Based on clinical record review, policy review, and staff interview, the facility failed to document whether or not a resident wished to appeal the decision of skilled services ending for 1 of 3 residents reviewed who discharged from skilled services(Resident #234). The facility reported a census of 30 residents. Findings include: a. A 2/1/24 Notice of Medicare Non-coverage(NOMNOC) documented the facility informed Resident #234 that her skilled services would end on 2/1/24. The facility lacked documentation they informed the resident of the reason her services would end and lacked documentation regarding whether the resident wished to appeal the decision of the services ending. b. A 3/18/24 NOMNOC documented the facility informed Resident #234 that her skilled services would end on 3/20/24. The facility lacked documentation they informed the resident of the reason her services would end and lacked documentation regarding whether the resident wished to appeal the decision of the services ending. The facility Social Services Manual, dated 2/2015, stated the facility would provide a completed copy of the Notice of Medicare Non-Coverage form to a resident no later than two days before the termination of the services. The notice enabled the resident to an immediate independent medical review of the decision to end Medicare coverage. The manual directed staff to maintain a copy in the resident's record. On 7/10/24 at 3:51 p.m., the Social Services Supervisor stated she did not keep documentation regarding whether or not residents desired to appeal the decision of skilled services ending. She stated she had the residents fill out the form but then gave it to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility policy review, the facility failed to complete a Significant Change Minimum Data Sheet (MDS) within 14 days for a resident placed on hospice care for 1 of 1 residents (Resident #27) reviewed. The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed significant change in status assessment with completion of the MDS on 6/5/24. The Progress Notes dated 5/15/24 at 3:00 PM revealed the Social Worker (SW) stated resident #27 was admitted to hospice care. The Encounter Note dated 5/22/24 revealed the Nurse Practitioner (NP) stated resident #27 had been evaluated by hospice and admitted with diagnosis of cerebral atherosclerosis. On 7/11/24 at 4:04 PM the Regional Director of Nursing stated MDS Coordinators are remote. He stated any care plan areas that trigger on the Care Area Assessments (CAA) of a comprehensive MDS is the responsibility of the remote MDS Coordinator to care plan. Daily updates should be done within the facility, and that is the responsibility of Staff P, Licensed Practical Nurse or of the DON. The facility policy titled Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) dated 7/2015 includes the following documentation: Comprehensive or full assessments include the admission, significant change, significant correction of a prior full assessment and annual include all required MDS items along with State-designated sections, use of Care Area Assessment (CAA) including CAT's and CAA summary. Within 14 days after the facility determines that there has been a significant change in the resident's status that will not normally resolve itself, which has an impact on one or more area of the residents' health status and requires an interdisciplinary review and/or revision of the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, resident interview, direction from the Resident Assessment Instrument (RAI), and policy review, the facility failed to assure each resident received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 1 of 14 residents (#21) reviewed for Accuracy of Assessment. The facility reported a census of 30 residents. Findings include: On 7/08/24 at 12:08 PM, the Administrator stated the facility currently had one (1) resident who received hemodialysis (HD) treatments On 7/08/24 at 3:00 PM, the resident stated he had been dependent on hemodialysis (HD) for several years and received HD treatments every Monday, Wednesday, and Friday. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of congestive heart failure (CHF), chronic kidney disease (CKD), end-stage renal disease (ESRD), and diabetes mellitus. The MDS did not include the resident's HD treatments during the 7-day look-back period. The Electronic Health Record (EHR) dialysis communication forms indicated the resident received HD on 6/05/24, 6/07/24, and 6/10/24. A Progress Note dated 6/05/24 at 5:09 AM indicated the resident was being sent to dialysis at 5:20 AM. On 7/11/24 at 12:27 PM, the interim Director of Nursing (DON) stated the resident's HD should be included in the resident's MDS. A document titled Documentation Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) dated 7/15 indicated the RAI/MDS assessment must include special treatments and procedures completed by nursing or designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility policy review, the facility failed to notify Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents reviewed for mental diagnosis and medications (Resident #6). The facility reported census of 30 residents. Findings include: The PASRR dated 1/4/24 for Resident #6 was prior to admission to facility, 5/21/24. The PASRR revealed no mental diagnosis or medications listed. The Minimum Data Sheet (MDS) assessment dated [DATE] revealed Resident #6 admitted to the facility with the diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance, non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. Resident #6 admitted to facility with drug classifications of antipsychotic, antianxiety, and antidepressant. The Care Plan initiated on 6/5/24 reveals diagnosis of dementia, depression, anxiety, and psychoactive drug use. On 7/10/24 at 10:20 AM the Social worker (SW) revealed the only PASRR for resident #6 is 1/4/24. On 7/11/24 at 3:08 PM, the SW stated she submits a new PASRR before residents admit to the facility. The SW stated when resident #6 admitted her medications were wrong. The staff clarified the resident was not taking antipsychotic medication, she was taking antidepressant and medications for dementia. An antipsychotic was started 6/27/24. The SW stated this is a trial medication. The facility policy titled Resident/Family Care & Services, Pre-admission Screening for MR/MI revised 2/2015, includes the following documentation: -The facility verifies that all residents/patients are screened prior to admission to determine whether they have a mental illness (MI) or mental retardation/developmental disability (MR/DD) diagnosis and if the facility is able to meet the specialized needs of the resident/patient. A level II screen is done to assist the facility in determining the types of services required to care for the resident/patient. -Verify that the appropriate State-designated agency is contacted for any resident/patient requiring a MI/MR level II screen: Admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and policy review, the facility failed to implement a comprehensive care plan for 1 of 15 residents reviewed (#9). The facility reported a census of 30 residents. Findings include: On 7/09/24 at 9:06 AM, Staff I, Certified Nurse Aide (CNA) transferred Resident #9 from the bathroom to her wheelchair and from the wheelchair to her bed without a gait belt. She placed the resident's oxygen nasal cannula (NC - pronged tubing used for oxygen delivery through the nose) back on the resident. The resident's portable oxygen tank supply regulator was set on 2 Liters Per Minute (LPM) and the indicator registered in the red, refill zone. The resident's room concentrator was also set on 2 LPM. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not conducted and indicated the resident was rarely or never understood. It included diagnoses of heart failure (HF), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and non-Alzheimer's dementia. It also indicated the resident required maximum assistance with all transfers and was dependent with tub/shower transfers. It also revealed the resident used oxygen. The Electronic Health Record (EHR) Fall Risk assessment dated [DATE] indicated the resident was a high fall risk and required hands-on assistance to move from place to place. It also included a physician order dated 10/13/23 for oxygen at 3 liters (L) via nasal cannula (NC) every shift. The Care Plan focus dated 10/22/24 directed staff to use a mechanical aid for transfers. The Care Plan focus dated 10/20/23 indicated the resident had oxygen (O2) via nasal prongs/mask at 3 LPM continuously. On 7/09/24 at 12:19 PM, the resident was observed in her wheelchair in the dining room with her NC and oxygen tank. The oxygen tank regulator was set at 2 LPM and the indicator registered 0 in the red, refill zone. At 1:02 PM, Staff K, CNA removed the resident's nasal cannula and transferred her from her wheelchair to her bed. The resident's oxygen saturation was checked and observed at 92%. Staff A, Registered Nurse (RN) placed the resident on the oxygen concentrator at 2.5 LPM. On 7/11/24 at 12:27 PM, the interim Director of Nursing (DON) stated staff should follow the doctor's order and/or therapy expectations and use the mechanical aid if the mechanical aid was ordered. A document titled Transfer Technique dated 1/13 directed staff to review any special precautions or approaches to take when transferring a resident/patient and to obtain assistance as needed. A document titled Oxygen Administration dated 1/13 directed staff to monitor the oxygen flow rate and oxygen saturation, as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family interviews, staff interview and hospital record review, the facility failed to perform complete and accurate assessments following a fall for 1 of 1 residents reviewed for falls (Resident #34). The facility reported a census of 30 residents. Findings include: The Minimum Data Set assessment of Resident #34, dated 5/27/24 identified a Brief Interview of Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. The MDS documented the resident admitted to the facility on [DATE]. The Risk Management form dated 6/3/24 at 8:45 pm documented Resident #34 was observed on the floor beside her bed, lying on her stomach. It revealed documentation the resident stated she was self transferring to her bed and slid off the side of the bed. The form noted no injuries observed at the time of the incident or post incident. The Progress Notes for the resident documented the following: On 6/4/24 at 3:12 am nurse summoned to resident room earlier. Resident found on stomach lying next to her bed. Resident stated she had been attempting to self transfer and slid off the side of the bed. Resident denied injury, and denied pain. Neuro's started. On 6/4/24 at 5:31 pm resident had a previous fall with no injuries, pain or bruising. On 6/5/24 at 5:45 pm resident denied pain from previous fall and stated she is fine. On 6/10/24 at 9:00 am resident discharged to another facility. The Progress Notes failed to reveal any other fall documentation, assessments, vitals or neuro's. On 7/8/24 at 12:49 pm, a nurse at Resident #34's prior nursing facility stated she had come to visit Resident #34 at the current facility on 6/6/24. She stated she noticed a bruise on the resident's forehead and said Resident #34 had told her she had fallen out of her chair and also told her she was having pain in her legs. On 7/8/24 at 1:50 pm, a family member of Resident #34 stated the resident discharged from the facility and transferred to another nursing facility a few days after her fall. He stated after continuing to complain of pain at the new facility, x-rays were taken and it was discovered the resident had a fractured leg. He stated she had no falls at the new facility but the fracture was discovered there. Hospital records of Resident #34 dated 