factors in this process. A policy titled Catheter Care, effective 10/1/18, provided the procedure for emptying the catheter bag. It didn't address the other components of catheter care, assessments, monitoring, communication with providers, patterns in fluid intake, voiding patterns, interventions, cleaning care, or symptoms associated with short or long term catheter use.

Based on observation, record review, and interviews the facility failed to maintain an adequate number of supplies to provide for the daily needs of all residents in the facility. The facility reported a census of 83 residents. Findings include: The Treatment Administration Record for Resident #2 lacked documentation of completion of 12 treatments between 5/1/24 and 5/6/24. During an interview with Staff L, Licensed Practical Nurse (LPN) on 5/28/24 at 4:34 PM she stated sometimes she didn't have the supplies she needed for catheter care. On 5/28/24 at 4:45 PM Staff D, Certified Nursing Assistant (CNA) stated 3 different residents complained of missed wound care treatments. She provided that information to the nurse on duty. On 5/28/24 at 5:00 PM Staff E, Registered Nurse (RN) stated there were not enough supplies to complete care. She gave the example of a need the week before to use pudding cups instead of medication cups because they ran out. At 6:25 AM on 5/29/24 Staff C, RN, stated supplies were an issue in the facility. She felt they didn't keep track of the used items and the acuity of the residents admitted . Staff C mentioned running out of medication cups, cups used to measure 30 cc when flushing catheters, blood glucose test strips when there were 11 diabetic residents on one floor, alcohol squares which required them to order some from the pharmacy to ensure they could continue to provide care, tissues, and gloves. She also reported the facility had to ask a family member to bring in colostomy supplies from home for a new resident because they were not properly prepared for her arrival. On 5/29/24 at 1:29 PM the Assistant Director of Nursing (ADON) stated the Director of Nursing (DON) ordered supplies. She would order once a month and could ask for emergency orders if needed. The ADON stated she had heard multiple instances of running out of supplies including medication cups. She stated she put multiple notes under the DON's door and added that the Administrator had to come in on a Saturday to help get supplies so staff could complete their work. On 5/29/24 at 1:55 PM the DON confirmed she was responsible for supplies and ordered them once per month. She stated she tried her best to figure out the supplies needed and noted high acuity put a strain on their supply. The DON stated she started ordering more stock supplies because insurance only allowed specific amounts. On 6/4/24 at 11:50 AM observed the lower level storage room. A white plastic organizer held drawers labeled with different sizes of Mepilex wound dressings. All of the drawers were empty except the one labeled with the 6 inch by 6 inch size which held two of the dressings. The Director of Nursing (DON) stated she was placing an order that day. On 6/4/24 at 12:00 PM observed a second floor medication cart. There was one 2 inch by 2 inch Mepilex in the second drawer, with 3 more in a box in the 3rd drawer. The double-locked bottom drawer of the cart contained approximately 3, 6x6 Mepilex. Staff H reported they locked those dressings so they didn't disappear when he needed them to provide treatment. He stated people took them and didn't tell anyone so he would run out when he needed to complete treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interviews, the facility failed to notify 1 of 3 resident's family/guardian in a timely manner when the resident had a change in condition (Resident #2). The facility reported a census of 85 residents. Findings include: The MDS (Minimum Data Set) an assessment tool dated 3/7/2024 revealed Resident #2 had moderately impaired cognitive abilities, dependent on staff to transfer from one surface to another, failed to ambulate, had a history of falls prior to admission, had a skin tear that required a dressing, and no pressure ulcers. The resident admitted to the facility on [DATE]. The Resident's Census Report revealed the resident had a room change on 3/11/2024. The resident's admission record documented the resident had a responsible party, guardian, conservator, and emergency contact #1 person listed, not a family member. In the Progress Notes, an admission assessment dated [DATE] identified the resident had a skin tear to the right upper arm and scattered faint bruises to the left arm. The note failed to indicate staff notified the resident's guardian of the skin issues. A Progress Note dated 4/4/2024 revealed the resident's family visited and noted bruising to the resident's bilateral upper extremities. Staff noted faded purple bruise to the left lower forearm that measured 3 cm (centimeters) by 2.5 cm, faded purple bruise to the left upper forearm that measured 2 cm by 2 cm., and yellow to faded red scattered bruising to the right lower forearm. Staff A, LPN (Licensed Practical Nurse) initiated skin assessment sheets and indicated family aware from being at the facility. Staff A failed to document guardian notification. No Progress Note documented the resident had a room change on 3/11/2024. Staff failed to document they notified the resident's guardian of the room change. On 5/6/2024 at 1:45 P.M., Staff A, LPN indicated family identified Resident #2's bruises during their visit on 4/4/2024; therefore they knew about the issue. Staff A initiated the skin assessment sheets. The bruises looked like they may have been present for awhile, some were faded. Staff A failed to notify the guardian. On 5/6/2024 at 1:00 P.M., Staff B, DON (Director of Nursing) revealed staff should have initiated the skin assessment sheets upon admission. The nurse performing the admission assessment should have notified the resident's family or guardian of any identified concerns. Staff B had the responsibility of notifying the responsible party when a resident had a room change. The clinical record failed to document Staff B made the guardian aware when Resident #2 changed rooms. The facility policy regarding Physician Notification effective 10/10/2019 included: To inform a physician of a resident's change in condition. PROCEDURE: 1.) Physicians will be notified promptly of the following: A. Any accident or unusual incident. B. Any accident or incident which results in injury which may require physician intervention. C. A significant change in resident condition which is life threatening. D. A significant change in resident condition which has potential for clinical complication (i.e. urinary tract infections, open skin, etc.) E. A change in condition which requires a significant alteration in treatment. F. Death of a resident. G. Discharge or transfer of a resident. EFFECTIVE: 10/10/2019 REVISED: The resident's representative shall be notified of any accident, injury, or adverse change in a resident's condition requiring physician notification. PROCEDURE: Resident representatives shall be notified of the following: Any accident or unusual incident, regardless of injury. A significant change in a resident's condition. o Death o Discharge or transfer to another healthcare facility or home. - Any change in condition which may be life-threatening should be immediately called. Same day notification may be utilized for condition changes that are not life- threatening. Next day notification may be utilized for condition changes that are not life- threatening and occur during sleeping hours. Attempts to notify the resident representative shall be documented in the clinical record. A minimum of 3 attempts must be made. Residents who are designated as their own responsible party may exercise their right to refuse family notification. The facility Room Change policy dated 5/2/2022 included: POLICY: The resident or resident's representative will be notified prior to a change in room or roommate. PROCEDURE: Prior to the change: The resident or resident's representative will be notified prior to a change in room or roommate. A change in room assignment will be documented in Point Click Care through a census entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, facility policy review, staff and resident interviews, the facility failed to provide