**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, payroll record review, facility policy review, resident and staff interviews the facility failed to prevent neglect which resulted in a fall, and verbal abuse which caused a resident to feel bad about them self for 1 of 7 (Resident #1) residents reviewed for abuse. The facility reported a census of 66 residents.Findings include:Review of the Minimum Data Set (MDS) assessment tool dated 4/2/25 revealed a list of diagnoses for Resident #1 which included hypertension (high blood pressure), depression, generalized weakness and difficulty walking. The Brief Interview for Mental Status (BIMS) score of 14 out of 15 points, indicated intact cognition. The assessment indicated Resident #1 always able to make herself understood, understood others and had no symptoms of delirium. The assessment revealed the resident required maximal staff assistance to reposition in bed, transfer to and from bed or chair, toileting, toileting hygiene, dressing the lower body and the resident unable to ambulate.Review of the Care Plan, initiated date of 4/3/25, revealed a Focus area to address The resident is at risk for falls. Interventions included:a. Keep call light within reach and encourage the resident to use it, if not cognitively impaired, for assistance as needed. Date initiated 4/3/25.b. Anticipate and meet the resident's needs. Date initiated 4/3/25. A Focus area, initiated date of 4/3/25 addressed Resident is at risk or has actual IMPAIRED ABILITY TO TRANSFER INDEPENDENTLY. The Intervention directed:a. TRANSFER: The resident is DEPENDENT for transfers and requires a Sara lift (a brand name for mechanical stand lift) with 2 helpers for transfers. Date, initiated 4/3/25. Review of the facility self-reported incident revealed on 6/6/25, the Administrator [former] was notified by the resident [name redacted, Resident #1] that employee [name redacted, Staff A, Certified Nursing Assistant (CNA)] is always angry with her, yells at her and says you're not doing things for yourself and makes her feel bad. Says it happened a couple of days ago on Wed evening [June 4, 2025].Employee [name redacted, Staff A, CNA] was immediately suspended pending the results of the investigation.Review of the facility investigation documentation revealed a hand-written note transcribed by the administrator [former] during the investigation. The statements on the note, written out in bullet like format, included: , in part:6/6/25[Name redacted, Resident #1]a. Consistent problem with ladyb. Always anger with mec. Yells at herd. Under impression that she can do [NAME]. Says your not doing things for yourself'f. Made her stand and walk to toilet *fell - then got mad that she fell. Day before yest. (yesterday) Wed. 6/4.g. Doesn't want her as a caregiver anymoreh. Makes me feel bad i. Directing anger at mej. Throw clothes at mek. Says I'm not going to wheel you downl. Used lift by self. Hit back of head on fallm. Everyone else has been wonderfuln. Feels it was a verbal and physical. Review of facility payroll records revealed Staff A worked on the 2 p.m. to 10 p.m. evening shift on 6/2/25, 6/3/25 and 6/5/25. Review of electronic resident care records, revealed an electronic signature by the CNA staff assigned to Resident #1 on 6/2/25 and 6/3/25. Staff A, CNA electronic signature present on the care records for 6/2/25 and 6/3/25.During an interview on 6/26/25 at 10:20 a.m., Resident #1 stated Staff A would berate her, say you have to get up to go to the bathroom. I can't lift you. Staff A had taken care of her on several days, thought Staff A was under the impression that she could walk, and was angry when she spoke to her, she threw her clothes at her. Resident #1 stated she reported her concerns to the Administrator and had not seen Staff A since then. During an interview on 7/9/26 at 7:54 a.m., Resident #1 stated she was transferred by 1 or 2 staff, sometimes they use a gait belt but they usually did not, they used to transfer her with a stand lift machine, but they had not used that for about a month. When asked if she had fallen when Staff A had taken care of her, the resident stated yes, Staff A transferred her by herself, out of bed and into the wheelchair, she never used a gait belt. Staff A told her she could walk and needed to walk to the toilet, and pushed her in the wheelchair up to the bathroom doorway. The wheelchair wouldn't fit through the door, Staff A told her she needed to walk to the toilet and threw the walker in front of her. The resident stated she hit her head when she stood up and fell to the floor. Staff A was angry with her because she fell, picked her up off the floor by herself, she put the belt under her and pulled her up with the Stand Lift machine. She did not get the nurse and the nurse did not assess her for injuries after the fall. This happened on the last evening that Staff A took care of her and the resident reported the fall to the Administrator when she talked to him about it.During an interview on 6/25/25 at 10:36 a.m., the interim Administrator stated staff are expected to treat residents with dignity and respect, and to report any concerns about resident mistreatment immediately to the Administrator or manager in charge.During an interview on 7/2/25 at 3:03 p.m. the former Administrator stated when he spoke to Resident #1, she reported Staff A was rude to her, made her feel bad about herself when she told the resident she could do things and just didn't want to do them. The Administrator stated he had not received other complaints about Staff A from the residents.During an interview on 7/2/25 at 1:03 p.m. the Director of Nursing (DON), stated she was not aware of any specific complaints from the residents about Staff A's care, but it has come up a few times that she's very loud. During an interview on 7/10/25 at 1:27 p.m. Staff B, Physical Therapist, stated in the therapy room there were days when Resident #1 could take 5 to 10 steps with maximal support by therapy staff, but more often than not she couldn't lift her feet from the floor or ambulate with maximal therapy staff support. She stated in therapy, they had worked on 1 to 1 and 2 to 1 stand pivot transfers with her, always with a gait belt. Staff B explained if therapy got her [Resident #1] up from her bed they may have been assisted by a nursing employee with the transfer under therapy staff direction, but the resident had been care planned as a Stand Lift transfer since she was admitted to the facility. Staff B stated that never changed, therapy never approved her [Resident #1] transfer method to be decreased to a 1 to 1 or 2 to 1 transfer with gait belt, because she was not safe for nursing staff to transfer her that way, they needed to use the Stand Lift. During an interview on 7/2/25 at 3:41 p.m. Staff A, CNA, stated the resident was supposed to be a 1:1 transfer, but she wouldn't try so she was a 2:1 transfer with a lot of support by staff. On the last evening that she worked with the resident therapy said she had to get up for therapy so she got her up by herself. She positioned the wheelchair right next to the bed, the resident was seated on the side of the bed, Staff A did not use a gait belt and as the resident put her feet on the floor she wouldn't pick her feet up to turn, so Staff A had to use all her strength to pull and turn the resident towards the wheelchair, she had a hold of the waistband of her pants because she didn't have a gait belt. She was able to get her into the wheelchair without incident. During a second interview on 7/16/25 at 10:30 a.m. Staff A, CNA, stated the resident used to be a 2:1 transfer with walker. The last day she worked with the resident, physical therapy staff told her she was a 1:1 transfer with walker. They had been transferring her with a Stand Lift to put her to bed to change her, but otherwise they never used the Stand Lift, they transferred her 2 to 1. Staff A denied that she knew anything about the resident's fall in the bathroom. Staff A stated the resident wore briefs, and had never known her to use the bathroom, the resident put her call light on when she wanted to be changed.During an interview on 7/8/25 at 3:28 p.m., the DON stated she was not aware the resident had a fall at the facility and would look for documentation related to the fall. The DON stated if a resident fell, the staff should notify the nurse, not move the resident until the resident is assessed for injuries, and document all issues related to the fall.During an interview on 7/9/25 at 3:06 p.m. Staff C, facility corporate nurse, stated the CNA nursing staff were expected to follow the plan of care for resident transfers.Review of the facility policy titled Abuse, Neglect and Exploitation policy, last reviewed on 3/25/25, directed staff:a. It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.b. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being.c. The facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents.d. Establish policies and procedures to investigate any such allegations, ande. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and resident abuse prevention.f. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.

Based on record review and staff interviews, the facility failed to ensure resident freedom from potential abuse by permitting an alleged preparator to return to work prior to the initiation and completion of an investigation by the State Agency for 1 of 2 allegation of resident abuse reviewed. The facility reported a census of 66 residents. Findings include:Review of the Minimum Data Set (MDS) assessment tool dated 5/9/25 revealed a list of diagnoses for Resident #2 which included schizophrenia, non-Alzheimer's dementia, and anxiety. The Brief Interview for Mental Status (BIMS) score of 8 out of 15 points indicated a severe cognitive impairment. The MDS revealed Resident #2 presented with history of delirium, which included disorganized thoughts and unable to focus attention. The MDS assessed Resident #2 required substantial staff assistance to transfer on and off the toilet and toilet hygiene. Review of a facility self-reported incident revealed, in part,.On 6/13/25, HR Manager [name redacted] reported to the administrator that Resident [name redacted, Resident #2] told her that the night shift C.N.A (Certified Nursing Assistant) [Name redacted, Staff D, CNA] did not help her get dressed or use the bathroom on the night shift last night. Resident [name redacted, Resident #2] describes the C.N.A who fits the description of employee [name redacted, C.N.A, Staff D, CNA]. Immediate Actions: - Family and physician were notified. - Night shift C.N.A [name redacted, Staff D, CNA] was immediately suspended.Review of a document titled Initial Federal Report revealed an Incident Information section, which in part documented A. Allegation, Abuse. B. Date and Time: 6/13/25. C. Name of Resident(s): [name redacted Resident #2]. D. Name(s) of Alleged Perpetrator(s): [name redacted, Staff D, CNA].Final Report Findings section, Investigation Summary:.After record review, staff interview and resident interview, the facility found the following: The employee [name redacted, Staff D, CNA] was suspended due to alleged abuse/neglect to resident [name redacted, Resident #2]. On the same day, 6/13/25 it was found that employee [name redacted, Staff D, CNA] was indeed NOT the individual who resident [name reacted, Resident #2] who accused of alleged abuse neglect.Upon discovery of this, C.N.A [name redacted, Staff D, CNA] was reinstated/brought back to work and resumed her shifts as normal.Review of the document titled Documentation Survey Report v2 for June 2025 and July 2025 revealed Staff D, CNA initiated having provided various care tasks to Resident #2 during third shift (10 p.m. to 6 a.m.) on 6/13/25, 6/16/25, 6/21/25, 6/26/25, 6/27/25, 7/8/25 and 7/10/25.The State Agency entered the facility on 6/25/25 to initiate the investigation regarding the allegation of abuse regarding Staff D, CNA made by Resident #2 on 6/13/25. During an interview on 7/1/25 at 10:59 a.m., Staff C, Corporate Nurse, stated they brought Staff D back to work because the resident's description of the perpetrator had changed, the resident knew Staff D and liked her.During an interview on 7/2/25 at 3:03 p.m., the former facility Administrator stated when he spoke to the resident she provided a physical description that matched Staff D, who had worked the night before. Later in the day the resident changed her description of the staff member, said she knew who Staff D was, liked her and she took good care of her. They didn't think they could go by the resident's description of the responsible staff member because she had changed it 3 times and they returned Staff D to work status that same day. Review of the facility policy titled Abuse, Neglect and Exploitation policy, last reviewed on 3/25/25, revealed a Policy statement which declared It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.VI. Protection of Resident section directed: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:A. Responding immediately to protect the alleged victim and integrity of the investigation;B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents;D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed;G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

Based on observations, clinical record review, facility policy review, resident and staff interviews, the the facility failed to ensure staff followed transfer precautions identified on the resident's care plan that resulted in a fall (Resident #1) for 1 of 3 residents reviewed for transfer techniques, and failed to ensure that nursing staff utilized gait belts during resident transfers as required. The facility reported a census of 66 residents. Findings include:Review of the Minimum Data Set (MDS) assessment tool dated 4/2/25 revealed a list of diagnoses for Resident #1 which included hypertension (high blood pressure), depression, generalized weakness and difficulty walking. The Brief Interview for Mental Status (BIMS) score of 14 out of 15 points, indicated intact cognition. The assessment indicated Resident #1 always able to make herself understood, understood others and had no symptoms of delirium. The assessment revealed the resident required maximal staff assistance to reposition in bed, transfer to and from bed or chair, toileting, toileting hygiene, dressing the lower body and the resident unable to ambulate.Review of the Care Plan, initiated date of 4/3/25, revealed a Focus area to address The resident is at risk for falls. Interventions included:a. Keep call light within reach and encourage the resident to use it, if not cognitively impaired, for assistance as needed. Date initiated 4/3/25.b. Anticipate and meet the resident's needs. Date initiated 4/3/25.A Focus area, initiated date of 4/3/25 addressed Resident is at risk or has actual IMPAIRED ABILITY TO TRANSFER INDEPENDENTLY. The Intervention directed:a. TRANSFER: The resident is DEPENDENT for transfers and requires a Sara lift (a brand name for mechanical stand lift) with 2 helpers for transfers. Date, initiated 4/3/25.During an interview on 7/9/26 at 7:54 a.m., Resident #1 stated she was transferred by 1 or 2 staff, sometimes they used a gait belt but they usually did not, they used to transfer her with a stand lift machine, but they had not used that for about a month. The resident described on 6/3/25 Staff A, CNA transferred her by herself, out of bed and into the wheelchair, she never used a gait belt. Staff A told her she could walk and needed to walk to the toilet, and pushed her in the wheelchair up to the bathroom doorway. The wheelchair wouldn't fit through the door, Staff A told her she needed to walk to