6/25/24 revealed documentation the resident was found to have a right distal femur fracture with timeline of the injury being undetermined. On 7/10/24 at 1:17 pm, the Regional Director of Clinical Services stated a Risk Management form should be started by the nurse on duty at the time of the incident. From there, there should be a full investigation of the incident and it would be discussed in the morning meeting on the next business day. It should be assured an intervention was put in place on the resident's care plan. He stated follow up charting by the nurses should be completed for 72 hours after an incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility document review, observation, staff interviews, and facility policy review, the facility failed to provide an environment that is free from accidents/hazards for 2 of 5 residents reviewed for environmental hazards (Resident # 11, #9). The facility reported a census of 30 residents. Findings include: 1. The facility document titled 5 Day Investigation Summary documented information which included the following: Staff F, Registered Nurse, (RN) was walking down the east hall at 6:30 pm on 6/28/24 when she observed the door to Resident #11's room slightly ajar and saw a male in the room. Staff F, RN entered the room and observed it was hazy with an odor of marijuana present with Resident #11 and two additional residents. Staff F observed two vapes lying on Resident #11's chest as she was in her wheelchair. Staff F separated the residents and removed the vapes from the room. The Minimum Data Sheet (MDS) assessment dated [DATE] for Resident #11 identified a Brief Interview of Mental Status (BIMS) score of 15 which indicates cognition intact. The MDS revealed the resident totally dependent upon staff for all cares. The MDS documented diagnoses that included: quadriplegia, anxiety disorder, depression, autonomic dysreflexia, and muscle spasms. The Comprehensive Care Plan of Resident #11, initiated 10/11/22, failed to reveal resident to be a smoker. The untitled facility document provided during survey listed 4 residents as smokers which including resident #11. The Progress Notes dated 6/28/24 at 8:46 PM revealed Staff F, RN walked by resident #11 room, seen a male in the room, smelled an odor at the door, and entered the room. Staff F, RN found resident #11, resident #24, and resident #30 in the room, noted a strong odor, and saw two vapes on Resident #11 right side of the chest. Staff F stated she removed the two vapes and asked resident #24 and #30 to exit the room. Resident #11 went to the front desk with sister, requested Staff F to return the two vapes. Staff F instructed resident #11 to discuss with management. Resident #11 left facility with sister. Observation on 7/9/24 at 2:41 PM, revealed Resident # 11 is dependent on staff for vaping. On 7/10/24 at 6:32 AM, Staff F recalled incident on 6/28/24 at 6:30 PM. Staff F, RN stated she walked back from vending machines at end of East hall toward Nurse Station/Center of building. She noted odor in hallway. Seen Resident #11 door was slightly opened Staff F seen male figure in room. Staff F entered room noted haze with strong odor present. Resident # 11 in w/c facing door way, Resident # 24 sitting in w/c facing window, and Resident # 30 was standing by end of bed. Staff F asked male residents to exit the room and return to their rooms. Staff F observed two vapes sitting on Resident # 11 chest. Staff F removed the two vapes and placed them in a locked area. Staff F called on call manager who updated Administrator. Staff F was instructed to call local Police Department. Resident # 11 and Resident # 11's sister went to Nurse's Station. Resident # 11 told nurse she was leaving and left the facility with sister. Local Police Officer arrived at 7:00 PM, Staff F updated Officer of incident. Officer took items and left facility. Resident # 11 arrived back to facility at 9:39 PM, noted intoxication. Staff F assessed resident #11, and updated doctor. Doctor stated to send to hospital for evaluation. Staff F updated Resident # 11, EMT's arrived evaluated, Resident # 11 refused to go to the hospital. Staff F updated doctor, ordered to monitor. Staff F monitored resident the remainder of shift. On 7/10/24 at 2:00 PM, a Police Officer with local police, stated he arrived to the facility on 6/28/24 at 7:00 PM, He reported Staff F, RN told him of the incident and surrendered the two vapes. The Officer was unable to complete an investigation as resident was no longer on the property at that time, no harm was committed, no chargers were filed. He stated the two vapes were not tested. but stated one vape was nicotine and the other vape was THC. On 7/11/24 at 3:23 PM, the Social Worker (SW) stated interventions put in placed, resident #24 room was changed, re-educated about facility tolerance, reviewed smoking policy, encouraged residents to meet in common area, education provided to all residents no males in females rooms and no females in males rooms. On 7/11/24 at 3:27 PM, the Administrator stated all residents had been educated about intolerance of illegal substances in facility, staff educated about situation and interventions. The facility policy titled Smoking: Resident/Patient Overview revised 9/19 included the following documentation: -Instructed staff smoking materials/electronic or vapes devices will be secured by the facility. -Designated smoking areas for residents/patients who smoke. -Evaluation/Assessment will include but is not limited to, the Admission/re-admission Documents & Initial Care Plan, Smoking Safety Screen, The RAI/MDS, and Physician orders. 2. On 7/09/24 at 9:06 AM, Staff I, Certified Nurse Aide (CNA) transferred Resident #9 from the bathroom to her wheelchair and from the wheelchair to her bed without a gait belt. Staff I stood in front of the resident, wrapped her arms around the resident's back, and lifted the resident off of the toilet and placed her in the wheelchair. She used the same technique to transfer the resident to her bed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted and indicated the resident was rarely or never understood. It included diagnoses of heart failure (HF), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and non-Alzheimer's dementia. It also indicated the resident required maximum assistance with all transfers and was dependent with tub/shower transfers. The Electronic Health Record (EHR) Fall Risk assessment dated [DATE] indicated the resident was a high fall risk and required hands-on assistance to move from place to place. The Care Plan focus dated 10/22/24 directed staff to use a mechanical aid for transfers. On 7/11/24 at 12:27 PM, the interim Director of Nursing (DON) stated when anyone is manually transferring a resident, a gait belt is to be used unless medically ordered otherwise. A document titled Transfer Technique dated 1/13 indicated the purpose was to safely transfer a resident/patient while minimizing the risk of injury to the resident/patient and caregiver and was resident/patient specific. It directed staff to review any special precautions or approaches to take when transferring a resident/patient and to obtain assistance as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interview, and policy review the facility failed to follow infection prevention standards during incontinence cares for 2 of 2 residents review for incontinence cares (Residents #6, #12). The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment of Resident #6 dated 6/5/24 reflected the resident to have short term and long term memory problems. The MDS revealed the resident totally dependent on toileting and personal hygiene. The MDS reflected the resident always frequently incontinent of urine and not rated for bowel incontinent. The Care Plan, last reviewed 6/3/24, identified the resident to be incontinent of bladder. The Care Plan directed staff to provide incontinence care after each incontinent episode. The Care Plan did not state bowel incontinence. On 7/9/24 at 1:28 PM, Staff L, Certified Nurse Aide (CNA) entered resident #6 room. Resident #6 in wheelchair. Staff M, Certified Nurse Aide (CNA), brought the mechanical lift in room to assist resident and Staff L, CNA. Staff did not complete handwashing or hand hygiene. Staff provided privacy and stated to resident, assist with transfer and incontinent care. Staff hooked sling to equipment, transferred to bed, unhooked sling, equipment placed by door. Staff gathered items for incontinent care. Staff L stated task steps to resident. Staff remove pants, unfastened incontinent product. Staff L gathered wipe from Staff M, wiped front to back the outer labia, disposed the soiled wipe, gathered wipe from Staff M, wiped front to back the outer labia, disposed soiled wipe, with assistance from Staff M, Staff rolled resident to her right side toward the wall, Staff tucked the mechanical lift sling under resident, Staff M held onto resident, Staff L took soiled incontinent product and wipe bowel movement from anus, disposed soiled incontinent product, Staff L gathered wipe from Staff M, wiped perineum, anus, sacrum, disposed wipe, gathered wipe from Staff M wiped perineum, anus, sacrum, disposed wipe, gathered new incontinent product and placed under resident buttocks, Staff L tucked incontinent product fastener under right buttock, Staff rolled resident to her left onto her back, Staff rolled resident to her left side, Staff removed the mechanical lift sling, Staff L adjusted the incontinent product fastener, Staff assisted resident to her back. Staff L closed and fastened incontinent product. Staff L removed soiled gloves, Staff L completed hand hygiene. Staff assisted resident to comfortable position, covered resident, placed call light within reach, placed floor mat at bed side, lowered bed to appropriate level. Staff L completed hand washing, Staff M took soiled bag and mechanical lift equipment to hallway, Staff M placed mechanical lift equipment against the wall, Staff M put soiled bag in soiled utility room, another staff member took the mechanical lift, mechanical lift was not disinfected. Staff M went back to resident's room, performed hand washing, Staff shut off light and exited room. During cares, staff failed to change gloves and wash/sanitize hands when going from dirty to clean. On 7/11/24 at 3:01 PM the Director of Nursing (DON) stated the staff should perform hand washing or hand hygiene before and after incontinent care, when soiled, and when gloves are removed. Stated the staff should change gloves before and after cares, during cares when soiled. Mechanical lift equipment should be cleaned per policy, routine cleaning. The facility policy titled Perineal Care revised 4/13 included the following documentation: -Separate the labia with one hand and wash with the other, using gentle downward strokes from the front to the back of the perineum. -Remove gloves, wash hands, and apply clean gloves if original gloves were visibly soiled. -Clean, rinse, and dry the anal area, starting at the posterior vaginal opening and wiping from front to back. -Remove gloves, wash hands, and apply clean gloves. 