appropriate skin assessment and interventions for 2 of 6 residents reviewed (Residents #1 & #2). The facility reported a census of 85 residents. Findings include: 1. The MDS (Minimum Data Set) an assessment tool dated 3/7/2024 revealed Resident #2 had moderately impaired cognitive abilities, dependent on staff to transfer from one surface to another, failed to ambulate, had a history of falls prior to admission, a skin tear that required a dressing, and no pressure ulcers. The resident admitted to the facility on [DATE]. In the Progress Notes, an admission assessment dated [DATE] identified the resident had a skin tear to the right upper arm and scattered faint bruises to the left arm. The note failed to indicate staff notified the resident's guardian of the skin issues. A Progress Note dated 3/11/2024 revealed the skin tear healed and staff made the resident's guardian aware. A Progress Note dated 4/4/2024 revealed the resident's family visited and noted bruising to the resident's bilateral upper extremities. Staff noted faded purple bruise to the left lower forearm that measured 3 cm (centimeters) by 2.5 cm, faded purple bruise to the left upper forearm that measured 2 cm by 2 cm., and yellow to faded red scattered bruising to the right lower forearm. Staff A, LPN (Licensed Practical Nurse) initiated skin assessment sheets and indicated family aware from being at the facility. Staff A failed to document he notified the guardian. Observation on 5/6/2024 at approximately 11:40 AM revealed the resident in bed on her back with a body pillow placed on her right side. The resident's right upper arm had a gauze dressing with tape that appeared dark red in color. The resident's right upper arm had a small amount of dried blood present. The resident's left arm had scattered bruises and dark/red discoloration. Staff C, CNA (Certified Nurse Aide) indicated she needed to report the right upper arm concern to the nurse. A Progress Note dated 5/6/2024 at 8:36 PM, revealed physician orders for the wound treatment. On 5/6/2024 at 1:45 PM, Staff A, LPN indicated family identified Resident #2's bruises during their visit, therefore they knew about the issue. Staff A initiated the skin assessment sheets. The bruises looked like they may have been present for awhile, some were faded. Staff A failed to notify the guardian. On 5/6/2024 at 1:00 PM, Staff B, DON (Director of Nursing) revealed staff should have initiated the skin assessment sheets upon admission. The nurse performing the admission assessment should have notified the resident's family or guardian of any identified concerns. 2. According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognitive status. The resident experienced a hospitalization from 5/1-5/4/2024 and returned with a BIMS score of 3, which indicated severely impaired cognitive ability. The MDS revealed the resident moved about the facility via his wheelchair independently and had independence with personal cares. The MDS revealed the resident had diagnoses which included Dementia, peripheral vascular disease, chronic foot ulcers, heart disease, and chronic leg wounds with cellulitis. Review of the Care Plan dated 8/21/2023 indicated the resident had a risk for skin breakdown due to physical deconditioning, peripheral vascular disease, dementia, and neuropathy. The Care Plan directed the staff to document weekly; measurements, drainage, and any other notable changes and to contact the resident's physician with changes noted. Review of nursing Progress Notes from 3/15/24 - 5/1/24 failed to include documentation of wound assessments with included measurements and the condition of the venous ulcers. Observations on 5/6/24 at 1:00 PM revealed Staff E-LPN remove the residents bilateral lower leg dressings which enabled Staff D-LPN/Facility Skin Nurse as of 5/6/24 to measure the resident's leg wounds. Staff D measured three areas of impaired skin: -Wound A located on the resident's left lateral malleous measured 3 cm x 5 cm with 50% granulation and 50% slough. -Wound B located on the right lower lateral shin area which measured 17.5 cm x 7 cm x .3 cm in depth with 75 % slough. Wound B appeared to be actively dripping serous fluid. -Wound C located on the right dorsal foot measured 20 cm x 7.5 cm x 0.1 cm in depth. The resident's Primary Care Physician present during the dressing change and stated all of the wounds are considered venous ulcers and will most likely not be healed due to severe venous insufficiency. Review of the Wound/Skin healing records for Wound A-revealed the nursing staff completed a skin assessment on this wound on 2/8/24, 2/28/24, 3/13/24, and 5/5/24. Review of the Wound/Skin healing record for Wound B revealed 2 wounds on the right dorsal foot and the right anterior leg conjoined into the current Wound B. Review of the skin sheets revealed the staff completed skin assessments on these wounds on 1/17/24, 2/8/24, 3/13/24, and 5/5/24. Review of the Wound/Skin healing records for Wound C revealed the resident had a wound on his right medial ankle, first discovered on 12/13/23. The staff assessed the wound on 12/13/23, 2/28/24, and 5/5/24. During an interview with Staff B/RN/Director of Nurses on 5/6/24 at 11:30 AM, Staff B stated she did not have any additional skin sheets for Resident #1, stating the staff failed to complete weekly skin assessments on the resident's wounds. During an interview with Staff B/RN/Director of Nurses on 5/8/24 at 10:00 AM, Staff B stated the nurses are required to complete weekly assessments on every resident with a skin issue. The nurse is expected to report to the resident's Primary Care Provider changes noted to the wound, to request changes in the treatment regime if needed. Staff B stated prior to 5/6/24 they did not have a skin nurse but has since assigned Staff D/LPN to this task, prior to Staff D's assignment each charge nurse for the resident on the day assessments were due was responsible to complete the wound assessment. During an interview with Staff E/LPN on 5/6/24 at 9:00 AM, Staff E stated she works Monday-Friday day shift with Resident #1. She stated the resident had been to the wound clinic inconsistently. She stated the resident is non-complaint and does as he chooses. Staff E stated she completes the prescribed wound dressing change Monday-Friday but admits she does not measure the wounds weekly as she should. Staff E stated she was to measure the resident's wounds every Wednesday on her shift but admits she does not assess and measure the wounds weekly. During an interview with Staff F/Administer on 5/6/24 at 12:45 PM, Staff F stated the nursing staff failed to perform weekly skin assessments as per facility policy and directed the nursing staff to examine every resident's skin condition on 5/1/24. As a result of the completion of the facility wide mandated resident skin assessments the nursing staff identified an additional 15 residents with impaired skin. During an interview with Staff B/Director of Nurses on 6/8/24 at 10:00 AM. Staff B stated the aides are to observe the resident's skin with cares and report areas of concern to the charge nurse. She stated with each bath the aides are to report areas of skin concerns by placing their findings on a bath sheet and handing it off to the resident's charge nurse. Staff B was asked for copies of bath sheets for Resident #1 but failed to provide them, stating she couldn't find them. The facility Skin Care: Management of Wounds and Pressure Injuries policy effective 6/20/2023 included: Policy: Wound management involves assessment and proper treatment of wounds to promote healing, minimize pain, and prevent infection. PROCEDURE: Assessment: The purpose is to evaluate wounds to determine appropriate treatment and response to the treatment. Visual assessment with every dressing change. Documented assessment at least weekly. Documented assessment includes: Date of onset/date updated Location, size, depth, stage, condition of surrounding skin, condition of wound bed, current treatment and response, family notification, physician notification, and dietary notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS dated [DATE] for Resident #4 documented diagnoses to include debility, cardiorespiratory conditions, coronary artery disease, heart failure and renal insufficiency. The MDS documented a BIMS score of 15 out of 15, indicating intact cognition status. The MDS further documented under