the toilet and threw the walker in front of her. The resident stated she hit her head when she stood up and fell to the floor. Staff A picked her up off the floor by herself, she put the belt for the Stand Lift under her and pulled her up with the Stand Lift machine. She did not get the nurse and the nurse did not assess her for injuries after the fall. Review of the investigation for a facility reported incident revealed a hand-written note transcribed by the former administrator. The note documented Resident #1 reporting Staff A, Certified Nursing Assistant (CNA) was under the impression the resident could do more, said you are not doing things for yourself. Resident #1 reported Staff A made her stand and walk to toilet, *fell - then got mad that she fell.the resident reported Staff A used the lift by self. Hit back of head on fall.Review of Resident #2's electronic health record did not reveal the alleged fall, and the facility could not provide documentation related to the alleged fall. he resident's electronic health record did not reveal, and the facility could not provide documentation related to the resident's alleged fall. During an interview on 7/2/25 at 3:41 p.m. Staff A, CNA, stated the resident was supposed to be a 1:1 transfer, but she wouldn't try so she was a 2:1 transfer with a lot of support by staff. Staff A explained on the last evening that she worked with the resident she got her up by herself. She positioned the wheelchair right next to the bed, the resident was seated on the side of the bed. Staff A stated she did use a gait belt and as the resident put her feet on the floor she wouldn't pick her feet up to turn. Staff A stated she had to use all her strength to pull and turn the resident towards the wheelchair, she had a hold of the waistband of her pants because she didn't have a gait belt. She was able to get her into the wheelchair without incident. During an interview on 7/8/25 at 3:28 p.m., the DON stated she was not aware the resident had a fall at the facility and would look for documentation related to the fall; if a resident fell, the staff should notify the nurse, not move the resident until the resident was assessed for injuries, and document all issues related to the fall.During an interview on 7/10/25 at 1:27 p.m., Staff B, Physical Therapist, stated there were days when Resident #1 could take 5 to 10 steps with maximal support by therapy staff in the therapy room, but more often than not she couldn't lift her feet from the floor or ambulate with maximal therapy staff support. The resident had always been care planned as a Stand Lift transfer for nursing staff because she was not safe to transfer by a manual 1 to 1 or 2 to 1 staff pivot method. During a 2nd interview on 7/16/25 at 10:30 a.m., Staff A, CNA, stated the resident [Resident #2] used to be a 2:1 transfer with walker. The last day she worked with the resident, physical therapy staff told her she was a 1:1 transfer with walker. They had been transferring her with a Stand Lift to put her to bed to change her, but otherwise they never used the Stand Lift, they transferred her 2 to 1. Staff A denied that she knew anything about the resident's fall in the bathroom. Review of resident transfer requirements revealed 7 residents transferred 1:1 staff assistance with the use of a gait belt, and 8 residents transferred with 2:1 staff assistance with the use of a gait belt. Observations completed on 7/9/25 revealed:a. Between 8:00 a.m. and 2:00 p.m., 7 CNA working the 6 a.m. to 2 p.m. shift did not have a gait belt readily available. b. At 12:27 p.m., Staff H, Certified Nursing Assistant (CNA) and Staff N, CNA used a stand lift and transferred Resident #2 to a wheelchair from her bed without incident. c. At 1:35 p.m., a gait belt observed to be positioned on the grab bar by the toilet in the Left/Right shower room.d. Between 2:00 p.m. and 2:26 p.m., 4 of the 4 CNA's on duty for the 2 p.m. to 10 p.m. shift did not have a gait belt on their person. The 4th CNA retrieved a gait belt from a handbag stored in a closed cupboard at the Nurse's Station, and a 5th CNA scheduled for the evening shift had not arrived as of 2:40 p.m. e. The Director of Nursing and Corporate Nurse present in the facility between 8:00 a.m. and 4.pm.Follow up interviews on 7/9/25 regarding the observations completed on the same day revealed:a. At 1:01 p.m., Staff H, CNA, stated residents have gait belts in their rooms, and if not she could go to the therapy room and get one, they would let her keep it if needed.b. At 1:04 p.m., Staff I, CNA, working as a bath aide for A and B halls, did not have a gait belt on her body. When asked if she had 1 she stated she had one in the shower room.c. At 1:05 p.m., Staff J, CNA, working as a bath aide for L and R halls, did not have a gait belt on her body. When asked if she had 1 she stated she kept hers in her car.d. At 1:09 p.m., Staff K, CNA, stated she usually kept her gait belt in the shower room, and sometimes they swap them out.e. At 1:13 p.m., Staff L CNA, stated her gait belt was out in the car. She was assigned to the L hall that day and stated she hadn't needed it that day, all the residents were mechanical lift transfers (at that time there were 3 residents on the Left hall that required 1 to 1 transfer with gait belt, and 2 residents that required 2 to 1 transfer with gait belt).f. At 1:46 p.m., Staff M, CNA, stated there was usually a gait belt in the shower room, and some residents have them in their rooms.g. At 1:47 p.m., Staff N, CNA, stated she could get a gait belt in the therapy room if needed.h. At 2:04 p.m., Staff O, CNA, stated she didn't have a gait belt but there should be some in the therapy room if you needed one.i. At 2:07 p.m., Staff P, CNA, did not have a gait belt on her body. When asked if she had 1 she went to a cupboard behind the A/B hall Nurses Station and retrieved a blue belt from a purse/handbag in the cupboard.j. At 2:26 p.m., Staff Q, CNA, stated there was a gait belt in the shower room, and sometimes residents had them in their room.k. At 3:06 p.m., Staff C, corporate nurse stated CNA nursing staff were expected to have gait belts/use gait belts with resident transfers that required them, to follow the plan of care for resident transfers.During observations on 7/10/25 from 8:46 a.m. to 10:03 a.m., the 7 CNA's scheduled for the day shift wore blue gait belts on their body and available for resident care.During an interview on 7/10/25 at 10:13 a.m., the DON, stated all CNA staff had been provided with gait belts and all had been instructed they were to have them on their person/readily available and use them as directed by resident care, they should always follow the plan of care unless there is a contraindication and if so they should review that with the nurse.The facility's Safe Resident Handling/Transfers policy, last revised 10/4/23 directed staff, in part:a. It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines.b. Residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them.c. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies.d. Handling aids may include gait belts, transfer boards, and other devices.e. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment.f. Resident lifting and transferring will be performed according to the resident's individual plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, Food and Drug Administration Drug Labeling resource, resident responsible party and staff interviews, the facility failed to ensure prescribed psychotropic's where adequately clinically indicated and necessary to treat a specific condition for 4 of 4 residents (Resident #1, Resident #4, Resident #5, and Resident #6). The facility failed to coordinate services between the psychiatric provider and primary care provider to prevent the potential of administering unnecessary medications for 1 of 4 residents (Resident #1) in the sample. The facility reported a census of 64 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 4/20/25 revealed a list of diagnoses for Resident #1 which included cerebrovascular accident (a stroke), anxiety, and depression. A Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicated moderately impaired cognition. The Behavior section indicated no hallucinations, delusions, or physical or verbal behavioral symptoms towards others in the last 7 days. The MDS documented Resident #1 utilized a feeding tube since 8/5/24. The MDS indicated Resident #1 admitted to the facility on [DATE]. Review of the electronic health record (EHR) Medical Diagnosis list dated 6/2/25, indicated the following diagnoses related to mental health: a. Anxiety disorder, unspecified. Date: 11/27/24. Classification: Acquired during stay. b. Depression, unspecified. Date: 7/5/24. Classification: admission [prior]. Review of the Care Plan, Date Initiated: 10/13/24 revealed a Focus area to address The resident uses ANTI-ANXIETY medication r/t anxiety. Interventions included, in part: a. Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Date Initiated: 10/13/24. Review of the electronic health record (EHR) revealed a Telemed Psych Note encounter entered on 10/14/24 at 3:05 PM by [name redacted, Staff D, Psychiatric Advanced Nurse Practitioner]. The note indicated: a. Chief Complaint: Psychiatric evaluation and psychotropic medication management. b. History of Present Illness: [Name redacted] .seen for psychiatric evaluation and medication management. She has a psychiatric history of depression. Staff reports she was admitted at the hospital but returned to the facility confused. It is difficult to have a conversation with her sometimes, during today's assessment she kept saying No', she is seen in bed she said she is angry and wants to go home .she doesn't sleep at night, occasional agitation needed. c. Psychiatric OBSERVATION: MOOD: IRRITABLE .HALLUCINATION: NONE SUICIDALITY: NONE DELUSION: NONE BEHAVIOR: AGITATED . d. Psych/GDR (gradual dose reduction) Visit NP/PA/MD (nurse practitioner/physician assistant/medical doctor) 1. Major depressive disorder, single episode, moderate, Generalized anxiety disorder. Current Medication: Increase Trazodone (antidepressant) to 50 mg (milligrams) daily via tube feed; Start Hydroxyzine HCL (antihistamine used for antianxiety effect) 25 mg daily via tube feed; Alprazolam (antianxiety) 0.5 mg every 12 hr (hour) as needed for anxiety; Paroxetine (antidepressant) 20 mg by mouth daily for depression; Hydroxyzine HCL 25 mg every 6 hours as needed for anxiety. 2. Continue supportive non-pharmacological interventions: Assess for pain during periods of agitation; Reorient as needed; Gentle redirection as needed; Maintain daily routine as much as possible; Communicate simply about aspects of care/ activities/changes; Keep familiar or favorite objects/pictures around; Behavior monitoring and documentation; Notify writer if there are any concerns related to changes in mood or behavior. Review of the EHR revealed the following Physician Orders from the primary care provider: a. Seroquel (antipsychotic) Oral Tablet 25 mg .Give 25 mg orally three times a day for anxiety/behaviors related to UNSPECIFIED SEQUELAE OF CEREBRAL INFARCTION; ANXIETY DISORDER, UNSPECIFIED. Start Date: 12/21/24. b. Haloperidol Lactate (antipsychotic) Injection Solution 5 MG/ML (milligrams/milliliter) 5 mg IM (intramuscular injection) Q8 hours PRN (every 8 hours as needed) - AGITATION/ANXIETY/RESTLESSNESS. Start Date: 12/30/24 with D/C (discontinue) 2/17/25. Start Date: 2/26/25 with D/C: 4/7/25. Start Date: 4/8/25 with D/C: 4/9/25. Start Date: 4/16/25 with D/C: 4/17/25. Start Date: 4/17/25 with D/C: 5/1/25. c. Bupropion (antidepressant, brand name Wellbutrin) Extended Release (ER) (antidepressant) 150 mg administered oral daily. Start Date: 2/27/25 with D/C 4/17/25. Review of the Care Plan, Date Initiated: 12/22/24 revealed Focus area to address The resident uses PSYCHOTROPIC medications r/t (related to) anxiety. Interventions included, in part: a. Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effective and effectiveness Q-SHIFT (every shift). Date Initiated: 12/22/24. b. Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc and document per facility protocol. Date Initiated: 12/22/24. Review of the Telemed Psych Note encounter notes entered on 1/27/25, 3/24/25, and 3/31/25 entered by Staff D, Psychiatric Advanced Practice Nurse revealed: a. Chief Complaints for each encounter: Follow up b. History of Present Illness: [per encounter] 1. Today, 1/27/25, she is seen for follow up visit. She is in bed. States she is doing ok. States she gets a bit depressed because she is in here. Reports her dad died and she fell 2 days ago. Mood and appetite are stable. Will continue to monitor. 2. Today, 3/24/2025, she is seen for follow up visit. She is seen in her bed. States it is not a good day for her because she has gas and it is bothering her. Staff is aware. Mood and appetite are stable. will continue to monitor. 3. Today, 3/31/25, she is seen for follow up visit. She is in bed. States she is doing ok. States she gets a bit depressed because she is in here. Reports her dad died and she fell 2 days ago. Mood and appetite are stable. Will continue to monitor. c. Psychiatric OBSERVATION for each encounter, in part: MOOD: IRRITABLE; HALLUCINATION: NONE; SUICIDALITY: NONE; DELUSION: NONE; and BEHAVIOR: AGITATED. d. Psych/GDR (gradual dose reduction) Visit NP/PA/MD (nurse practitioner/physician assistant/medical doctor) for each encounter: 1. Major depressive disorder, single episode, moderate, Generalized anxiety disorder Current medication. Trazodone to 50mg daily via tube feed. Hydroxyzine HCL 25mg daily via tube feed. Alprazolam 0.5mg every 12c hours as needed for anxiety. Paroxetine 20mg by mouth daily for depression. Hydroxyzine HCL 25mg every 6 hours as needed for anxiety. The note for the encounter on 3/31/25 included Discontinue Wellbutrin 150 mg by mouth daily. 2. Continue supportive non-pharmacological interventions: Assess for pain during periods of agitation; Reorient as needed; Gentle redirection as needed; Maintain daily routine as much as possible; Communicate simply about aspects of care/ activities/changes;Keep familiar or favorite objects/pictures around; Behavior monitoring and documentation. Notify writer if there are any concerns related to changes in mood or behavior. e. Additional Notes for each encounter included, in part: Patient was seen for a telemedicine visit. Patient seen and in stable condition. Education provided to nursing. Nursing concerns addressed. Anxiety addressed. GDR addressed. Review of the Telemed Psych Notes encounter entries on 1/27/25, 3/24/25 and 3/31/25 lacked documentation of the primary care physician orders for Seroquel and Haloperidol 5 mg IM Q8 hours PRN Review of the Drugs@FDA (Food and Drug Administration) - Approved Drugs site (https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm revealed the following indicated uses: a. Seroquel 25 mg: Labeling-Packet insert 1/22/25: Indications and Usage: Schizophrenia, Bipolar I disorder manic episodes, and Bipolar disorder, depressive episodes b. Haloperidol IM 5 mg/ml: Labeling-Packet insert 11/17/20: Indications and Usage: Schizophrenia. During an interview on 6/5/25 at 11:02 AM, Staff A, Licensed Practical Nurse (LPN), stated Resident #1 had frequent symptoms of anxiety that included restlessness and calling out, sometimes relieved by staff reassurance or 1 to 1 activity. Staff A stated sometimes it didn't matter what was attempted, the resident remained extremely anxious. Staff A stated she had administered the haloperidol injection, and notified the facility physician when the resident had increased anxiety. Staff A stated she had not notified the Psychiatric Nurse Practitioner as she had not