2. The MDS assessment dated [DATE] for Resident #12 identified a BIMS score of 4 which indicates severe cognitive impairment. The MDS revealed the resident totally dependent upon staff for all cares with exception of eating. The MDS documented diagnoses that included: unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety, non-Alzheimer's dementia, seizure disorder or epilepsy, anxiety disorder, schizophrenia, and dysphagia. The Care Plan revised 2/13/24 identified the resident to be incontinent of bladder and bowel. The Care Plan directed staff to provide incontinence care after each incontinent episode of bladder. The Care Plan directed staff to take resident to toilet at same time each day resident usually has bowel movement. On 7/09/24 at 1:15 PM Staff L, CNA assisted resident #12 to his room. Staff K, CNA assisted Staff L, CNA. Staff gathered mechanical lift equipment, instructed resident of the task, permission granted, staff completed hand washing, staff hooked up mechanical lift to sling, Staff L controlled the mechanical lift equipment, Staff K guided resident to bed, resident positioned over bed, Staff L lowered resident onto the bed. Staff unhooked the sling from the lift. Staff moved the mechanical lift away from the bed. Staff gathered items for incontinent care. Staff L stated task steps to resident. Staff remove pants, unfastened incontinent product. Staff L gathered wipe from Staff K, wiped right groin then left groin, disposed the soiled wipe, gathered wipe from Staff K, Staff L wiped left groin, disposed soiled wipe, with assistance from Staff K, Staff rolled resident to his right side toward the wall, Staff tucked the mechanical lift sling under resident, Staff K held onto resident, Staff L disposed soiled incontinent product, Staff L gathered wipe from Staff K, wiped perineum, anus, sacrum, disposed wipe, gathered wipe from Staff K wiped perineum, anus, sacrum, disposed wipe, gathered new incontinent product and placed under resident buttocks, Staff rolled resident to his left onto his back, Staff rolled resident to his left side, Staff removed the mechanical lift sling, Staff L adjusted the incontinent product, Staff assisted resident to his back. Staff L closed and fastened incontinent product. Staff L removed soiled gloves, Staff completed hand washing. Staff assisted resident to comfortable position, covered resident, placed call light within reach, lowered bed to appropriate level. Staff removed soiled bag. During cares, staff failed to change gloves and wash/sanitize hands when going from dirty to clean and failed to disinfect the mechanical lift. On 7/11/24 at 3:01 PM The Director of Nursing (DON) stated the staff should perform hand washing or hand hygiene before and after incontinent care, when soiled, and when gloves are removed. Stated the staff should change gloves before and after cares, during cares when soiled. Mechanical lift equipment should be cleaned per policy, routine cleaning. The facility policy titled Perineal Care revised 4/13 included the following documentation: -Hold the shaft of the penis with one hand and wash with the other, beginning at the tip and working in a circular motion from the center to the periphery. -Gently retract the foreskin, if uncircumcised, and clean beneath it. -Replace the foreskin to avoid constriction of the penis. -Wash the rest of the penis, using downward strokes toward the scrotum. -Clean the top and sides of the scrotum gently. -Position resident to expose, clean the bottom of the scrotum and the anal area. -Remove gloves, wash hands, and apply clean gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews clinical record review, and policy review, the facility failed to provide oxygen per physician orders for 1 of 14 residents reviewed (#9). The facility reported a census of 30 residents. Findings include: On 7/09/24 at 9:06 AM, Staff I, Certified Nurse Aide (CNA) placed the resident's oxygen nasal cannula (NC - pronged tubing used for oxygen delivery through the nose) back on the resident. The resident's portable oxygen tank supply regulator was set on 2 Liters Per Minute (LPM) and the indicator registered in the red, refill zone. The resident's room concentrator was also set on 2 LPM. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted and indicated the resident was rarely or never understood. It included diagnoses of heart failure (HF), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and non-Alzheimer's dementia. It also indicated the resident used oxygen. The Electronic Health Record (EHR) included a physician order dated 10/13/23 for oxygen at 3 LPM via nasal cannula (NC) every shift. The Care Plan dated 10/20/23 indicated the resident had oxygen (O2) via nasal prongs/mask at 3 LPM continuously. On 7/09/24 at 12:19 PM, the resident was observed in her wheelchair in the dining room with her NC and oxygen tank. The oxygen tank regulator was set at 2 LPM and the indicator registered 0 in the red, refill zone. At 1:02 PM, Staff K, CNA removed the resident's nasal cannula and transferred her from her wheelchair to her bed. The resident's oxygen saturation was checked and observed at 92%. Staff A, Registered Nurse (RN) placed the resident on the oxygen concentrator at 2.5 LPM. On 7/11/24 at 12:27 PM, the interim Director of Nursing (DON) stated staff should follow the doctor's order and/or therapy expectations. On 7/11/24 at 4:00 PM, the Regional Director of Clinical Services stated the facility did not have a policy for following physician's orders. A document titled Oxygen Administration dated 1/13 directed staff to verify physician's order to include the flow rate and duration of use.

Based on observations, clinical record review, staff interview and facility policy review the facility failed to administer medications at an error rate of under 5%. The facility reported a census of 30 residents. Findings include: The continuous observation of medication pass on 7/9/24, beginning at 7:35 am observed the following: Staff A, Registered Nurse (RN) passed medications to Resident #26. A total of 19 medications were observed being administered to Resident #26. The State Surveyor recorded each medication given to Resident #26 during the observation which included: - Furosemide, 10 mg, 2 tablets - Magnesium Oxide, 400 mg, 1 tablet - Fiber Lax, 625 mg, 1 capsule Staff A, RN next passed medications to Resident #3. A total of 8 medications were observed being administered to Resident #3. The State Surveyor again recorded each medication given to Resident #3 during observation which included: - Calcium, 500 mg, 1 tablet Following the observation of the medication pass, the list of administered medications were reconciled against the July 2024 Medication Administration Record (MAR) of both of the residents. The MAR of Resident #26 revealed the following: - The AM order of Furosemide was for 40 mg, not 20 mg which was administered. - The order for Magnesium Oxide was for 250 mg, not 400 mg which was administered - The order for the Fiber supplement was for 500 mg, not the 625 mg which was administered. The MAR of Resident #3 revealed the following: - The order for Calcium was for 600 mg, not 500 mg which was administered. Four errors for 27 medication administrations calculated a medication error rate of 14.8%. On 7/9/24 at 8:30 am, the Director of Nursing stated all orders should be checked against the medication for accuracy. The facility policy Medication Administration, dated 01/2013 included the following documentation: Point 10 - Read the Medication Administration Record (MAR) for the ordered medication, dose, route and time. Point 11 - Verify the pharmacy prescription label on the drug and the manufacturer's identification system matches the MAR. Point 13- Verify the following, again, by comparing medication to MAR prior to administering: - Correct resident/patient - Correct medication - Expiration date - Dose and dosage form - Route - Time

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The MDS assessment dated [DATE] for Resident #24 identified a BIMS score of 4 which indicates severe cognitive impairment. The MDS revealed the resident to need minimal assistance with personal care and dressing. Resident is dependent on staff for toileting hygiene and shower/bathe self. The MDS documented diagnoses that included: cerebral infarction, unspecified, Non-Alzheimer's dementia, hemiplegia, depression, and vascular dementia. The Care Plan, revised 3/5/24, revealed resident incontinent of bowel and bladder, staff to encourage resident to toilet before and after each meal, at bedtime, and at least once during the night, Check him for incontinence at that time, staff to assist as needed. Revealed resident sometimes needs some help with sit to stand, resident is able to transfer independently with his walker. Revealed resident is usually able to toilet independently, resident does need cues and assist to complete toileting hygiene and needs reminders to change soiled clothing. The Progress Note of Resident #24 dated 6/28/24 at 7:24 PM documented: Daughter was updated, resident was found in another resident's room, exposed to marijuana. Daughter voiced concern about exposure to marijuana interacting with medications and comorbidities. The Progress Note dated 6/28/24 at 10:27 PM noted blood pressure of 82/60. Resident stated to Staff P, Licensed Practical Nurse (LPN) I think someone's trying to kill me. Staff P, LPN asked who and why he thinks that, resident stated I'll tell you tomorrow, I forgot how to talk. The Progress Note dated 6/29/24 at 12:04 AM noted blood pressure 112/63. Resident stated to staff I'm ok. The Progress Note dated 6/29/24 at 2:02 AM noted blood pressure 117/66. The Progress Note dated 6/29/24 at 4:00 AM noted blood pressure 119/68. On 7/9/24 at 4:09 PM Staff Q, Certified Nurse Aide stated on 6/28/24 she worked 6:00 PM to 6:00 AM shift. She stated Resident #24 baseline is stand by assist. She took care of Resident # 24 that evening and resident required maximum assistance to total assistance of one staff to complete personal cares and toileting. Staff stated this is not his normal, he is very out of it. She stated she reported to the nurse on shift. On 7/10/24 at 6:32 AM Staff P, Registered Nurse (RN) stated on 6/28/24 at 6:30 PM, Resident #24 was found smoking marijuana, in Resident # 11 room, she removed the resident from the room and assisted the resident to his room. She monitored the resident the remainder of the shift. She noted during shift the resident was having delusions, people were trying to kill him. Staff stated she updated doctor via fax. Staff stated she did speak with the Doctor regarding resident #11, but did not update the doctor about resident #24 having delusions. Staff stated the resident does not have delusions of someone killing him at baseline. On 07/11/24 at 2:43 PM Staff P, LPN stated the resident has delusions at baseline. The residents delusions come and go. The resident is seen by a Psychiatrist. Staff P stated the resident needs assistance from staff most of the time for cares, and transferring varies depending on his status that day. The facility policy titled Notification of Resident/Patient Change in Condition, Review date 11/2019 directs: Point 7: Notify the Physician and family/resident representative at the earliest possible time, during waking hours, if there is a change in condition. Point 10: Document in the Progress Notes the times notification was made and the names of the person(s) spoken to. Based on clinical record review, family interview, staff interviews and facility policy review, the facility failed to notify the family and/or physician of a medication error, a fall and a significant change for 4 of 6 residents reviewed (Resident #3, #24, #26, and #34). The facility reported a census of 30 residents. Findings include: 1. Observation of medication pass began on 7/9/24 at 7:35 am with Staff A, Registered Nurse. Staff A first administered medications to Resident #26. The administration of 18 medications were observed for Resident #26. Of the 18 medications administered, three of the medications were medication errors of the incorrect dosage. Following administering the medications to Resident #26, Staff A then administered Medications to Resident #3. One medication error was noted for Resident #26, also being an incorrect dosage. On 7/9/24 at 8:30 am, the Director of Nursing (DON) stated if a stock medication does not match the order, the nurse should notify the doctor and get an order change or get the correct dose from the pharmacy based on the doctor's preference. Review of the Progress Notes for Resident #26 and Resident #3 on 7/11/24 failed to reveal the physician had been notified of either resident having been administered medications not matching physician orders. 