Section GG for functional abilities and goals for toileting hygiene: The Resident dependent on the assistance of 2 or more helpers is required. The Care Plan for Resident #4, with a revision date of 12/1/23, under the Focus Area for bladder documented resident experienced occasional bladder incontinence related to impaired mobility, type II diabetes mellitus, physical deconditioning, and weakness. The intervention and task for this area directed staff to check and change before and after meals, at bedtime, and as needed, as well as to provide incontinence care after each incontinent episode and use incontinence products to promote hygiene and dignity. On 1/16/24 at 1:00 PM, Resident #4 stated staff, she cannot remember who, but it was a CNA, had stuck their head in the door to see what she wanted after she has pushed her call light. The resident told the CNA she needed to go to the bathroom, the CNA told her since she had a brief on, to go in the brief and they will get to her when they can. The resident said she tries to hold it as long as she can because she does not want to go in her brief or on her bed, but she cannot hold it and has urinated in her brief while sitting in her wheelchair or on her pad while laying in bed; she has also had a bowel movement. Resident #4 stated this has happened more than once that she has been told to just go to the bathroom in her brief after pushing the call light for assistance. The resident stated this is very uncomfortable, she does not like how this feels, in any way. She has waited an hour after being told to just go in her brief or on the pad in her bed, sitting in urine or in a bowel movement. 3. The MDS dated [DATE] for Resident #20 documented diagnoses to include fractures and other multiple trauma, heart failure, peripheral vascular disease, renal insufficiency, anxiety disorder and depression. The MDS showed a BIMS score of 15 out of 15, indicating intact cognition status. The MDS further documented under Section GG for functional abilities and goals for toileting hygiene: The resident required assistance of 2 or more helpers and frequently incontinent of urine. The Care Plan, with a revision date of 8/28/23, under the Focus Area for bladder documented the resident experiences occasional bladder incontinence related to physical deconditioning and diuretic use. The intervention and task for this area directs staff to check and change before and after meals, at bedtime, and as needed, as well as use incontinence products to promote hygiene and dignity. The Resident Life Profile Assessment, dated 9/19/23, for Resident #20 under Section D for preferences, asked the question what the resident disliked and the resident replied, when asked someone to help,the staff said they will be back but never did. Under this same section when the resident was asked, when she become anxious, the resident replied, when waiting for help. On 1/07/24 at 11:30 AM, Resident #20 advised staff can be short and inpatient with her, and she has been left to sit in her urine while waiting for staff to assist her in toileting. In an interview on 1/16/24 at 2:21 PM, a family member of Resident #20, the family member reported witnessing a time the resident pushed the call light for assistance to use the bathroom and a Certified Nursing Assistant (CNA) put their head in the door, asking what the resident wanted, the resident replied assistance to use the bathroom, at which point the CNA said they were busy, and told the resident to go to the bathroom in her brief. The CNA said you have a brief on, use it, just go in your brief. The family member exclaimed the resident then sat in urine for 20 - 30 minutes waiting for the CNA to return. The family member believes this has happened more than once, in the past few months. In an interview on 1/16/24 at 3:00 PM, the Administrator advised being told recently about a staff member, a CNA, telling a resident to just go in their brief and the CNA would clean them up after breakfast, and this same CNA telling another resident to just go to the bathroom in their brief, the CNA would clean them up later. The administrator conducted an internal investigation and this CNA was terminated. The administrator stated an expectation of staff to take residents to the bathroom when the resident needs to use the bathroom and it is not acceptable to tell a resident to urinate or have a bowel movement in their brief or on their bed, this is not treating the resident with dignity. Based on clinical record review, staff, resident and family interviews and review of the Resident Handbook, the facility staff failed to treat residents with dignity for 3 out of 4 residents reviewed (Resident #4, #20, and #50). The facility reported a census of 73 resident. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #50 dated 10/24/23, included diagnoses of hypertension (HTN), diabetes mellitus, and peripheral vascular disease (PVD). The MDS reflected Resident #50's Brief Interview for Mental Status (BIMS) as 15 out of 15, indicating intact cognition. The Progress Note for Resident #50 dated 11/28/23, reflected dental work caused pain. She received an as needed order for pain medication. On 1/07/24 11:17 AM, Resident #50 revealed one of the staff called her a baby. She reported the staff told her to not act like a baby after a tooth pulled. Resident #50 stated it made her very mad after they called her a baby. On 1/10/24 at 11:46 AM, the Director of Nursing (DON) denied knowledge that staff talked to Resident #50 in a derogatory manner. The DON confirmed Resident # 50's dental work. The DON revealed she let an employee go for their poor attitude as they cared for residents. On 1/10/24 at 11:50 AM, the Assistant (DON) reported not knowing of any resident concerns with the way staff treated residents. The facility provided the Resident Handbook dated 2024 with the Resident's [NAME] of Rights that directed: a. The resident has the right to a dignified existence, self-determination, and communication with and access to persona and services inside and outside the facility , including those specified in this section. b. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident as an individuality. The facility must protect and promote the rights of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident, family and staff interviews, and facility policy review, the facility failed to assure residents had the right to choose their own schedule for 1 of 1 residents reviewed for choices and self-determination (Resident #20). The facility reported a census of 73 residents. Finding Include: The Minimum Data Set (MDS) dated [DATE] for Resident #20 documented diagnoses to include fractures and other multiple trauma, heart failure, peripheral vascular disease, renal insufficiency, anxiety disorder and depression. The MDS documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition status. Review of the Baseline Care Plan, with a completion date of 8/21/23, on page 3, titled Resident's Daily Routine and Preferences Section, noted the section left blank. The Resident Life Profile Assessment, dated 9/19/23, under Section B for Special Considerations, question #7: How do you like to wake up in the morning, the resident responded wake up by myself. On 1/07/24 at 11:30 AM, Resident #20 reported staff make her get up at 6:30 AM every morning, stating she does not like to get up that early, her preference is to get up for the day at around 8:30 AM or 9:00 AM. The resident stated staff tell her they wake her up at 6:30 AM to get her dressed and ready for breakfast. Resident #20 stated a belief that she would not get breakfast if they did not get her to the dining hall by 8:00 AM. In an interview on 1/09/24 at 11:00 AM, Staff A, Certified Nursing Assistant (CNA), acknowledged waking resident #20 in the morning shortly after 6:00 AM, staff start getting residents up at this time so they are ready for breakfast at 8:00 AM when breakfast is served. Staff A indicated if a resident voices at that time a desire to sleep in, the light is left on in their bedroom and the resident is advised it is time to get up for the day. Staff return to the resident's room three times to redirect them to wake up and get ready for breakfast. Staff A indicated Management wants the residents up and in the dining room for breakfast at 8:00 AM. In an interview on 1/10/24 at 10:30 AM, the Administrator explained all residents