worked when the resident had telemed psych appointments. During an interview 6/5/25 at 4:10 PM, Staff C, LPN, stated she administered Haldol to the resident when she had increased anxiety and restlessness, would try to calm the resident by talking to her, administered analgesics and Alprazolam when needed, repositioned the resident and offered snacks/beverages, but sometimes it didn't matter what was attempted, the resident would remain anxious, would call out for help, but when she was asked what she needed the resident couldn't say what she needed. The resident would ask for the Haldol, and Staff C stated sometimes when she administered the medication it didn't seem like it had any effect on the resident as she remained anxious. Staff C stated she had not notified the Psychiatric Nurse Practitioner of the resident's increased anxiety or use of Haldol, and communicated with the primary care physician when needed for the resident. During an interview 6/4/25 at 10:49 AM, Staff F, the Interim Director of Nursing (DON) and Corporate Nurse stated she could not locate documentation that staff communicated with Staff D about the resident's anxiety or administration of Haldol. The DON explained Staff D was no longer a provider with the contracted company, and could not contact her. The DON provided contact information for the current Psychiatric Nurse Practitioner. Staff E. The DON was not aware that staff had administered Haldol and agreed the matter should have been addressed with the Psychiatric Nurse Practitioner. The DON stated staff should have communicated the resident's symptoms with the Psychiatric Nurse Practitioner and in the process of providing that education to the nursing staff. The DON stated she had recently assumed her position, after the resident's physician prescribed Seroquel and Haldol, and would also address the matter with the physician, their Medical Director. During an interview 6/4/25 at 4:40 PM, Staff E, Psychiatric Advanced Practice Nurse Practitioner stated she had not received any communication from the facility staff about the resident having increased anxiety or the need to administer Haldol IM. Staff E stated if the resident had increased or unmanageable anxiety, they should communicate that with her so she could provide appropriate services and direction to staff. Staff E stated it is not appropriate to use Haldol for resident as it is to be used when there is extreme agitation/aggression with the risk of harm to the resident or others, an emergent situation, and not indicated for anxiety with restlessness. During an interview on 6/2/25 at 5:48 PM, the resident's responsible party/Power of Attorney (POA) stated the resident had anxiety and needed frequent reassurance. The POA stated the resident received too many medications and questioned if the medications were actually making the resident more anxious for the resident. 2. The MDS Assessment tool dated 4/14/25 revealed a list of diagnoses for Resident #4 which included acute respiratory failure with hypoxia, anoxic brain damage, anxiety and depression. A BIMS score of 5 out of 15 points indicated severely impaired cognition. The Behavior section indicated no hallucinations, delusions, or physical or verbal behavioral symptoms towards others in the last 7 days. The MDS indicated an admission date of 10/16/24, with a readmission date of 12/18/24. Review of the EHR Medical Diagnosis list, date 6/5/25 revealed the following diagnoses: a. Delirium due to unknown physiological condition. Date: 12/18/24. Classification: Admission b. Depression, unspecified. Date: 12/18/24. Classification: Admission. c. Anxiety disorder, unspecified. Date: 12/13/24. Classification: Acquired during stay. Review of the Care Plan, Date Initiated: 12/8/24 revealed a Focus area to address The resident uses PSYCHOTROPIC medications r/t anxiety, hallucinations. Interventions included, in part: a. Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Date Initiated: 12/8/24. b. Discuss with MD, family re ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Date Initiated: 12/8/24. c. Monitor/record occurrence of for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc) and document per facility protocol. Date Initiated: 12/08/24. Review of the Care Plan, Date Initiated: 4/15/25 revealed a Focus area to address The resident uses ANTIDEPRESSANT medication r/t (related to) depression. Interventions included, in part: a. Administer Antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Date Initiated: 4/15/25. Review of the Care Plan. Date Initiated: 12/23/24 revealed a Focus area to address The resident has a behavior problem r/t episodes of calling out, verbal and physical aggression towards staff, pulling at g tube (tube that goes into the abdomen to meet hydration and nutrition needs when unable to safely eat and or drink by mouth), has episodes of yelling, spitting, awake all night. Interventions included: a. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 12/23/24. b. Anticipate and meet the residents needs c. Explain all procedures to the resident before starting and allow the resident to adjust to changes d. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and /or under unacceptable to the resident e. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed f. Monitoring of behavior episodes and attempt to determine underlying causes. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Review of Physician Orders revealed the following orders: a. ALPRAZolam Oral Tablet 0.5 MG .Give 1 tablet by mouth at bedtime related to ANXIETY DISORDER, UNSPECIFIED. Start Date: 12/18/24. b. ALPRAZolam Oral Tablet 0.5 MG .Give 1 tablet by mouth as needed for anxiety related to o ANXIETY DISORDER, UNSPECIFIED. Start Date: 12/18/24. c. OLANZapine (brand name Zeprexa, an atypical antipsychotic) Oral Tablet 5 MG .Give 2 tablets by mouth two times a day for agitation. Start Date: 12/19/24. End Date: 4/7/25. d. SEROquel Oral Tablet 25 mg .Give 1 tablet by mouth three times a day for agitation/anoxic brain injury related to DEPRESSION, UNSPECIFIED. Start Date: 1/29/25. Review of EHR revealed a Physician Progress Note entered on 1/29/25 at 1:33 PM .Reason for Visit: staff reports he is having increased behaviors, he is hitting, and yelling profanity at staff. Subjective: resting in chair, Smiling. He is pleasant, no complaints today. Denies having behaviors .Assessment and Plan; discussed with staff that I do not feel comfortable with prescribing medication for his behaviors due to his history of anoxic brain injury. I recommended that they notify [provider name redacted] for further guidance. An Order Note entered on 1/29/25 at 2;15 PM revealed Note Text: The order you have entered Seroquel Oral Tablet 25 MG .Give 1 tablet by mouth three times a day for agitation/anoxic brain injury . Review of the Drugs@FDA (Food and Drug Administration) - Approved Drugs site (https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm revealed the following indicated uses: a. Olanzapine 5 mg: Labeling-Packet insert 1/22/25: Indications and Usage: Schizophrenia, Acute Treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder, Medication therapy for pediatric patients .Adjunct to valproate or lithium in the treatment of manic or mixed episodes associated with bipolar I disorder b. Seroquel 25 mg: Labeling-Packet insert 1/22/25: Indications and Usage: Schizophrenia, Bipolar I disorder manic episodes, and Bipolar disorder, depressive episodes Review of Progress Notes revealed a lack of documentation regarding: a. The Care Plan Intervention to Discuss with MD, family re ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. b. Monitoring of behavior episodes and attempt to determine underlying causes. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. 