2. On 7/8/24 at 12:49 pm, a nurse at Resident #34's prior nursing facility stated she had come to visit Resident #34 at the current facility on 6/6/24. She stated she noticed a bruise on the resident's forehead and said Resident #34 had told her she had fallen out of her chair and also told her she was having pain in her legs. The nurse stated after the visit, she called Resident #34's family member who was not aware of Resident #34 having fallen or having any bruising or pain. On 7/8/24 at 1:50 pm, a family member of Resident #34 stated he had not been notified by the facility of Resident #34 having fallen or having any injuries. He stated he had not been aware of this until the nurse from the prior nursing facility informed him. Review of the Profile section of Resident #34's Electronic Health Record reflected the son of Resident #34 to be: - Responsible Party - Financial Responsible Party - Power of Attorney, Financial - Power of Attorney, Care - Emergency Contact #1 The Minimum Data Set (MDS) assessment of Resident #34, dated 5/27/24 identified a Brief Interview of Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. The Risk Management form dated 6/3/24 documented Resident #34 was observed on the floor beside her bed, lying on her stomach. It revealed documentation the resident stated she was self transferring to her bed and slid off the side of the bed. Page 3 of the Risk Management document revealed the Nurse on call and the Physician were both notified of the incident. The Risk Management form failed to document the Power of Attorney/Emergency Contact for Resident #34 was notified. Review of Resident #34's Progress Notes failed to reveal any documentation of the Power of Attorney/Emergency Contact for Resident #34 being notified of the fall. On 7/11/24 at 12:27 pm, the DON stated staff should notify family for falls and/or change of condition as soon as possible for injuries and within an acceptable time for family preference unless the resident competently represents themselves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE] for Resident #11 identified a BIMS score of 15 which indicates cognition intact. The MDS revealed the resident totally dependent upon staff for all cares. The MDS documented diagnoses that included: quadriplegia, anxiety disorder, depression, autonomic dysreflexia, and muscle spasms. The Comprehensive Care Plan of resident #11 initiated 10/11/22 failed to reveal resident to be a smoker. The untitled facility document provided during survey listed 4 residents as smokers which included Resident #11. Observation on 7/9/24 at 2:41 PM, revealed Resident # 11 is dependent on staff for monitoring during vaping at the designated facility times and place. The facility policy titled Smoking: Resident/Patient Overview revised 9/19 included the following documentation: Evaluation/Assessment will include but is not limited to, the Admission/re-admission Documents & Initial Care Plan, Smoking Safety Screen, The RAI/MDS, and Physician orders. 3. The MDS assessment dated [DATE] for Resident #12 identified a BIMS score of 4 which indicates severe cognitive impairment. The MDS revealed the resident totally dependent upon staff for all cares with exception of eating. The MDS documented diagnoses that included: unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety, non-Alzheimer's dementia, seizure disorder or epilepsy, anxiety disorder, schizophrenia, and dysphagia. The Care Plan of resident #12 revised 2/27/24 reveals the resident transfers with assistance of one staff member, the resident requires (supervision, cueing, encouragement, specify physical assistance) with transferring, and the resident can transfer with one assist and use of his walker. Assist as requested or as needed. The Progress Note dated 1/26/24 at 3:02 PM revealed the Social Worker (SW) states Resident #12 brother called facility, SW updated brother on the decline in condition. SW provided details of decline stated staff is assisting with meals and staff uses a Hoyer to transfer him into a wheelchair. On 7/08/24 at 1:20 PM Resident #12 observed sitting in wheelchair with a sling for a full body mechanical lift under him. On 7/09/24 at 1:15 PM Staff L, Certified Nurse Aide (CNA) assisted Resident #12 to his room. Staff K, CNA assisted Staff L. Staff gathered mechanical lift equipment, instructed resident of the task, permission granted, staff hooked up mechanical lift to sling, Staff L controlled the mechanical lift equipment, Staff K guided resident to bed, resident positioned over bed, Staff L lowered resident onto the bed. Staff unhooked the sling from the lift. Staff moved the mechanical lift away from the bed. On 7/11/24 at 12:27 PM, the Director of Nursing (DON) stated Care Plans should be continuously revised to meet the needs of the resident's care. On 7/11/24 at 3:50 PM Staff P, Licenses Practical Nurse, Nurse Manager stated she does not do care plan revisions. On 7/11/24 at 4:04 PM the Regional Director of Nursing stated MDS Coordinators are remote. He stated any care plan areas that trigger on the Care Area Assessments (CAA) of a comprehensive MDS are the responsibility of the remote MDS Coordinator to care plan. Daily updates should be done within the facility, and that is the responsibility of Staff P, LPN or of the DON. The facility policy titled Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) dated 7/15 includes the following documentation: Comprehensive or full assessments include the admission, significant change, significant correction of a prior full assessment and annual include all required MDS items along with State-designated sections, use of Care Area Assessment (CAA) including CAT's and CAA summary. Within 14 days after the facility determines that there has been a significant change in the resident's status that will not normally resolve itself, which has an impact on one or more area of the residents' health status and requires an interdisciplinary review and/or revision of the care plan. Based on observations, clinical record review, resident interview, staff interviews, and policy review, the facility failed to fully review and revise the comprehensive care plan for 4 of 15 resident reviewed (#11, #12, #26, and #34). The facility reported a census of 30. Findings include: 1. An observation on 7/08/24 at 3:25 PM revealed Resident #26's legs and feet were swollen. The resident stated she was taking a water pill (diuretic) for a while for the swelling in her legs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of hypertension, deep vein thrombosis (DVT; deep vein blood clot), hyperlipidemia (high cholesterol in the blood), diabetes mellitus, and morbid obesity. It revealed the resident was independent with eating and oral hygiene, required maximum assistance with upper body dressing, and was dependent in all other activities of daily living (ADLs) and all mobility. It also revealed the resident received a diuretic within the 7-day look-back period. The Electronic Health Record (EHR) included a diuretic medication order dated 11/03/23. A physician's order dated 1/23/24, increased the diuretic dose. The Care Plan did not include the resident's use of diuretic medication nor interventions. On 7/11/23 at 12:27 AM, the interim Director of Nursing (DON) stated Care Plans should be continuously revised to meet the needs of the resident's care. A document titled Care Plan Development dated 8/15 indicated the Care Plan will be reviewed and revised on an as needed basis and at least every 92 days. 4. The Minimum Data Set assessment of Resident #34, dated 5/27/24 identified a Brief Interview of Mental Status (BIMS) score of 7 which indicates severe cognitive impairment. The Care Plan of Resident #34 revealed a focus area of Actual Fall related to poor balance and unsteady gait dated 6/4/24. The intervention put in place was to monitor for 72 hours. No intervention was put in place to prevent or reduce future falls. The Risk Management form dated 6/3/24 at 8:45 pm documented Resident #34 was observed on the floor beside her bed, lying on her stomach. It revealed documentation the resident stated she was self transferring to her bed and slid off the side of the bed. The form noted no injuries observed at the time of the incident or post incident. On 7/10/24 at 1:17 pm, the Regional Director of Clinical Services stated a Risk Management form should be started by the nurse on duty at the time of the incident. From there, there should be a full investigation of the incident and it would be discussed in the morning meeting on the next business day. He stated during the meeting, it should be assured an intervention was put in place on the resident's care plan. If the intervention initially put in place was not an appropriate intervention, it would be changed. He additionally stated follow up assessment and charting by the nurses should be completed for 72 hours after an incident. The facility policy Fall Risk Reduction & Management, revision date 12/2015 documented the following: The Interdisciplinary team will develop a care plan for all residents/patients requiring a fall management program. The interdisciplinary team will develop the care plan with input from the resident/patient and/or the family/responsible party. Point 2: Develop the goal for fall risk reduction with the resident/patient and/or family/responsible party. Point 3: Develop interventions to assist resident/patient in reaching their goal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 7/9/24 at 1:28 PM, Staff L, Certified Nurse Aide (CNA) entered resident #6 room. Observed Resident #6 in her wheelchair. Staff M brought the mechanical lift in the room to assist resident and Staff L. Staff did not complete handwashing or hand hygiene. Staff provided privacy and stated to resident, assist with transfer and incontinent care. Staff hooked sling to equipment, transferred to bed, unhooked sling, and placed equipment by her door. Staff gathered items for incontinent care. Staff L stated task steps to resident. Staff removed pants, and unfastened incontinent product. Staff L gathered wipe from Staff M, wiped front to back the outer labia, disposed the soiled wipe, gathered wipe from Staff M, wiped front to back the outer labia, and disposed soiled wipe. With assistance from Staff M, Staff rolled resident to her right side toward the wall. Staff tucked the mechanical lift sling under the resident, Staff M held onto resident, Staff L took soiled incontinent product and wipe bowel movement from anus then disposed soiled incontinent product. Staff L gathered wipe from Staff M, wiped perineum, anus, sacrum, disposed wipe, gathered wipe from Staff M wiped perineum, anus, sacrum, disposed wipe, gathered new incontinent product and placed under resident buttocks. Staff L tucked incontinent product fastener under right buttock, Staff rolled resident to her left onto her back, Staff rolled resident to her left side, Staff removed the mechanical lift sling. Staff L adjusted the incontinent product fastener, and staff assisted resident to her back. Staff L closed and fastened incontinent product. Staff L removed soiled gloves and completed hand hygiene. Staff assisted resident to comfortable position, covered resident, placed call light within reach, placed floor mat at bed side, and lowered bed to appropriate level. Staff L completed hand washing, Staff M took soiled bag and mechanical lift equipment to hallway, Staff M placed mechanical lift equipment against the wall, Staff M put soiled bag in soiled utility room, another staff member took the mechanical lift, mechanical lift was not disinfected. Staff M went back to resident's room, and performed hand washing, Staff shut off light and exited room. On 7/11/24 at 3:01 PM the Director of Nursing (DON) stated the staff should perform hand washing or hand hygiene before and after incontinent care, when soiled, and when gloves are removed. Stated the staff should change gloves before and after cares, during cares when soiled. Mechanical lift equipment should be cleaned per policy, routine cleaning. The facility policy titled Perineal Care revised 4/13 included the following documentation: -Separate the labia with one hand and wash with the other, using gentle downward strokes from the front to the back of the perineum. -Remove gloves, wash hands, and apply clean gloves if original gloves were visibly soiled. -Clean, rinse, and dry the anal area, starting at the posterior vaginal opening and wiping from front to back. -Remove gloves, wash hands, and apply clean gloves. The facility policy titled Infection Control Manual: Equipment revised 3/15 included the following documentation: -A facility specific cleaning schedule will be developed for the routine cleaning of noncritical equipment such as, but not limited to, the following: Resident/patient care equipment: Mechanical lifts 4. On 7/09/24 at 1:15 PM Staff L assisted resident #12 to his room. Staff K assisted Staff L. Staff gathered mechanical lift equipment, instructed resident of the task, permission granted, and staff completed hand washing. Staff hooked up mechanical lift to sling, Staff L controlled the mechanical lift equipment, Staff K guided resident to bed, resident positioned over bed, Staff L lowered resident onto the bed and Staff unhooked the sling from the lift. Staff moved the mechanical lift away from the bed. Staff gathered items for incontinent care. Staff L stated task steps to resident. Staff remove pants, and unfastened incontinent product. Staff L gathered wipe from Staff K, wiped right groin then left groin, disposed the soiled wipe, gathered wipe from Staff K, Staff L wiped left groin, disposed soiled wipe, with assistance from Staff K, and Staff rolled resident to his right side toward the wall. Staff tucked the mechanical lift sling under resident, Staff K held onto resident, Staff L disposed soiled incontinent product, Staff L gathered wipe from Staff K, wiped perineum, anus, sacrum, disposed wipe, gathered wipe from Staff K wiped perineum, anus, sacrum, and disposed the wipe. Staff failed to wash hands or change gloves. Staff gathered new incontinent product and placed under resident buttocks, Staff rolled resident to his left onto his back, Staff rolled resident to his left side, Staff removed the mechanical lift sling, Staff L adjusted the incontinent product, and then Staff assisted resident to his back. Staff L closed and fastened incontinent product. Staff L removed soiled gloves, and completed hand washing. Staff assisted resident to comfortable position, covered resident, placed call light within reach, and lowered bed to appropriate level. Staff removed soiled bag. Mechanical lift equipment was not disinfected. On 7/11/24 at 3:01 PM the Director of Nursing (DON) stated the staff should perform hand washing or hand hygiene before and after incontinent care, when soiled, and when gloves are removed. Stated the staff should change gloves before and after cares, during cares when soiled. Mechanical lift equipment should be cleaned per policy, routine cleaning. The facility policy titled Perineal Care revised 4/13 included the following documentation: -Hold the shaft of the penis with one hand and wash with the other, beginning at the tip and working in a circular motion from the center to the periphery. -Gently retract the foreskin, if uncircumcised, and clean beneath it. -Replace the foreskin to avoid constriction of the penis. -Wash the rest of the penis, using downward strokes toward the scrotum. -Clean the top and sides of the scrotum gently. -Position resident to expose, clean the bottom of the scrotum and the anal area. -Remove gloves, wash hands, and apply clean gloves. The facility policy titled Infection Control Manual: Equipment revised 3/15 included the following documentation: -A facility specific cleaning schedule will be developed for the routine cleaning of noncritical equipment such as, but not limited to, the following: Resident/patient care equipment: Mechanical lifts Based on observation, record review, staff interview, and policy review, the facility failed to implement infection control practices to prevent cross contamination by staff failing to perform appropriate hand hygiene during resident cares, medication administration, and meal service for 5 of 5 residents (Resident #3, #6, #12, #16, and #26) reviewed for infection control. The facility also failed to ensure resident equipment was sanitized after use for 2 of 2 residents (Resident #6 and #12). The facility reported a census of 30 residents. Findings include: 1. An observation on 7/08/24 at 1:18 PM revealed Resident #3's indwelling catheter tubing had a dependent loop with clear, yellow urine and sediment in it. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated severely impaired cognition. It included diagnoses of neurogenic bladder (nerves that control the bladder do not function), epilepsy, cognitive communication deficit, mild intellectual disability, normal pressure hydrocephalus (fluid buildup in the brain), and benign prostatic hyperplasia (prostate enlargement). It also revealed he was independent with eating but dependent with all other activities of daily living (ADLs) and all mobility. It indicated the resident had an indwelling catheter. The Care Plan revised 10/20/23 indicated the resident's catheter goal was to show no signs or symptoms of a urinary tract infection (UTI) and directed staff to position the catheter bag and tubing below the level of the bladder an away from the entrance room door. The Electronic Health Record (EHR) progress notes indicated the resident Suprapubic (indwelling) catheter was changed on 6/22/24. On 7/10/24 at 2:33 PM, Staff N, Certified Nurse Aide (CNA) performed Resident #3's catheter care. Staff N donned a protective gown and gloves and entered Resident #3's room. She obtained a graduated cylinder (container used to measure urine) from the resident bathroom cabinet then opened the resident's chest-of-drawers and night stand to get alcohol wipes. She opened the urine collection bag drain spout with her right hand, emptied the urine into the cylinder, opened the alcohol wipe package, grabbed the alcohol wipe with her right hand, and wiped the drain spout. She closed the spout and secured it to the drain bag. She emptied the urine into the toilet, removed her gown and gloves, performed hand hygiene with soap and water, and left the room. At 2:42 PM, Staff N and Staff O, Nurse Aide (NA) returned to the resident's room. Staff N donned a protective gown, entered the resident's room and donned gloves. Staff O did not don a protective gown nor gloves. Staff O connected the resident's transfer sling to the mechanical lift, picked up the indwelling catheter drainage bag, and held it while Staff N raised the resident from the wheelchair. Staff O handed the drainage bag to Staff N. Staff N held the drainage bag in her right hand, grabbed the upper handle on the mechanical lift above the resident's bladder, and lowered the resident onto his mattress. Staff N laid the drainage bag on the resident's mattress, removed her gloves and donned new gloves without performing hand hygiene. Staff O moved the mechanical lift, and both Staff N and Staff O adjusted the resident's pants. Staff N handed Staff O the periwipe package. Staff O removed a periwipe and gave it to Staff N. Staff N wiped Resident #3's waistline at the level of the suprapubic catheter (SPC) insertion site. They repeated this process three (3) times. They pulled the resident's pants back up, connected the sling to the mechanical lift, raised the resident off the bed, and positioned him over the wheelchair. Staff N held the drain bag above the resident's bladder while she leaned around the left side of the mechanical lift, adjusted the wheelchair seat antiskid pad, and lowered the resident down onto the wheelchair seat. At 4:20 PM, Staff O stated the facility requires hand hygiene after bathroom use, removing gloves, changing resident briefs, risk of body fluid exposure, and working with indwelling catheters. He stated the policy does not require staff to wear gloves while touching residents. At 4:35 PM, Staff N stated hand hygiene and gloves are required before and after resident care and when contacting visibly soiled items or residents. She stated she should've washed her hands prior to beginning the procedures. On 7/11/24 at 12:27 PM, the interim Director of Nursing stated staff should follow the orders of the care plan and the drainage bag is to remain below the resident's bladder. She also stated hand hygiene should be done before, after, and as needed during a procedure. A document titled Catheter Care dated 1/13 directed staff to not allow the end of the drainage spout to touch other surfaces and position the catheter and drainage bag below the level of the resident's bladder. 2. On 7/09/24 at 9:01 AM, Resident #16 pointed to his abdomen and indicated he had a gastric tube (G-tube; tube directly into the stomach). The Electronic Health Record (EHR) included a Speech Therapy note dated 11/21/23 which directed staff to continue an alternate means of hydration and nutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have a Brief Interview for Mental Status (BIMS) score. It included diagnoses of cerebrovascular accident (stroke), aphasia (inability to speak), left sided hemiplegia (one-sided paralysis), and dysphagia (difficulty swallowing). It also revealed he was independent with eating, required moderate assistance with bathing and rolling in bed, and was dependent with all other activities of daily living (ADLs) and all mobility. It indicated the resident had a feeding tube. The Care Plan revised 8/14/23 directed staff to provide local care to the G-tube site as ordered and monitor for signs and symptoms of infection. A physician order dated 8/09/23 directed staff to clean the peg tube site with normal saline and cover with a split 4 x 4 gauze one time per day. On 7/10/24 at 2:56 PM, Staff A, Registered Nurse (RN) performed G-tube site care. Staff A entered the resident's room, performed hand hygiene with soap and water, closed the door with her foot, and donned a protective gown and gloves. She opened the bottle of normal saline (NS) and the package of 2 x 2 s, saturated the 2 x 2 s with the NS, pulled up the resident's shirt, wiped the top of the insertion site, folded the 2 x 2 s, and wiped the bottom of the insertion site. She removed her gloves, sanitized her hands, donned new gloves, and put slit dressing on his site. She taped the slit together for secure and dated it. She removed her gown and gloves and performed hand hygiene. At 3:03 PM, Staff A stated the opportunities to perform hand hygiene are when gloves are soiled, when moving from dirty to clean cares, and between patient-to-patient care. She stated packaged supplies should be opened after gloves are donned. On 7/11/24 at 12:27 PM, the interim Director of Nursing stated hand hygiene should be done before, after, and as needed during a procedure. 