are asked about their preferences at the time of admission and this would be on the Social Service Assessment History Form. If a resident has a special preference, this might go in the Care Plan. The Administrator stated residents can say they want to sleep in and not get out of bed, they have that right and choice. The Administrator stated they do not tell staff or give an impression to staff that residents need to be up and ready for breakfast by 8:00 AM. They encourage residents who have a special diet to get up to eat. The Administrator said it should be on a resident's Care Plan if they want to sleep in and there is a section on the 48-hour Care Plan about preferences. In an interview on 1/10/24 at 1:30 PM, Resident #20 reported staff have been waking her up every morning since she was admitted to the facility at 6:30 AM to get her ready for breakfast. The resident stated she would rather sleep in and skip breakfast, or eat breakfast after she gets up for the day. In an interview on 1/16/24 at 2:21 PM, a family member of Resident #20 explained staff wake the resident up and get her out of bed at 6:30 AM. Resident #20 had stated a preference to sleep in, however is woken up at 6:30 AM, being told by staff they need to get her up for breakfast. In an interview on 1/16/24 at 3:00 PM, the Administrator stated they try to be proactive in getting residents up in the morning, to be social and eat in the dining room and not be isolated in their room. The Administrator indicated an importance to educate the staff on the populations they serve. The Administrator acknowledged an expectation for staff to follow residents preferences. The 2024 Resident Handbook, under section F for Self-Determination, documented the resident had the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, to include the resident has a right to choose schedules, including sleeping and waking times.

Based on clinical record review, observations, and staff interviews, the facility failed to ensure safe wheelchair transfers when pedals were omitted on wheelchairs for 2 of 2 residents observed during wheelchair transportation (Residents #34 and #47). The facility reported a census of 73 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment, dated 1/10/24, documented Resident #34 with impairment to one side, for both upper and lower extremities, and required staff dependence for transfers. Resident #34 utilized a manual wheelchair for mobility. Diagnoses included: non-Alzheimer's dementia, Peripheral Vascular Disease, Spondylolysis of the lumbar region, and polyneuropathy. The Care Plan, initiated 7/07/24, revealed the Focus Area for deterioration of Activities of Daily Living (ADLs) with an intervention, Resident #34 often asks other residents to push him in the wheelchair and instructed staff to intervene when seen and re-educate both residents on wheelchair safety. On 1/07/24 at 12:34 PM, observed Resident #34 transported out of the 2nd floor dining room via a wheelchair, pushed by another resident, with no foot pedals in place. Resident #34 held legs up in front of the wheelchair during transport. After exiting the dining room, the pair of residents passed Staff E, Registered Nurse (RN), stationed at a medication cart, Staff E informed Resident #34 who their nurse would be. Resident #34 continued to be pushed by another resident towards the Nurse's Station, Staff F, Certified Nursing Assistant (CNA), stopped and spoke briefly to the pair of residents before continuing in the opposite direction towards the dining room. Resident #34 transported without foot pedals from the dining room to Resident #34's room, located on another hallway, without staff intervention. On 1/16/24 at 11:00 AM, Staff A, CNA, informed that residents should never be pushed in a wheelchair without foot pedals in place. Staff A stated staff would stop the residents and take over if observed a resident being pushed in wheelchair by another resident without foot pedals in place. On 1/16/24 at 3:30 PM, Facility Administrator, explained residents should not be transported without foot pedals on the wheelchair and reported Resident #34 will sometimes receive help from another resident for wheelchair transportation. Administrator stated the expectation that staff intervene, either by going to get foot pedals or request Resident #34 to self propel in wheelchair, if staff observe a resident being pushed by another in wheelchair without pedals. On 1/18/24 at 09:50 AM, Staff D, Licensed Practical Nurse (LPN), reported they would intervene if a resident observed being pushed by another resident in a wheelchair without foot pedals in place. 2. The MDS Assessment, dated 12/13/23, documented Resident #47 with fluctuating inattention and disorganized thinking. Resident #47 required partial to moderate amount of staff assistance with transfers and utilized a wheelchair for mobility. Diagnoses included: peri-prosthetic fracture at left hip, mild cognitive impairment, and generalized muscle weakness. The Care Plan, initiated 9/18/23, revealed the Focus Area for risk of falls with the intervention for staff to ambulate Resident #47 with assist of one staff using walker and gait belt, followed by a wheelchair. On 1/07/24 at 12:36 PM, Staff E, Registered Nurse (RN) pushed Resident #47 in wheelchair from the dining room table to the doorway of dining room, approximately 8 feet in distance, without foot pedals placed on wheelchair. On 1/16/24 at 11:00 AM, Staff A, Certified Nursing Assistant (CNA), stated residents should never be pushed in a wheelchair without foot pedals, even for short distances because anything could happen in that time. On 1/16/24 at 3:30 PM, Facility Administrator, stated residents should not be transferred in wheelchair without foot pedals, even for short distances due to the concern that injuries or accidents may occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, Advanced Registered Nurse Practitioner (ARNP) interview, and facility policy review, the facility failed to assure residents who require Dialysis receive services consistent with professional standards of practice by not following Physician Orders for 1 of 1 residents reviewed for Dialysis (Resident #227). The facility reported a census of 73 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] documented Resident #227 with a Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating intact cognition. The MDS further documented the resident's diagnoses to include non-traumatic brain dysfunction, heart failure, hypertension, and end-stage renal disease. The Care Plan for Resident #227, revised 1/9/24 with a Focus Area hemodialysis, instructed staff under interventions and tasks area to monitor vital signs and weight, and notify provider with concerns. The electronic Medication Administration Record (MAR) for January of 2024 for Resident #227 contained an order for daily weight every day shift and notify Doctor of Medicine (MD) of a 3 pound weight increase in a day or 5 pound increase in a week with a start date of 1/01/2024. Review of daily weight charting in the MAR revealed Resident #227 weighed 203.6 pounds on 1/7/24 and weighed 210.2 pounds on 1/8/24, a 6.6 pound weight gain in a day. Review of electronic records for Resident #227 failed to show the MD notified of the 6.6 pound weight gain. In an interview on 1/10/24 at 10:50 AM, the Assistant Director of Nursing (ADON), acknowledged the MD was not notified of this weight gain. The ADON advised an expectation the MD be notified of this weight gain. In an interview on 1/10/24 at 11:02 AM, Staff B, Licensed Practical Nurse (LPN), acknowledged documenting Resident #227's weight on 1/8/24, further acknowledging this was more than a 3 pound weight gain in a day. Staff B reported the MD was not notified of this weight gain and should have been done on 1/8/24. In an interview on 1/10/24 at 12:13 PM, the Advanced Registered Nurse Practitioner (ARNP) for Resident #227 advised the MD/ARNP for Resident #227, were not notified of the resident's weight gain of 6.6 pounds on 1/8/24. The ARNP ordered the daily weights due to the resident being on a diuretic and the resident being on Dialysis. The ARNP explained the potential for lab work to have been ordered on 1/8/24 after asking the Charge Nurse to check for fluid retention or if the resident had weight gain from consuming more calories that day with nutrition. The ARNP will follow up with the