3. The Minimum Data Set (MDS) Assessment tool dated 5/14/25 revealed a list of diagnoses for Resident #5 which included cerebrovascular accident (a stroke), and hemiplegia (paralysis on one side of the body). The BIMS score of 3 out of 15 indicated severely impaired cognition. The Behavior Assessment section indicated no hallucinations, delusions, or physical or verbal behavioral symptoms towards others in the last 7 days. The MDS indicated Resident #1 admitted to the facility on [DATE], with a readmission date of 5/7/25. Review of the EHR Medical Diagnosis list, date 6/5/25 revealed a lack of a mental health diagnosis upon admission on [DATE] or after admission. Review of Physician Orders revealed an order for Seroquel 25 mg .Give 25 mg via G-tube three times a day for anxiety. Start Date: 5/14/25. Review of the Care Plan, Date Initiated: 5/15/25 revealed a Focus area to address The resident uses PSYCHOTROPIC medication r/t anxiety. Interventions included, in part: a. Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. Date Initiated: 5/15/25. b. Discuss with MD, family re ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy Date Initiated: 5/15/25. c. Monitor/record occurrence of for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Date Initiated: 5/15/25. Review of the Drugs@FDA (Food and Drug Administration) - Approved Drugs site (https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm revealed the following indicated uses: a. Seroquel 25 mg: Labeling-Packet insert 1/22/25: Indications and Usage: Schizophrenia, Bipolar I disorder manic episodes, and Bipolar disorder, depressive episodes 4. The MDS Assessment tool dated 4/24/25 revealed Resident #6 list of diagnoses included paraplegia (paralysis of the lower part of the body), anxiety and depression. A BIMS score of 15 out of 15 indicated intact cognition. The Behavior section indicated no hallucinations, delusions, or physical or verbal behavioral symptoms towards others in the last 7 days. The MDS indicated an admission date of 4/17/25. Review of the EHR Medical Diagnosis List, dated 6/5/25 revealed: a. Insomnia, Unspecified. Date: 4/17/25. Classification: Admission. Review of the Care Plan, Date Initiated: 4/18/25 revealed a Focus are to address The resident uses PSYCHOTROPIC medications r/t insomnia. Interventions included, in part: a. Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. Date Initiated: 4/18/25. b. Monitor/record occurrence of for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Date Initiated: 4/18/25. Review of Physician Orders revealed an order for Quetiapine (generic Seroquel) 50 mg .Give 1 tablet by mouth every 24 hours as needed for insomnia once nightly. Review of the Drugs@FDA (Food and Drug Administration) - Approved Drugs site (https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm) revealed the following indicated uses: a. Seroquel 50 mg: Labeling-Packet insert 1/22/25: Indications and Usage: Schizophrenia, Bipolar I disorder manic episodes, and Bipolar disorder, depressive episodes During an interview on 6/5/25 at 4:50 PM, Staff F, DON, agreed that insomnia was not an appropriate indication for Seroquel. The DON stated she has been compiling a list of all residents who are prescribed psychotropic medications to ensure the appropriateness of the medication and planned to seek physician orders as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family and staff interviews, the facility failed to notify the resident representative of a change in the medication regime for 1 of 2 residents (Resident #10) reviewed. The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #10 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 12 out of 15. Diagnoses listed on the MDS included: depression, cognitive communication deficit, and dysphagia (difficulty swallowing). Review Resident #23 Care Plan, Date Initiated: 1/13/22 included a Focus area to address The resident has impaired cognitive function or impaired through processes r/t (related to) HX (history) of ETOH (alcohol) abuse. Interventions included, in part: a. Communicate with the resident/family/caregivers regarding his capabilities and needs. Date Initiated: 1/13/2022. b. The resident needs supervision/assistance with all decision making. Date Initiated: 1/22/22. During an interview on 3/3/25 at 8:27 AM, Resident #10's Power of Attorney (POA) stated he had not been informed of a new medication prescribed for the resident until he received the bill from the pharmacy. The POA stated the medication was depoprovera. Review of Physician's Orders revealed an order for Depo-Provera Intramuscular Suspension 150 Mg (milligrams)/Ml (milliliters) (Medroxyprogesterone Acetate (Contraceptive)) Inject 1 ml intramuscularly one time a day every Fri (Friday) for Hypersexuality. The order start date 12/6/24. During an interview on 3/5/25 at 10:48 AM, the Director of Nursing stated she would expect the family or resident representative to be notified whenever there is any change of condition, new medications, new appointments out of the facility, or any other related changes. A review of the facility policy Notification of Changes, last reviewed date of 11/8/23 Compliance Guidelines statement declared: The facility will inform the resident, consult with the resident ' s physician and/or notify the resident ' s family member or legal representative when there is a change requiring such notification. Circumstances requiring notification included, in part: #3. Circumstances that require a need to alter treatment. This may include: a. New treatment.

Based on observation, interview, and clinical record review the facility failed to complete a significant change Minimum Data Set (MDS) assessment when the resident discontinued hospice services for one of one resident reviewed for hospice (Resident #53). The facility reported a census of 65 residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #53 dated 1/24/25 revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident was cognitively intact. The General Note dated 12/24/24 at 12:23 PM revealed, Resident expressed wanting to come off hospice, hospice RN (Registered Nurse) and social worked came and resident signed off services effective today. MD (Medical Doctor) notified. The Physician Progress Note dated 12/27/24 at 12:13 PM revealed, Reason for visit: staff reports resident is off hospice and wishes to pursue treatment for her cancer .States that she did not want hospice any longer when she was informed that they do not do chemo (chemotherapy) treatments .Assessment/plan: no longer receiving hospice care. Review of Resident #53's MDS history revealed the resident had a significant change MDS assessment completed 10/24/24, and next had a quarterly MDS assessment completed 1/24/25. On 2/24/25 at 2:01 PM, Resident #53 observed in wheelchair and used the telephone at the nursing station. On 2/27/25 at 11:36 AM, the MDS Coordinator explained the team would let her know needed significant change, she would open one up, and the IDT (interdisciplinary) team and the MDS Coordinator would work on completing the significant change. The MDS Coordinator explained she would needed communication that [resident] stopped hospice so that one could be opened. When queried for this instance if the facility let her know stopped hospice services, the MDS Coordinator responded not that she could remember, she would have opened one. The MDS Coordinator explained if wanted a MDS opened, needed to communicate so let MDS Coordinator know. On 3/5/25 at 11:13 AM, the Director of Nursing (DON) confirmed when get off of hospice, should have triggered significant change. Per the DON, didn't change payer in the system and got missed, and as soon as happened (payer source change), triggered significant change so everyone could go in and do/document assessments. On 3/4/25 at 2:36 PM, a Facility Policy for significant change MDS requested via email to the facility's Administrator. On 3/5/25 at 11:17 AM, the facility's Administrator explained via email the facility followed the RAI (Resident Assessment Instrument), and did not have a policy to address significant change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to address smoking as a focus area for 2 of 3 residents reviewed for smoking (Residents #51 and #264). The facility reported a census of 65. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #264 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: malnutrition, anxiety disorder and respiratory failure. The MDS identified Resident #264 dependent on staff for toileting, lower body dressing, putting on and taking off footwear. During an observation on 2/24/25 at 1:33 PM, Staff A, Certified Nursing Assistant (CNA) pushed Resident #264 in her wheelchair outside to the smoking area. Resident #264 proceeded to smoke a cigarette. Review of the Care Plan revealed a lack of a Focus area, Goal and Interventions to address Smoking. During an interview on 3/3/25 at 3:04 PM Staff B, Registered Nurse (RN) reported Resident #264 smoked and that should have been identified on her Care Plan. Staff B stated the MDS Coordinator completes the Care Plans. During an interview on 3/5/25 at 10:48 AM, the Director of Nursing (DON) stated if a resident smokes, this should be included on the Care Plan. She explained MDS Coordinator works remotely and is responsible for developing the initial Care Plan. When asked why Resident #264's Care Plan did not identify her as a smoker, the DON explained she reviewed Resident #264's smoking assessment and realized the nurse who completed the admission assessment may have failed to ask the question. A review of the facility policy titled Comprehensive Care Plans, last revised in March 2023, Policy Expectations and Compliance Guidelines directed, in part: #3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental and psychosocial well-being. 2. The MDS dated [DATE] revealed Resident #51 diagnoses list included:anxiety disorder, adult failure to thrive, and fracture of the right femur. Resident #51 BIMS score as 11 out of 15,indicated a moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance for oral hygiene, and dependent on staff for upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During an observation on 02/25/25 at 9:30 AM, Resident #51 outside smoking in designated smoking area, with facility staff present. Resident #51 noted to not be wearing a smoking apron for safety. During the observation, Staff D, CNA stated residents can go outside at designated smoking times four times per day, and can smoke up to two cigarettes each time. She stated a staff member is always outside with the residents during the designated smoking times and possesses the lighter. Staff D stated each resident's cigarettes are in individual baggies marked with their name and date. She stated residents can not have cigarettes or lighters in their position inside the facility. Staff D stated all cigarettes and lighters are kept in a locked room behind the nurses desk, and residents do not have access to the room. On 02/25/25 at 3:50 PM Resident #51 was observed lined up with other residents to go outside and smoke. At 4:00 PM the resident went outside with a staff member and was handed two cigarettes. Review of a quarterly Ivy Smoking Screen assessment, dated 2/20/25, identified Resident #51 as currently smoking, requires supervision when smoking, and the Care Plan is updated to reflect smoking status. Review of Resident #51 Care Plan revealed a lack of a Focus area with associated Goals and Interventions to address Smoking. During an interview on 3/4/25 at approximately 3:15 PM, the DON stated any resident who smokes should have it addressed on the Care Plan, and quarterly Smoking Screen assessments completed. She stated she was not aware Resident #51's Care Plan did not include smoking as a Focus area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility policy review the facility failed to hold care conferences quarterly, failed to revise the care plan when the resident discontinued hospice services for four of twenty-two residents reviewed for care plans (Resident #18, Resident #52, Resident #53, Resident #54). The facility reported a census of 65 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident was cognitively intact. On 2/26/25, review of Resident #53's Care Plan revealed, I am receiving Specialty Services such as Hospice with [Hospice Company Redacted]. The General Note dated 12/24/24 at 12:23 PM revealed, Resident expressed wanting to come off hospice, hospice RN (Registered Nurse) and social worked came and resident signed off services effective today. MD (Medical Doctor) notified. The Physician Progress Note dated 12/27/24 at 12:13 PM revealed, Reason for visit: staff reports resident is off hospice and wishes to pursue treatment for her cancer .States that she did not want hospice any longer when she was informed that they do not do chemo treatments .Assessment/plan: no longer receiving hospice care. On 3/5/25 at 11:14 AM, when queried about revision of the resident's care plan and how soon would occur, the facility's Director of Nursing explained normally [MDS Coordinator] would do the change when triggered the significant change, explained the [MDS Coordinator] was not always on the call when had meetings (when such information discussed), if the MDS Coordinator had known. The Facility Policy titled Comprehensive Care Plans dated 3/22 and revised 3/23 revealed, 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 2. The MDS assessment dated dated 1/23/25 revealed Resident #54 scored a 6 out 15 on the BIMS exam, which indicated cognition severely impaired. During an interview on 2/25/25 at 10:20 AM, Resident #54 wife stated she never attended a care conference for her husband. Resident #54 wife asked if she ever received a call or a letter requesting her attendance for the call conference and she stated no. During an interview on 2/26/25 at 3:13 PM, Social Services queried if residents or their families invited to the care conferences and she stated yes, she invited the resident and would call family and she documented who came in her care note in the progress notes. Social Services asked when Resident #54 last care conference was and she stated she didn't think they done with him in awhile. Social Services asked how often the facility completed care conferences and she stated quarterly and Resident #54 was overdue for a care conference and they should of completed one on him on 10/17//24. During an interview on 2/27/25 on 1:18 PM, the DON queried how often care conferences needed completed and she stated anytime the resident had concerns and she thought quarterly. The DON informed of Resident #54 care conference had not been completed and it was due on 10/17/24 and she stated Resident #54 needed a care conference completed by now unless he refused. 3. The MDS assessment dated [DATE] revealed Resident #18 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The Care Plan Note dated 11/8/24 at 11:02 AM, revealed Meeting with Resident #18 and her mother to do a care plan meeting During an interview on 2/24/25 at 2:36 PM, Resident #18 stated she had not attended a care conference since the first month she admitted to the facility. During an interview on 2/26/25 at 3:16 PM, Social Services queried on care conferences with Resident #18 and she stated the last care conference they had was on 11/8/24 and Resident #18 and her mother attended. Social Services asked when Resident #18 next care conference scheduled and she stated she didn't believe they had one scheduled but they would have one pretty soon because Resident #18 going to discharge. Social Services confirmed Resident #18 should of had a care conference around 2/8/25. During an interview on 2/27/25 at 1:19 PM, the DON queried on Resident #18 last care conference on 11/8/24 and Resident #18 not having another scheduled and the DON stated she was pretty sure the care conferences needed completed quarterly. 