5. Observation of morning medication pass began on 7/9/24 at 7:35 am. Staff A, Registered Nurse was passing medications. She stated she would begin with Resident #26. Staff A brought the medication cart to the doorway of Resident #26. She knocked on the door to verify the resident was awake and let her know she was preparing her medications. Staff A brought the Medication Administration Record of Resident #26 up on the computer screen and opened the medication drawer to remove the medications. She prepared the oral medications and administered them. After administering the medications, she stated she needed to check the resident's blood sugar. She gathered supplies, donned gloves, swabbed the resident's finger with an alcohol wipe and obtained her blood sugar. She held a cotton ball to the resident's finger to stop any bleeding. She disposed of the contaminated items in a sharps container and removed her gloves. She placed the glucometer back in the medication cart near the front of the top drawer. The State Surveyor asked Staff A if the glucometer was dedicated to a single resident or if it was shared. She stated it was dedicated to Resident #26 and she moved the glucometer from a general area in the cart to a divided area in the cart which was labeled with Resident #26's name. The glucometer was not sanitized before or after use. She also failed to sanitize the top drawer of the medication cart where the glucometer was initially placed. Staff A then prepared the first of three insulin shots for Resident #26. After preparing the insulin pen, she donned gloves, and administered the insulin appropriately. After administering the insulin and disposing of sharps, she removed her gloves. She repeated this for two more injections. Staff A then administered an inhaled medication and a nasal spray medication to Resident #26 which completed medication pass for this resident. No hand hygiene was witnessed during the observation. 6. Staff A then moved the medication cart across the hall to Resident #3. With no hand hygiene witnessed, Staff A prepared and administered all morning medications to Resident #3. The facility policy Medication Administration, dated 01/2013 documented the following: Point 6: Wash hands Point 7: Assemble equipment for administering medications Point 15: Administer oral medication with a full glass of water unless otherwise ordered. Point 18: Wash hands.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement required training for multiple topics for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in communication, Quality Assurance and Performance Improvement (QAPI), compliance and ethics, and behavioral health. The facility lacked documentation that Staff J completed training in resident rights and infection control. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement communication training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in communication. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement resident rights training for 1 of 5 staff reviewed (Staff J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire date: Staff J 3/28/23. The facility lacked documentation that Staff J completed training in resident rights. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement Quality Assurance and Performance Improvement (QAPI) training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in QAPI. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement infection control training for 1 of 5 staff reviewed (Staff J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff J 3/28/23. The facility lacked documentation that Staff J completed training in infection control. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement compliance and eithics training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in Compliance and Ethics. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement behavioral health training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in Behavioral Health. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on observations and staff interview, the facility failed to maintain proper food temperature during lunch service. The facility reported a census of 30 residents. Findings include: Continuous observation of lunch service on 7/9/24 at 12:00 pm. Temperatures were obtained prior to meal service beginning which reflected the following: Creamy cheddar macaroni salad - 40 degrees Fruit - 38 degrees Ham salad - 40 degrees Tomatoes slices - 38 degrees Bacon (previously fully cooked) - 150 degrees Deviled eggs - 40 degrees. All of the cold items had been removed from the refrigerator just prior to checking temperatures. The bacon was placed on the steam table turned to heat. The macaroni salad, the fruit and the tomatoes were placed on the opposite end of the steam table which was turned off. The wells of the the cold end of the steam table were packed with ice. A full sized sheet pan of deviled eggs was placed on the counter with a cake pan underneath of it full of ice. It was noted during meal service the sheet pan was moved off of the cake pan of ice with approximately the half of the deviled eggs over the ice. Meal service was completed on 7/9/24 at 12:43 pm. When end of service temperatures were checked, the following was noted: Creamy cheddar macaroni salad - 50 degrees Tomato slices - 58 degrees Deviled egg - 60 degrees. On 7/11/24, Staff C, the current Activity Director and former Dietary Manager stated cold foods should be maintained at 41 degrees or colder. She stated the procedure is for the wells of the steam table to be filled with ice for cold foods and that this will be monitored. She additionally stated kitchen staff will continue to receive education regarding dangerous food temperatures and food borne illnesses. The facility document Sanitation and Food Production, dated 6/2015 documented: Point 7 - Maintain hot foods above 140 degrees F (Fahrenheit) and cold foods at or below 41 degrees F

Based on observation, interview and facility policy review, the facility failed to properly label, date, store and serve resident foods. The facility reported a census of 30 residents. Findings include: During initial walk through of the facility kitchen on 7/8/24 at 12:05 pm, the following items were found in the kitchen refrigerator: - A gallon of chocolate milk, approximately half empty, with no open date noted. - Three 20 oz bottles of cola. One of the bottles was greater than 3/4 empty. None of the bottles were labeled with a resident name or dated. - The bottom shelf of the refrigerator had a large plastic bowl of ice. On top of this bowl was a second plastic bowl filled with hard boiled eggs. The eggs were not covered with any protective wrap and had no date on them. Continuous lunch service observation began on 7/9/24 at 12:00 pm with Staff B, Cook, serving the lunch meal and observed the following: The meal for residents with a regular diet consisted of: - Bacon, lettuce and tomato (BLT) sandwich - 2 deviled egg halves - Creamy cheddar macaroni salad - Fruit The meal for residents with a mechanical soft diet was the same with the exception of a ham salad sandwich in place of the BLT sandwich The meal for residents on a puree diet was the same as the mechanical soft, but all items were pureed. On 7/9/24 at 12:05 pm, Staff B, Cook, began lunch service. She washed her hands and placed gloves on her hands. After placing gloves on her hands, she picked up the steam table lid covering the bacon. She then removed a large pan of bread from the refrigerator and removed the plastic wrap from the bread pan and disposed of it in the trash. She then began, without changing gloves, to prepare lunch trays. She picked up a slice of bread with her gloved hand, placed bacon, lettuce and tomato on the bread using tongs, and then picked up a second slice of bread with her gloved hand to complete the process of making the sandwich. She then proceeded to use serving utensils to place the remaining food items on the plate, then walked to the counter and picked up 2 deviled eggs with her gloved hands to add to the plate and placed the plate on the tray to be served to residents. This process was observed for each resident of the facility that a regular diet order tray plated during observation. On 7/9/24 at 12:10 pm Staff B, Cook, began to prepare the plate of pureed food for Resident #9. The plate included pureed macaroni salad which was not at a proper or safe puree texture. Staff B was instructed by Staff D, Certified Nurse Aide (CNA) and also a former Dietary Manager, to discard the macaroni salad and puree a substitute item. Staff B opened the refrigerator and removed cottage cheese. She appropriately pureed two servings of cottage cheese and returned to the serving area. No glove change or hand hygiene was witnessed. Staff B then placed a clean plate on the serving area. She covered the macaroni salad with one gloved hand and dumped the plate upside down for the pureed ham salad sandwich to land on the clean plate. She went to the sink and obtained a paper towel, and wiped her soiled glove off with a paper towel. She then resumed lunch service. On 7/9/24 at 12:20 pm, Staff B was observed, with her gloved hands, having prolonged contact with contaminated portions of the steam table. She then began preparing a tray for Resident #25. She made a BLT sandwich, and using her gloved hands, ripped it into several pieces and stuffed it into a two handled cup. Staff B, [NAME] stated I know I didn't do that right. The State Surveyor asked Staff E, Dietary Aide what Resident #25's diet order was. He looked at the resident's tray card and stated he is on a regular diet with thin liquids. He further stated the resident eats all of his meals out of two handled cups. On 7/9/24 at 12:23 pm, Staff B removed her gloves, threw them in the trash can and placed clean gloves on. No hand hygiene was performed. She resumed meal services. At 12:32 pm she prepared the pureed meal for Resident #16. She went to the refrigerator, obtained a single serving of pureed ham salad sandwich which was wrapped in parchment paper and stored in a steam pan. She opened the parchment paper and held it over the plate, and scraped the parchment paper with her gloved hand to get as much of the salad off the parchment as she could. She took the contaminated pan and the parchment paper, disposed of the parchment and took the pan to the dishwasher and returned to the serving area. With no hand hygiene or glove change, she continued service. At 12:40 pm, service was ending, as Staff B was preparing the final plate. As she reached for the deviled eggs with her gloves hands, she stated I should probably be using tongs on those, oops. That might be a problem. Staff B stated she also should have used separate tongs for the tomato and lettuce which had been in the same steam pan. On 7/9/24 at 1:15 pm, the Registered Dietitian (RD) stated she has always encouraged tongs because gloves give a sense of false security and staff don't think about what they are doing. She stated she prefers staff to use tongs, a spatula, even a fork is a better choice instead of gloves. The Dietary Manager was out of the facility during the survey week. Staff C, the current Activities Director, and also the former Dietary Manager was assisting to oversee the kitchen in her absence. On 7/9/24 at 2:35 pm, Staff C stated there was a recent meeting held for all kitchen staff which included multiple topics. She stated every kitchen staff member was educated on food storage, sanitizing the kitchen, food contamination, mechanical soft, puree textures. Everything was covered. Staff C provided copies of the paperwork from the in-service. Included in this paperwork was an undated policy titled Bare Hand Contact with Food and Use of Gloves. Point 3 - Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready to eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Point 6 - Remember, gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed: - After handling garbage or garbage cans - After handling soiled trays or dishes - After handling anything soiled - Anytime you touch any contaminated surface Additionally found in the in-service packet was an undated document titled How To Store Food Properly. This document included direction to staff to label and date all stored food. The paperwork also included a sign in sheet for the meeting dated 6/27/24. Staff B's signature indicated she had attended the meeting. On 7/11/24 at 8:40 am, Staff C stated staff education will be continued to include food borne illnesses as well as other topics.