facility about the weight gain. In an interview on 1/10/24 at 1:21 PM, Staff B advised she did speak with the ARNP just now about Resident #227's weight gain on the 8th of this month and the ARNP advised she will discontinue the order today for daily weights and will allow the Dialysis Center adjust treatment for the fluid. Review of facility policy titled Physician Visits, Medical Orders, Delegation of Tasks, with an effective date of 7/1/21, instructed members of the Interdisciplinary Team shall provide care, services and treatment according to the most recent medical orders and according to laws, regulations and standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The MDS, dated [DATE], revealed a BIMS score of 15 out of 15, indicative of intact cognition. Resident #18 required application of non-surgical dressings and ointments/medication to skin. Diagnoses included: Peripheral Vascular Disease (PVD), wound infection (other than foot), contusion of left lower extremity, and polyneuropathy. The Care Plan, initiated 09/28/23, revealed a Focus Area for wound to left lower extremity and a Focus Area for pain related to this wound, with the goal that laceration to left lower extremity will be healed without complications. Interventions instructed staff to complete skin treatments as ordered and monitor/document location, size and treatment of wound. The Medication Administration Record (MAR), dated January 2024, revealed treatment orders to cleanse wound on left calf with normal saline or mild soap and water, dry wound bed, and pack lightly with Dakins moistened Nu gauze strip, cover with padded dressing, then wrap with ace bandage every day and evening shift for wound care. On 1/07/24 at 2:51 PM, Resident #18 stated they had asked the Nurse for wound treatment to be completed at 1:30 PM and reported the Nurse had not been in to complete the treatment as of 2:51 PM. On 1/07/24 at 2:55 PM, Staff E, Registered Nurse (RN), entered Resident #18's room and notified they would be back in 15 minutes to complete wound treatment. Resident #18 stated they requested 1:30 PM for wound treatment due to a planned outing with a visitor, and then had to wait until treatment completed to leave. On 1/18/24 at 9:50 AM, Staff D, Licensed Practical Nurse (LPN), reported Resident #18 required twice per day wound treatments to left lower leg, typically completed in the morning after breakfast. Staff D informed an appropriate timeframe for a resident requested time would be a half hour before or after. On 1/18/24 at 3:30 PM, the Administrator reported Staff E had gotten busy on 1/07/24 and unable to determine the time wound treatment had been completed. Based on clinical record review, staff, resident, and family interviews, and review of the Resident Council Meeting Minutes, the facility failed to have sufficient nursing staff, including Nurse Aides, to meet the needs of the residents for three of five residents reviewed for sufficient staffing and call light response time (Residents #4, #18 and #20). The facility reported a census of 73 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses to include debility, cardiorespiratory conditions, coronary artery disease, heart failure and renal insufficiency. The MDS documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition status. The MDS further documented under Section GG for functional abilities and goals for toileting hygiene: The Resident dependent on the assistance of 2 or more helpers is required. The Care Plan for Resident #4, with a revision date of 12/1/23, under a Focus Area for bladder, documented the resident experiences occasional bladder incontinence related to impaired mobility, Type II Diabetes Mellitus, physical deconditioning, and weakness. The intervention and task for this area directed staff to check and change the resident before and after meals, at bedtime, and as needed, as well as to provide incontinence care after each incontinent episode and use incontinence products to promote hygiene and dignity. In an interview on 1/09/24 at 10:30 AM, the Administrator advised the facility does not have a call light policy, they follow regulations which state to answer the call light within 15 minutes. Staff are not to turn the call light off until the care needs are completed. When asked if there have been recent call light complaints or concerns, the Administrator said she does not believe there had any recent concerns. When a concern received, the facility does an internal audit, they take a list of residents, the Management Team, and divide the list among themselves and go into residents rooms and push the call light and see how long it takes for staff to respond to the call light. When they do an audit, they have not had any concerns, the last audit was in October of 2023. In an interview on 1/09/24 at 11:00 AM, Staff A, Certified Nursing Assistant (CNA), stated staff answer the call lights within 15 minutes, if they can. However, on the previous Friday they had a 62 minute call light wait for Resident #4. Staff A advised they did not have enough staff to get to this resident. Staff A reported approximately a month ago the facility got rid of a floater position saying they did not have the census for this position. Staff A stated an awareness of Resident #4 waiting 62 minutes because the call light system showed it was 62 minutes when Staff A went to hit the button on the call light system. Resident #4 wanted to get up for the morning and use the bathroom, when Staff A got to the resident's room, the resident was in her bed and her bed was wet, she was lying in urine. It was 8:20 AM when Staff A responded to the call light, and the call light had been on for 62 minutes. On 1/16/24 at 1:00 PM, Resident #4 advised it is very common to have to wait for her call light to be responded to. Resident #4 feels as though the facility does not always have adequate staff working. Resident #4 stated the longest time she has waited for a call light response time was two hours, this was approximately 6 months or so ago. The resident stated she pushed her call light because she needed a bed pan to have a bowel movement. The resident said she ended up having a bowel movement in her bed and laid in the bowel movement for two hours waiting for a response to the call light. The resident stated it is not uncommon to wait an hour for a call light response, she has laid or sat in urine and bowel movement while waiting for a response to her call light. The resident exclaimed this is very uncomfortable, she does not like how this feels, in any way. Resident #4 advised she has a clock on the wall by her bed, she has watched the clock and knows she has waited an hour and up to two hours for a call light response for assistance in toileting. 2. The MDS dated [DATE] for Resident #20, documented diagnoses to include fractures and other multiple trauma, heart failure, peripheral vascular disease, renal insufficiency, anxiety disorder and depression. The MDS showed a BIMS score of 15 out of 15, indicating intact cognition status. The MDS further documented under Section GG for functional abilities and goals for toileting hygiene: The resident required assistance of 2 or more helpers and frequently incontinent of urine. The Care Plan for Resident #20, with a revision date of 8/28/23, under a Focus Area for bladder documents resident experiences occasional bladder incontinence related to physical deconditioning and diuretic use. The intervention and task for this area directs staff to check and change the resident before and after meals, at bedtime, and as needed, as well as use incontinence products to promote hygiene and dignity. On 1/07/24 at 11:43 AM, Resident #20 stated the facility is short staffed on the weekends, sometimes people do not show up for their shifts. Resident #20 stated the longest she had waited for a call light response was around 20-30 minutes, stating she had an accident while waiting and had urinated in her brief while waiting for assistance to use the bathroom. Resident #20 advised this has happened a few times, waiting over 15 minutes for a call light response and having an accident, and it has happened at various times of the day and night. The resident stated sometimes she feels upset and anxious because she has pushed her button and staff walk past her room and look in but did not come in and then she had an accident while waiting. On 01/16/24 at 2:24 PM, a family member of Resident #20 reported witnessing the resident push the call light and then waiting 20-30 minutes for assistance. During this time, the resident has urinated while waiting and sat in the urine for 20-30 minutes. This has happened more than once. Review of Resident Council meeting documentation for October 24, 2023. During this meeting a resident wanted to know if the facility is hiring more help. A resident had a concern that sometimes it takes a long time to answer his call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policy review, the facility failed to secure medications by leaving the medication cart unlocked and unattended for 3 of 3 medication storage observations. The facility reported a census of 73 residents. Findings Include: On 1/08/24 at 3:15 PM, the medication cart located on the 200 hallway, parked between rooms [ROOM NUMBERS], observed with the lock in the up position and drawers able to be opened without a key, no staff present in this area. Staff C, Licensed Practical Nurse (LPN), returned to medication cart at 3:17 PM from a resident's room. On 1/08/24 at 3:18 PM, Staff C prepared medications and walked away from medication cart into a resident's room, medication cart remained unlocked with residents present in the area but no staff to attend the medication cart. On 1/08/24 at 3:27 PM, Staff C, left medication cart unlocked and went into a resident's room, Staff D (LPN), walked past medication cart and pressed the lock down into the locked position before they continued down the hall. Staff C returned to medication cart at 3:29 PM and unlocked cart with key. On 1/16/24 at 3:30 PM, the Facility Administrator stated the expectation that a medication cart must be locked unless within eyesight of appropriate staff. On 1/18/24 at 9:50 AM, Staff D confirmed that they had observed the medication cart unlocked and unattended on 1/08/24 and locked it in response. The facility policy, titled Medication Storage, dated 6/06/23, informed that medication carts are locked when not attended by persons with authorized access.

Based on observation, staff interviews, and facility policy review, the facility failed to follow sanitary practice when transporting clean linen uncovered through hallways for 2 of 2 linen carts observed. The facility reported a census of 73 residents. Findings Include: On 1/07/24 at 1:55 PM, Staff G, Laundry Staff grabbed clean resident clothing from an uncovered rolling linen cart, located in the hallway, and swung the clothes underneath left arm, the resident clothing then held against Staff G's uniform, and more resident clothing grabbed with right hand before Staff G entered a resident's room. The uncovered clean linen cart left unattended in hallway with various staff and residents passing by the area. Staff G returned to the clean linen cart and pushed the uncovered cart further down the hallway, a stack of resident clothing removed and hung on the side of linen cart, long sleeved shirts and pants touched outside of cart and the hallway floor. Staff G placed the stack of clothes hung on side of cart back into the clean linen cart and transported to the elevator. On 1/08/24 at 3:00 PM, observed Staff H, Laundry Staff push a linen cart that contained clean folded white towels, uncovered though the hallway and entered the elevator. On 1/16/24 at 3:30 PM, Facility Administrator reported linen carts are to be covered during transportation though the hallways. Review of the facility policy, titled Infection Prevention and Control- Laundry, dated 8/01/2017, directed that clean linen shall be handled, transported, and stored by methods that will ensure it's cleanliness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, document review and staff interview, the facility failed to follow the manufacturer's instructions for use of an insulin pen, by failing to perform a 2 unit air shot to prime the pen for 1 of 1 residents observed for insulin administration (Resident #1); failed to follow Physician Orders for the use of Tubigrips for 1 of 19 Residents (Resident #16), failed to track a Physician Ordered fluid restriction for 1 of 1 residents reviewed for fluid restrictions (Resident #16) and failed to consistently assess a vascular access site before and after Dialysis, including ongoing monitoring of the access site for 1 of 1 resident reviewed for Dialysis (Resident #48). The facility identified a census of 67 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #1 dated 3/16/22 showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS listed a diagnosis of Diabetes Mellitus and identified the resident received insulin injections 7 days a week. An Order Review History Report, electronically signed by the Provider on 4/20/22 documented a physician order for Novolog FlexPen Solution Peninjector 100 units/milliliter. Inject as per sliding scale, if 60 - 150 = 0; 151 - 400 = 20; 401 - 450 = 25 Notify primary care provider if blood sugar level is greater than 450. The May 2022 Medication Administration Record (MAR) documented to check blood sugar levels before meals and at bedtime related to type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye. The MAR listed an order for Novolog FlexPen Solution Peninjector 100 units/milliliter. Inject as per sliding scale: if 60 - 150 = 0; 151 - 400 = 20; 401 - 450 = 25. Notify primary care provider if blood sugar level is greater than 450, subcutaneously with meals related type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye. Hold if the blood sugar is less than 100 and/or not eating a meal. Start date 4/27/22. During an observation on 5/23/22 at 11:02 a.m., Staff B, Licensed Practical Nurse, (LPN), removed a Novolog insulin Flexpen from the Medication Cart. She noted the insulin pen as Resident #1's insulin. Staff B cleaned the hub with an alcohol prep pad and placed a needle on the pen. Prior to checking the blood sugar, she turned the pen dial to 20 units of Novolog and confirmed the dosage with the Medication Administration Record order for sliding scale insulin. She entered Resident #1's room and completed taking the resident's blood sugar which resulted in a blood sugar of 315. She then confirmed she was ready to give Resident #1's (Novolog 20 units) of insulin. The Surveyor stopped staff B from administering the insulin. Staff B then confirmed to the surveyor she had not primed the Novolog insulin pen and the right dosage of insulin would not be in the pen since it had not been properly primed. During an interview on 5/24/22 at 7:33 a.m., the Director of Nursing (DON) reported he would expect an insulin pen to be prepped with an air shot, 2 units, following the manufacturer's directions for use. The NovoLog insulin solution for subcutaneous use, Initial U.S. Approval: 2000, manufacturer instructions for preparing the Novolog pen directs to give an air shot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing, turn the dose selector to select 2 units cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. 2. The MDS dated [DATE] showed a BIMS of 13 indicating intact cognition. The Resident required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. The MDS listed a diagnosis of hypertension, diabetes mellitus and chronic kidney disease, stage 4. The MDS identified the resident took diuretic medications. A review of the Resident's Medical Record showed a Renal Function Panel dated 3/9/22 with documentation from the Registered Advanced Nurse Practitioner (ARNP) of elevated creatinine (CRT, kidney function test) with increased fluid retention to increase the Lasix (diuretic medication) 40 milligrams (mg) by mouth daily and to recheck the basal metabolic panel (BMP) on 3/16/22. A Order Review History Report signed by the electronically signed by the Provider on 4/01/22 at 12:19 p.m. documented the following orders: a. Tubi-Grips on in the AM and off in the PM every day and evening shift. Order start date 2/16/22. b. 2 liters of fluid per day, every 24 hours fluid restriction. Order start date 4/02/22. c. Hydrochlorothiazide Tablet 12.5 milligrams (ml). Give 1 tablet by mouth in the morning for water retention. Order start date 2/17/22. d. Spironolactone Tablet. Give 25 mg by mouth one time a day for diuretics. Order start date 3/02/22. e. Furosemide Tablet 20 mg. Give 2 tablets one time a day for diuretics. Order start date 3/11/22. A Physician Visit Progress Note, dated 4/15/22, completed