Based on clinical record review, staff, family and provider interviews, and facility policy review, the facility failed to update and revise a resident care plan to reflect non compliance with physician orders for 1 of 4 (Resident #1) residents reviewed. The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) of Resident #1 dated 10/10/23 identified a Brief Interview of Mental Status (BIMS) score of 13 which indicated cognition intact. The MDS revealed the resident required supervision or touching assistance for bed mobility and transfers. The MDS documented diagnoses that included high blood pressure, renal failure, diabetes mellitus, anxiety, depression, chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues). The Comprehensive Care Plan of Resident #1, reviewed 10/17/23, identified a focus area of the resident having COPD. The care plan directed to give oxygen therapy as ordered by the physician. The Care Plan identified additional focus areas of diabetes mellitus, psychotropic drug use, chronic pain, and activities of daily living self care performance deficit. The Care Plan failed to document a history of any non compliance with any of her cares or treatments. The Health Status Note dated 1/22/24 at 1:37 pm documented the resident alert to herself only, and unable to stand with one assist per her baseline. Vital signs were normal. Orders received to transfer the resident to the Emergency Room. The Orders section of the Electronic Health Record (EHR) of Resident #1 identified an order for oxygen at 1-3 liters/minute via nasal cannula for COPD, titrate to resident comfort. The Treatment Administration Record (TAR) for January 2024 revealed the resident to use oxygen daily. The TAR documented Yes for behavior observed 10 times of the 41 entries for January 2024. No details of the behaviors documented in the Progress Notes. On 5/15/24 at 11:13 am, Staff A, Registered Nurse (RN) stated Resident #1 did pretty much whatever she wanted. He stated during the day, she sat in her recliner and her oxygen concentrator was within her reach. He stated she was definitely capable of adjusting the oxygen levels herself but he had never witnessed her doing so. On 5/15/24 at 11:21 am, Staff B, Certified Nurse Aide (CNA) stated the weekend prior to Resident #1 being sent to the hospital, the resident was asking staff to increase her oxygen. Staff B stated she responded she was not allowed to adjust the oxygen. She stated she had heard she was found with a higher level of oxygen on than was ordered and had heard the resident had adjusted it herself but was not sure she was strong enough to have done so. On 5/15/24 at 11:45 am, Staff C, CNA, stated it was normal for the resident to complain of being short of breath. She stated the resident was capable of turning the oxygen up herself but she had never witnessed her doing it. On 5/15/24 at 12:58 pm, Staff D, CNA (former employee) stated she recalled the resident stating she couldn't breathe and was out of air prior to her hospitalization. She stated she reported this to the nurse and the nurse assessed her. She stated this was near the end of her shift and she did not see the resident again. She reported she never witnessed the resident turning up the oxygen herself but the concentrator was next to her and she was able to reach it. On 5/15/24 at 1:06 pm, Staff E, CNA stated the resident seemed to have a cold prior to being sent to the hospital. She stated it was constant for the resident to complain of having a hard time breathing and that day was no different. She said the resident often requested her oxygen to be turned up but the CNA's told her no as they were not allowed to adjust oxygen. She reported the nurse assessed the resident. Staff D reported the resident at times would adjust the oxygen on her own but the nurse would turn it back down. She said she had never witnessed the resident adjusting it but knew her oxygen had been found adjusted too high and staff would turn it back down. On 5/15/24 at 1:11 pm, Staff F, CNA stated the resident had reported having a hard time breathing and she had notified the nurse. She stated the resident requested to have her oxygen increased a couple of times that weekend. She stated nothing was out of the ordinary for the resident that weekend except looking a little pale on the day she was sent to the hospital. She said she never witnessed the resident adjusting her oxygen herself but she would request staff to do it and she would be told no, then they would find it increased later. She stated when she found the oxygen settings increased, she would notify the nurse to adjust it. She reported the oxygen was within the reach of the resident. On 5/15/24 at 1:24 pm, Staff G, RN, and former Director of Nursing (DON) stated the resident had a history of adjusting her oxygen levels. She said Resident #1 would lean over from her recliner and adjust the concentrator. She said she had provided education for her not to adjust it and the resident would state ok. On 5/15/24 at 2:26 pm, a family member of the resident stated the resident had told her that she needed to go to the emergency room on the weekend prior to her hospitalization. The family member notified the facility and they told her they would assess her and keep an eye on her. She reported this behavior was normal for her and had been happening for years. She recalled the facility called her on the date the resident was sent to the hospital and said the resident's vital signs were stable but she didn't seem herself and they were sending her to the hospital. She stated when she arrived at the Emergency Room, she saw the resident wearing 4 liters of oxygen and asked the staff why. She was told when the emergency services picked her up from the facility, she was wearing 4 liters so that is the level they kept her on. The hospital staff adjusted the oxygen to 2 liters per the family member request. She reported the facility told her they thought the resident had adjusted the oxygen herself but she was unsure if the resident did or not. She said she had seen the oxygen concentrator out of the resident's reach on prior visits due to the resident adjusting it herself in the past. She described the resident as very feisty and stated if the oxygen had been within her reach, she would guarantee the resident would have turned it up. On 5/15/24 at 3:14 pm, the MDS Coordinator stated in the past, they had attempted to move the resident's oxygen concentrator out of her reach. She said the resident used the oxygen tubing to pull the machine (machine was on wheels) back to within her reach. She reflected the resident was often an attention seeker. She stated she had been a charge nurse until January of 2024, shortly before the resident was transferred to the hospital. She had just become the MDS Coordinator in January. She reported she does baseline care plans, and the corporate MDS Coordinators do the full care plans. She stated her routine at this time is to notify the corporate MDS nurse if something on a care plan needs updated. On 5/15/24 at 3:26 pm, Staff G, RN, former DON, stated the resident had a BIMS of 15, and they did talk to her about not adjusting the oxygen levels herself. She stated at one time, they had placed a sign on the concentrator reminding the resident not to adjust the oxygen levels. She stated she did not know if this should have been placed on the care plan or not as she did not consider it to be excessive behavior. She stated she was not aware of whose responsibility it was at that time to update the care plans. On 5/15/24 at 3:42 pm, Staff I, RN stated the resident would occasionally adjust the oxygen levels herself. She believed the resident's oxygen was at 3 liters the day she was sent to the hospital. On 5/15/24 at 3:50 pm, the Nurse Practitioner stated the resident was very non compliant. She stated she was aware of times the resident would turn her oxygen concentrator up and when staff noted it, they would turn it back down. She relayed she was not sure of how frequently this was an issue but she had a history of other non compliance. She listed examples of the resident being non compliant with weight bearing orders and working with therapy when she previously had a broken knee, as well as not following orders on a prior wound she had. She reported the resident would listen to education but would not follow directions. She stated during her visits with the resident, the oxygen concentrator was between the residents chair and her bed. If it was not within the resident's reach, she stated the resident had enough strength she would lean over her chair and pull it to within her reach. On 5/15/24 at 4:11 pm, Staff J, Corporate MDS nurse commented she completed the care plans based on the Care Area Assessments triggered on the MDS. She stated for any significant changes to the resident, she updated those on the care plan but the day to day updates were the responsibility of the facility. She stated as she completed the MDS, she reviewed progress notes but she did not see any progress notes regarding the resident being non compliant with her oxygen so she did not place this on the care plan. She stated she works remotely, not at the facility, so she would not be aware to place this on the care plan unless she was notified by the facility or it was documented in progress notes. On 5/15/24 at 4:14 pm via email, the Administrator stated an initial care plan is to be started at the facility with the remainder of the care plan being completed by a corporate MDS nurse. She stated updates to the care plan are done by the facility. The facility policy Care Plan Development, dated 8/2015, included the following documentation: An individualized, comprehensive care plan using the results of the RAI/MDS assessment, resident/family/ legal representative and interdisciplinary input will be developed for each resident in the facility within 21 days of admission or 7 days after the completion date of a comprehensive MDS assessment, and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan will include measurable objectives, interventions, goals, and timetables. The care plan will be reviewed and revised on an as needed basis and at least every 92 days. Point 3 - Comprehensive care plans are designed to: - Include identified resident needs and strengths - Include risk factors associated with needs - Build upon resident strengths and abilities - The care plan will be reviewed and revised as needed, when a significant change in condition is noted, when outcomes were not achieved or when outcomes are completed, and at least every 92 days. Point 4 - The care plan is integral to the provision of care to the resident and will be available to team members who are responsible for providing care and services. The completed care plans will be maintained in the resident's clinical record. All team members are responsible for reporting any changes to the resident's condition to the primary/charge nurse and of any goals or objectives not being met. Any changes must be reported to the MDS coordinator for review. Documentation must be consistent with the resident's plan of care and revisions will be done on an as needed basis and can be done by any member of the Interdisciplinary team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document review, staff interviews and policy review, the facility failed to implement the abuse and neglect policy by not completing background checks appropriately prior to staff employment. The facility reported a census of 27 residents. Findings include: Review of a document titled, Employee List Report generated on 3/18/24 documented a hire date for Staff D of 1/14/24, Staff E of 1/14/24, and Staff F of 1/14/24. Review of the document titled Single Contact License and Background Check dated 1/25/24 for Staff D, Dietary Manager, documented results of further research needed in the criminal history check and submission of form [PHONE NUMBER] on the dependent adult abuse check. No subsequent research completed by the facility. Review of document titled Single Contact License and Background Check dated 1/26/24 for Staff E, Dietary Aide, documented results of further research needed in the criminal history check. No subsequent research completed by the facility. Review of document titled Single Contact License and Background Check dated 2/13/24 for Staff F, Cook, documented results of further research needed in the criminal history check. No subsequent research completed by the facility. On 3/18/24 at 2:42 PM Staff C stated the facility's expectation is the background checks would be completed on all employees prior to hiring. Review of policy titled, Abuse Prevention Program and Reporting Policy reviewed 4/23 documented the facility will screen all potential employees prior to hire for a history of abuse, neglect, or mistreating residents/patients, exploitation, and/or misappropriation of residents property during the hiring process. The screening would consist of but not limited to criminal background checks. On 3/19/24 at 11:33 AM the Administrator stated the facility's expectation is background checks would be completed prior to hiring or the first day of employment on all employees at the facility. The Administrator stated the three background checks were not completed appropriately for Staff C, Staff D and Staff E.