and signed by the Advanced Registered Nurse Practitioner, (ARNP) documented trace edema (swelling) to the right lower extremity and left lower extremity 2 + non-pitting edema. Instructed the nursing staff to apply Tubi-Grips to bilateral lower extremities and elevate the legs above the level of the heart as much as possible to manage edema. Continue the Lasix, Spironolactone and Hydrochlorothiazide as ordered. Continue the 2 liter fluid restriction per day. The Medication Administration Record (MAR) for May 2022 showed the following medications being administered to the Resident: a. Hydrochlorothiazide Tablet 12.5 mg. Give 1 tablet by mouth in the morning for water retention. Start date 2/17/22. Medication Administered May 1-24, 2022. b. Furosemide Tablet 20 mg. Give 2 tablets by mouth one time a day for diuretic. Start date 3/11/22. Medication Administered May 1-24, 2022. c. Spironolactone Tablet. Give 25 mg by mouth one time a day for diuretics administered May 1-24, 2022. The Care Plan dated 5/20/22 documented the Resident's ability to complete activities of daily living (ADLs) has deteriorated related to impaired mobility, weakness, debility, and advanced age and directed the staff to apply Tubi-Grips to the bilateral lower extremities as physician ordered. The Nutritional Care Plan, revised 3/21/22, directed the staff to follow the fluid restriction as ordered. During an interview and observation on 5/22/22 at 1:30 p.m., Resident #16 reported she did not have any special stockings that she wears on her feet/legs. She stated she wears either slippers or some tennis shoes that someone brought in for her. The resident observed with no Tubi-Grips on her bilateral lower extremities. Observation revealed a Styrofoam cup sitting by her sink out of her reach and sign on the room door stating, No pitcher at bedside please. room [ROOM NUMBER]-2. She stated she needs assistance to be able to get up with her walker. During an observation and interview on 5/23/22 at 9:20 a.m., Resident #16 sat in her recliner with her walker in front of her. Resident #16 observed not wearing Tubi-Grips on bilateral lower extremities. The resident's left foot exhibited a one plus pitting edema across the top of the foot. A sign remained on her door documenting, No pitcher at the bedside please. room [ROOM NUMBER]-2. Further observation revealed a Styrofoam cup with water sitting by the resident's sink out of her reach. During an interview and observation on 5/24/22 at 9:55 a.m., Resident #16 stated again she does not have any type of stockings she wears to prevent her feet or legs from swelling. She stated she just wears slippers or a pair of tennis shoes that someone gave her. Observed resident wearing slippers to both feet, no Tubi-Grips on. The left foot exhibited two plus slightly pitting edema over the top of the foot. The sign stating no water pitcher for room [ROOM NUMBER]-2 remained on the door. A Styrofoam cup with water sat by the resident's sink. During an observation 05/24/22 11:57 a.m., Resident # 16 ambulated with her forward wheeled walker and one assist from her room to the dining room. Resident Resident # 16 did not wear bilateral Tubi-Grips to her lower extremities. The May 2022 Treatment Administration Record (TAR) documented Tubi-Grips on in A.M. and Off in the P.M. every day and evening shift. Start date 2/16/22. Further review of the May 2022 TAR revealed the nursing staff signed off the use of Tubi-Grips for Resident #1 from 5/1/22 - 5/23/22. The evening of 5/13/22 on the TAR had been left blank. During an observation on 5/24/22 at 12:02 p.m.,. Resident #16 sat in a chair at the dining room table with a goblet style glass of water and orange juice in front of her. During an interview on 5/24/22 at 12:03 p.m., Staff C, Dietary Aide, reported she doesn't know how much fluid the glasses utilized held. She asked Staff D, Dietary Aide and Staff D reported she did not know how much fluid the glasses held. Staff C then reported the glasses held 140 milliliters (ml) of fluid to the surveyor. Staff C stated Resident #16 could have a glass of water and a glass of orange juice. During an observation on 5/24/22 at 12:03 p.m., Staff B, LPN, stated to Staff C an ounce of fluid is 30 milliliters (ml). Staff C stated she didn't know how many ounces the glasses held. At 12:04 p.m., Staff C then called on her walkie talkie to the Culinary Supervisor. The Culinary Supervisor reported the glasses hold 4 ounces of fluid. The Culinary Supervisor reported via the walkie talkie to come downstairs and talk to him personally. Staff D, reported they had asked many times if Resident #16 had a fluid restriction and asked about the size of glasses, but never really got any answers. The Culinary Supervisor came off the elevator and Staff D clarified they were asking in regards to the amount of fluid the goblet glasses hold. The Culinary Supervisor stated the goblets are 8 ounce glasses and should be filled to the rim. Staff D stated she had not been filling the glasses to the rim with fluid and the was her mistake. During an observation and interview on 5/24/22 at 12:09 p.m., Staff A, LPN, and Staff B, LPN, were standing in the hallway outside of the second floor dining room talking with Staff E, Resident Care Technician (RCT) about the fluid restriction. She stated she knew Resident #16 had a fluid restriction and could have one 8 ounce glass of fluids at a meal and no water pitcher in her room. During an interview on 5/24/22 at 12:11 p.m., Staff A reported Resident #16 does have an order for a 2 liter fluid restriction. He reported he generally gives about 4 ounces of water with each medication pass and she gets her fluids with her meals, but they really don't do much with recording the actual fluid amounts the Resident has taken. Staff B reported they document meal consumption records, but those do not do not have actual fluid amount recorded. Staff E reported she does not do much with recording or tracking of fluids. Staff B confirmed they track meal consumption but really don't document the actual amount of fluids taken. During an interview on 5/24/22 at 12:29 p.m., the Culinary Manager reported the resident could have two 8 ounce glasses of fluids per meal. He stated there used to be a fluid tracking sheet on the back of the Resident's door to document the amount of fluid taken but he had checked and he did not see a tracking sheet on the back of her door and hadn't seen for some time. He stated he does not have anything in the second floor kitchenette that directs his staff on how much fluid Resident #16 can have but if you take her fluids and divide it out by three meals she can have two eight ounce glasses of water per meal. He stated he had checked with the nurses and they pass medications three times a day so they give water with the medication passes. He stated the Certified Nursing Assistants (CNA's) pass a 20 ounce pitcher of water to each resident's room on each shift, but they don't document the amount of fluids she takes. Resident #16's Diet Order slip from the kitchen dated 12/5 showed Resident #16 on a house diabetic diet, regular texture, regular consistency of fluids. The Diet Order slip did not document Resident #16's fluid restriction. The Culinary Manager reported the meal ticket as the only information he had in the kitchen for Resident #16. A observation on 5/24/22 at 12:35 p.m. revealed no fluid tracking record behind Resident #16's room door. The Meals Consumption Record, provided by the facility as fluid intake documentation for Resident #16, documented the following: a. E - Excellent (approximately 100 percent (%). b. G- Good (approximately 75%). c. F - Fair (approximately 50%). d. P - Poor (25 - 50%) e. B/S - Bites/sips (25%) f. R - Refused. Review of the Meals Consumption Record from 4/24/22 - 5/23/22 revealed Resident #16's meal intake as G or E on most days. The Meals Consumption Record failed to document the actual amount of fluids taken with each meal. A review of the March, April, May 2022 MAR/TAR on 5/24/22 at 3:38 p.m. lacked documentation of fluid consumption for the 2 liter fluid restriction. During an interview on 5/24/22 at 1:30 p.m., the Director of Nursing (DON) stated that is an excellent question and he did not have an excellent answer regarding the procedure for tracking fluid restriction. He stated he could only refer to what the Corporation overseeing the facility had in place, but he didn't know what they had in place currently. He stated he had not been given a clean answer on the fluid restriction process and did not have an expectation of the fluid restriction procedure at that time. Review on 5/24/22 of the Clinical Medical Record, Care Plan, kitchenette, and MAR revealed lacked documentation of a Fluid Restriction Form for Resident #16. An observation on 5/25/22 at 7:45 a.m. of the second floor kitchenette revealed no Fluid Restriction Form in the kitchenette to guide the staff on the amount of fluids Resident #16 could have. During an interview on 5/25/22 at 8:12 a.m., The Assistant Director of Nursing (ADON) reported the facility has a policy and the facility doesn't count intake or track intake like a hospital. When nursing receives and order for a fluid restriction, the order is put in the computer and then the nurse fills out a Dietary Slip to notify Dietary Staff of the fluid restriction. A sign goes on the resident's door to communicate to staff the fluid restriction and not to put a pitcher of water in the resident's room. A Fluid Restriction Form is up on the nurses cart this morning for Resident #16's fluid restriction. They use a calculation of how much the resident can receive for each meal and medications and that information is on the Fluid Restriction Form. She stated Resident #16's Fluid Restriction Form had been missed. She would expect the Physician Order for the fluid restriction to be followed and staff to follow the fluids restriction signs for no water pitcher. The Nursing Staff and Dietary Staff have a Fluid Restriction Form that directs the fluid amount for meals and medications that should be followed. On 5/25/22 at 8:16 a.m., the DON reported the nurses should follow the Physician Orders or document in the Progress Notes and notify the physician why the Physician Order could not be completed. The Fluid Restriction, Dietary Policy and Procedure, dated 9/21, documented a Policy that any resident on a fluid restriction would have their fluids allocated between Nursing and Dietary to meet the prescribed amount. The Policy listed the following Procedure: 1. Upon admission, the Food Service Supervisor and Director of Nursing or Charge Nurse will confer to determine how much fluid is needed to administer medications. This amount should be divided among shifts. 2. The remaining fluids should be distributed between all meals. Whenever possible the resident should be interviewed to determine what their fluid preferences are and when they would like them served. 3. A listing of how fluids are allocated will be kept in the kitchen, resident chart, or the MAR or other nursing area so all staff is aware. Please refer to the attached chart. 4. Water pitcher should not be kept at the bedside for those resident on fluid restrictions. The Physician Visits and Medical Orders Policy, effective date 5/10/17, provided by the facility, directed the following: member of the interdisciplinary team shall provide care, services and treatment according to the most recent medical orders and according to laws, regulation and standards of practice. 3. The MDS dated [DATE] for Resident #48 showed a BIMS of 14 indicating intact cognition. The MDS listed a diagnosis of end stage renal disease and receiving dialysis while a resident. The Order Review History Report, electronically signed by the Provider on 4/14/22 documented a physician order for hemodialysis Dialysis on Tuesday, Thursday, Saturday and to obtain vital signs before and after Dialysis. Communicate vitals with Dialysis Center two times a day every Tuesday, Thursday, and Saturday for dialysis. Order start date 2/12/22. The Care Plan with an initiation date of 4/29/22 documented the resident needed Dialysis related to renal failure and directed the staff to check and change dressing daily at access site. Document. Date initiated: 4/29/2022 During an observation and interview on 5/22/22 at 2:13 p.m., Resident #48 lay in bed on her left side. She stated she goes to a Dialysis Center on Tuesday, Thursday, and Saturdays. She stated her access site is in her left upper arm. Observation revealed a dry dressing over the Resident's access site on the left upper arm from her dialysis yesterday. She stated they check her access site before and after she goes to Dialysis most of the time. During an interview on 5/23/22 at 3:31 p.m., Staff A, LPN reported they do a temperature, blood pressure, pulse as well as send a list of medications for paperwork to dialysis with the resident. He reported the Dialysis Center Nurses are to do the post assessment and return it with the resident, but they don't always do the assessment and sometimes do not return the paperwork with the resident. A Review of the Hemodialysis Communication Sheets on 5/23/22 at 3:30 p.m. revealed: a. The Hemodialysis Communication Sheet for May 2022 revealed no Hemodialysis Communication Sheets for May 19 and 21. b. The Hemodialysis Communication Sheet for April 2022 revealed no Hemodialysis Communication Sheets for April 5,7, 12, 14, 19, 23, 26. c. The Hemodialysis Communication Sheet for March 2022 revealed no Hemodialysis Communication Sheets for March 15, 17, 29, 31. d. The Hemodialysis Communication Sheet for February 2022 revealed no Hemodialysis Communication Sheets for February 12, 15, 19, 22, 24, 26. During an observation on 5/24/22 at 11:50 a.m., Resident #48 observed sitting in a wheelchair in her room doorway with a dry dressing on her left upper arm over her access site. She told staff she had a Dialysis treatment that morning and was really tired. A review of the March 2022 Medication Administration Record (MAR)/Treatment Administration Record (TAR) revealed a hole in the vital sign documentation for 3/10/22 and lacked documentation of monitoring of the vascular access site before and after Dialysis treatment and ongoing monitoring of the access site. A review of the April 2022 MAR/TAR revealed holes in the vital sign documentation prior to Dialysis treatment on April 16, 19, and 21st. The MAR/TAR lacked documentation of monitoring of the vascular access site before and after Dialysis and ongoing monitoring of the access site. A review of the May 2022 MAR/TAR revealed the MAR lacked documentation of monitoring the vascular access site after Dialysis or any ongoing monitoring of the access site. The May 2022 MAR/TAR lacked documentation of the checking and changing of the access site dressing daily per the care plan intervention implemented 4/29/22. During an interview on 5/24/22 at 1:34 p.m., the DON reported he did not know what their assessment process was regarding before and after Dialysis Treatments. During an interview on 5/24/22 at 2:30 p.m., Staff A clarified the nurses do the resident's vital signs before and check her access site before she leaves for Dialysis and then they repeat the vital signs, remove the dressing and look at the access site when the Resident returns. He stated if they do not return the Dialysis Communication Sheet, then they don't have any other area they document the assessment of the vascular access site. He stated they only monitor the access site on the Dialysis days. He stated if the resident reported problems with the access site, then they would assess it as needed, but they don't specifically monitor the access site in between Dialysis Treatments. During an interview on 5/25/22 at 8:17 a.m., the DON reported he expected the staff to utilize the Hemodialysis Communication Form to document the vascular assessment or do a Progress Note to document the assessment. He reported they had found some of the missing Hemodialysis Communication Sheets, but still had some missing. He had called the Dialysis Center yesterday to see if they had some of the missing Hemodialysis Communication forms and he had been told if the sheets were not sent back, they were shredded. The Dialysis Care Policy, dated 2/02/17, provided by the facility, directed: 1. Nursing shall assess and document vital signs, including blood pressure in the arm where the access site is not located, weights if ordered and communicate the information including the resident's status with Dialysis facility prior to and post Dialysis. 2. Nursing shall provide direct visual monitoring of the access site before and after Dialysis. 3. Nursing shall provide ongoing monitoring for Dialysis related to complications (e.g. bleeding, access site infection, hypotension.