Based on clinical record review, family interview and staff interview, the facility failed to treat each resident with dignity and respect for 1 of 3 residents reviewed (Resident #3) by not providing appropriate clothing when the resident was in a public area of the facility. The facility reported a census of 28 residents. Findings include: The Minimum Data Set (MDS) of Resident #3, dated 8/31/2023, indicated he had severe cognitive impairment for daily decision making. The MDS revealed the resident required extensive physical assistance of 2 people for bed mobility, transfer, walking, dressing and toileting. The MDS documented diagnoses that included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The MDS reflected no diagnoses of anxiety, depression, or any other psychiatric/mood disorders. The Care Plan of Resident #3 revealed a Focus Area of use of psychotropic medication related to vascular dementia, dated 8/28/2023. The Care Plan documented a goal of the resident remaining free of drug related complications including cognitive/behavioral impairment. The Focus Area of behavior problem, dated 8/31/2023 directed staff to intervene as necessary to protect the rights and safety of others, divert attention, and to remove from situation and take to alternate location as needed. On 1/29/2024 at 1:43 pm a family member of Resident #3 stated during an interview that Resident #3's bed was kept only a few inches off the floor for his safety from falls. She stated irregardless of this, he was often brought to the common area and put in a recliner rather than him resting in his bed. She stated that on three separate occasions, various family members witnessed him sitting in a recliner near the nurses station without an adequate amount of clothing on. One photograph was provided of the resident wearing one sock and an incontinence brief and no other clothing while in a recliner in the common area of the facility. On the left side of the photo the pant leg and shoe of a person standing nearby could be seen. On 1/31/2024 at 9:02 am, Staff A, Certified Nurse Aide (CNA) stated during the time Resident #3 was in the facility, he was anxious and unsteady. She stated he wiggled out of his chair frequently and fidget toys were provided to help keep him busy. She stated he was in the common area frequently. She stated he most often wore sweatshirts and sweatpants. She stated she never witnessed him being unclothed in the common area but if she ever witnessed anything like that, she would immediately intervene. On 1/31/2024 at 11:05 am the Director of Nursing (DON) stated Resident #3 was a short term resident who had been in the facility for skilled care. She stated he would get restless and anxious. She stated she was not aware of any issues that had happened during his time in the facility regarding dignity. She said he had a lot of heavy sweatshirts and sometimes tried to remove them so she had requested the family also provide some lighter weight clothes. The State Surveyor provided to the DON the photograph of Resident #3 in the recliner in the common area of the facility wearing only an incontinent brief and one sock. The DON agreed the photo displayed was of the common area by the nurses station of the facility. She stated she was not aware of that episode. However, she did recall an overnight shift where the resident was very anxious and Staff B, Registered Nurse (RN) was on duty. She stated Staff B had called the family during the night to come and sit with the resident due to his anxiety. She stated she had also been called in during the shift because the family was upset when they arrived. She stated she could tell from the photograph that the person who could be seen on the left side of the photo was Staff B. She stated she recognized the shoes as belonging to Staff B and guessed the photo was taken that night she had been called in. She further said that the family had never mentioned to her the resident had been clothed when they arrived. On 1/31/2024 at 3:35 pm, Staff B, RN stated she had no memory of Resident #3 having an episode at the nurses station of not having clothing on. She stated he was in the common area frequently. She stated if she witnessed an episode like this she would cover the resident up and provide clothing for the resident. The facility provided document titled Resident/Family Care & Services, dated 2/2015 which stated: • The facility strives to assure that each resident/patient has a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the center.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to follow physician orders for 2 of 3 residents reviewed (Resident #3, #5). The facility reported a census of 28 residents. Findings include: 1. The Minimum Data Set (MDS) of Resident #3, dated 8/31/2023, indicated Resident #3 had severe cognitive impairment for daily decision making. The MDS documented diagnoses that included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The MDS reflected no diagnoses of anxiety, depression, or any other psychiatric/mood disorders. The Care Plan of Resident #3 revealed a focus area of use of psychotropic medication related to vascular dementia, dated 8/28/2023. The Care Plan documented a goal of the resident remaining free of drug related complications including cognitive/behavioral impairment. The focus area of behavior problem, dated 8/31/2023 directed staff to intervene as necessary to protect the rights and safety of others, divert attention, and remove from the situation and take to an alternate location as needed. The Health Status note dated 9/5/2023 at 3:36 pm documented a meeting with nursing, the Advanced Registered Nurse Practitioner (ARNP), the therapy team, the administrator, and the family of Resident #3. The note stated the ARNP had written orders to discontinue two medications and to decrease a third medication, Seroquel (an antipsychotic medication) for 4 days and then discontinue. The Progress Note for the encounter date of 9/5/2023 authored by the ARNP documented the family of Resident #3 had concerns with the medications he was on due to a recent mental status change and decrease in physical ability. The medication portion of the note documented an order to take 1 tablet of Seroquel, 50 mg, daily for 4 days and then discontinue. The Progress Note for the encounter date of 9/13/2023 authored by the ARNP documented that on the last visit, the Seroquel was changed to daily and on the 5th day it was supposed to be discontinued. The note stated the ARNP would clarify with the facility what the stop date was on the Seroquel. The Medication Administration Record (MAR) of Resident #3 for September of 2023 documented the Seroquel order was changed from two times a day to once a day on 9/5/2023. The dose was continued as once daily through 9/13/2023 and discontinued on 9/14/2023. 2. The MDS dated [DATE] of Resident #5 reflected an admission date to the facility of 10/31/2023. The MDS revealed the resident to be dependent for bed mobility of rolling left and right. The MDS documented a height of 60 inches and a weight of 95 pounds. The MDS documented the resident to be at risk of development of pressure ulcers, but no unhealed pressure ulcers present on admission. The MDS documented the resident had no venous or arterial ulcers and no other ulcers, wounds or skin problems present. The Care Plan of Resident #5 revealed a focus area of potential for pressure ulcer development, dated 11/13/2023. It directed staff to administer medications as ordered, administer treatments are ordered, document and report changes in skin status, and clean and dry the resident's skin promptly after incontinence episodes. The Orders section of the Electronic Health Record (EHR) of Resident #5 reflected an order dated 11/13/2023 to complete weekly skin assessments. A review of the clinical record of Resident #5, performed on 1/31/2023 at 11:52 am reflected a weekly skin assessment had been performed on 11/13/2023, 11/20/23, 12/4/2023 and 12/8/2023. A skin assessment dated [DATE] was in the process of being done at that time. In the 12 week time span of the order being active, the order was followed 4 times. On 1/31/2024 at 10:05 am, the Director of Nursing (DON) stated wound assessments are to be done weekly in the Assessment portion of the EHR. On 2/1/2024 at 8:27 am, the DON stated her expectation when a nurse receives a new order is for the nurse to write a progress note documenting the order, and to complete the order in the EHR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview and policy review, the facility failed to keep complete and accurate resident records for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 28 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] of Resident #5 reflected an admission date to the facility of 10/31/2023. The MDS revealed the resident to be dependent for bed mobility of rolling left and right. The MDS documented a height of 60 inches and a weight of 95 pounds. The MDS documented the resident to be at risk of development of pressure ulcers, but no unhealed pressure ulcers present on admission. The MDS documented the resident had no venous or arterial ulcers and no other ulcers, wounds or skin problems present. The Care Plan of Resident #5 revealed a focus area of potential for pressure ulcer development, dated 11/13/2023. It directed staff to administer medications as ordered, administer treatments are ordered, document and report changes in skin status, and clean and dry the resident's skin promptly after incontinence episodes. The care plan failed to reflect a need for repositioning, specialty mattress, limb elevation or other pressure ulcer preventative measures. The Care Plan failed to document a focus area for activities of daily living to include how the resident turned in bed, transferred, ate, or any other daily activities. The Treatment Administration Record (TAR) of Resident #5 for January 2024 documented the following: A catheter change completed by Staff B, Registered Nurse on 1/26/2024. Daily wound treatment completed on a wound on the resident's right calf. Weekly skin assessments documented by Staff B, RN on 1/8/2024 and 1/22/2024. During an observation of wound care on 1/31/24 beginning at 9:55 am, it was noted that Resident #5 received wound care to her coccyx, her left calf and her left heel. No catheter present for Resident #5 during the observation. Staff B, Registered Nurse (RN) stated she would have to look up the exact date but she believed Resident #5's catheter had been discontinued 1-2 months prior. The Director of Nursing (DON) stated on 1/31/2024 at 10:05 am that she would need to look at the resident's record as to why the TAR stated the resident's wound was on her right calf. The Assessments section of the EHR, printed on 1/31/24 at 10:40 am, revealed skin assessments completed for resident #5 on 11/13/2023, 11/20/2023/ 12/4/2023 and 12/8/2023. No skin assessments completed after 12/8/2023 although they were documented on the TAR as being complete. Additionally in the Assessments section of the EHR, Pressure Injury Assessments documented as being complete on 11/27/2023, 12/11/2023, 12/27/2023 and 1/8/2024. On 1/31/2024 at 10:31 am, Staff B was looking at a notebook at the nursing station and stated she had completed a wound assessment on Resident #5 on 1/22/2024 on paper and had not entered it into the computer. She stated she had the wound measurements and would find out if she could do a late entry. The State Surveyor asked to see the paper assessment and Staff B stated it was in a book with a bunch of other papers and she walked down the hallway. The notebook which Staff B had looked at reviewed and found to be a binder of 24 hour report sheets. The notebook lacked any skin assessments. On 1/31/2024 at 10:36 am Staff B returned to the nurses station. She gathered the 24 hour report notebook and sat at the desk and began to place entries into the computer. At 10:46 am, Staff B reported she had been able to make a late entry into the EHR of Resident #5 and the Pressure Injury Assessment was now complete. The State Surveyor asked again to see the paper in the notebook which contained the skin assessment. Staff B held the notebook up and started looking through the book. She was unable to locate any skin assessment. She noted the fan was turned on at the nurses station and said the fan must have blown the paper out of the notebook. She looked around on the floor and the countertops and was unable to locate any assessment. She stated she was sorry but she could not produce the assessment. On 1/31/2024 at 11:14 am, the Director of Nursing stated her expectation is that skin assessments are to be done once a week and documented in the EHR. She verified Resident #5 had not had a catheter for at least a month. She stated Staff B may have documented the catheter change on the incorrect resident. She also stated some nurses keep their own notes on residents and that may be where Staff B had documented wound measurements. The document provided by the facility titled Documentation, dated 08/2015, directed: Facility nursing staff maintains daily, weekly, monthly and quarterly documentation to demonstrate nursing care provided to the resident/patient and assists the interdisciplinary team in evaluating the resident/patient clinical condition. Daily and weekly documentation is also done to assist in accurate completion of the MDS and to meet regulatory requirements. Monthly documentation summarizes the resident/patient clinical status and Quarterly documentation re-evaluates the resident/patient status for any changes required in the comprehensive care plan.