4. The MDS assessment dated [DATE] revealed Resident #52 scored a 5 out of 15 on the BIMS exam, which indicated cognition severely impaired. The MDS revealed wandering behavior not exhibited in the 7 day look back. The MDS indicated the resident used a wheelchair and wheeled 150 feet once seated in a corridor or similar space independently. The MDS revealed diagnoses of metabolic encephalopathy; anxiety disorder, and depression. The Care Plan revealed a focus area dated 9/16/24 for behavior problem related to episodes of agitation, difficulty sleeping at times. The Care Plan did not address the resident behaviors for wandering into other resident's rooms. During an interview on 2/26/25 01:37 PM, Staff D, CNA (Certified Nurse Aide) queried if Resident #52 wandered into other resident's rooms and she stated yes, he attempted to go into other resident's room. Staff D stated one time he went into Resident #31 room and Resident #31 said it scared her. During an interview on 2/26/25 at 2:25 PM, Staff B, RN (Registered Nurse) queried if Resident #52 went into other resident's rooms and she stated yes and he tried to follow the nurse into rooms also. Staff B stated Resident #52 a busy body and strolled around in his wheelchair, but didn't exit seek. During an interview on 2/26/25 at 4:45 PM, Resident #31 queried if other resident ever came into her room and she stated yes, last night. Resident #31 stated she didn't know his name, but he was the resident at the front of the hall on the left (Resident #52 room) came into her room and said something to Resident #31. Resident #31 stated she told Resident #52 to get out in a harsh voice and Resident #52 left her room. Resident #31 stated it scared her when Resident #52 came into her room. During an interview on 2/27/25 at 2:02 PM, the DON queried on Resident #52 behavior of wandering in other resident's rooms and she stated she didn't know Resident #52 did that. The DON asked if the behaviors of wandering into other residents rooms needed care planned and she stated yes, it should be. The Facility Comprehensive Care Plan Policy dated March 2022 revealed the following: a. It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment. b. The comprehensive care plan will describe, at a minimum the following . 1. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. The Facility Care Planning- Resident Participation Policy dated 9/24 revealed the following: a. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS dated [DATE] listed diagnoses for Resident #265 included: neurogenic bladder (lack of bladder control due to nerve damage) , urinary tract infection and epilepsy. The MDS indicated Resident #265 dependent on staff for assistance with toileting, showers, dressing, putting on and removing footwear and personal hygiene. The MDS identified Resident #265 with an indwelling catheter. Review of Resident #265's Care Plan, dated 12/18/24, revealed a Focus area to address The resident has a seizure disorder r/t (related to) epilepsy. Interventions included, in part: a. Give medications as ordered. Monitor/document for effectiveness and side effects. Date Initiated: 12/18/24. b. Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. Date Initiated: 12/18/24. Review of the Order Summary Report, document dated 3/4/25, revealed a Physician's Order for Epidiolex Oral Solution 100 Mg (milligrams/Ml (milliliters)(Cannabidiol). Give 2.5 ml by mouth two times a day for partial epilepsy with impairment. Start date 12/17/24. A review of the December 2024 MAR revealed: a. On 12/17/24, a 9 documented for the evening dose of Epidiolex b. On 12/18/24, a 9 documented for the morning and evening dose of Epidiolex. c. On 12/19/24, a 9 documented for the morning and evening dose of Epidiolex. d. On 12/20/24, a 9 documented for the morning dose of Epidiolex e. On 12/23/24, a 8 documented for the morning dose. Per the MAR Chart Codes, a 6 indicated resident hospitalized , a 8 indicated medication unavailable, and a 9 indicated Other/See Progress Notes. A review of the electronic health record revealed lack of documentation for the 9 indicated on the MAR for 12/17/24, 12/18/24, and 12/19/24. A General Note entered on 12/20/24 at 10:12 AM documented [Hospital name and department redacted] contacted to inform [provider name redacted] of our facility not able to obtain medication Epidiolex 2.5 ml dosage as ordered by [provider name redacted] upon admission. Voice message left for nurse to return call on proceeding with order. Upon getting clarification, Resident and her [redacted] POA will be updated as well as [provider and nurse Practioner name redacted]. A General Note entered on 12/20/24 at 5:19 PM documented [Hospital name and department redacted] contacted to notify that the medication Epidiolex was not able to be supplied by our facility pharmacy or specialty pharmacy per our pharmacy rep. [name redacted] due to DEA (Drug Enforcement Agency) issues. [Provider name redacted]contacted, and to call nursing back on cell number as it is after hours. Nursing will contact the facility upon receipt of updated order/s after he contacts the [provider name, hospital and department name redacted]. During an interview on 2/25/25 at 9:57 AM, Resident #265's representative and Power of Attorney (POA) stated Resident #265 had not gotten her seizure medications as scheduled, and the resident then had increased seizure activity. Review of a General Note entered on 12/23/24 at 11:01 AM revealed Residents family came to visit and as they were leaving they informed the receptionist that [name redacted] felt hot resident was assessed by this nurse and treatment nurse. residents vitals BP (blood pressure) 99/81 R (respirations) 14 and O2 (oxygen level) 93. Resident stated that she feels like she had a seizure. resident was lethargic. Per [provider name redacted] - sent to ER (emergency room) for evaluation. Report called to [name of hospital redacted]. Review of General Note entered on 12/24/25 at 1:13 PM documented .resident is still in ICU (Intensive Care Unit) at [name of hospital redacted]. Based on observation, interview, and clinical record review the facility failed to administer blood pressure medications and seizure medications per physician order for 2 of 4 residents reviewed for professional standards of practice (Resident #43, Resident #265). The facility also failed to complete weekly weights per physician order for 1 of 2 residents reviewed for nutrition (Resident #23). The facility reported a census of 65 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #43 dated 2/7/25 revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Review of the Care Plan for Resident #43 dated 8/25/24 revealed the following: The resident has altered cardiovascular status r/t (related to) HTN (hypertension), hypotension. The Physician Order dated 8/24/24 revealed, Midodrine HCl Oral Tablet 5 MG with instructions to give 1 tablet by mouth every 8 hours as needed for low <sic> blood pressure. Directions per order revealed, 1 TAB PER G -TUBE (gastrostomy tube) TID (three times a day) PRN (as needed) HYPOTENSION FOR SBP (systolic blood pressure) <90. Review of the resident's Medication Administration Record (MAR) dated February 2025 for the time period of 2/15/25 to 2/25/25 revealed following dates and resident blood pressures when the medication was not administered: a. 2/17/25 at 7:35 AM: blood pressure (bp) 85/72 b. 2/18/25 at 7:10 AM: bp 75/52 c. 2/18/25 at 4:33 PM: bp 80/64 d. 2/19/25 at 7:44 AM: bp 80/53 e. 2/19/25 at 4:25 PM: bp 81/60 The Physician Order dated 10/9/24 revealed, Metoprolol Tartrate Oral Tablet 25 MG (milligram) with instructions to give 1 tablet by mouth two times a day for htn hold if systolic bp (top reading of blood pressure) less than 120, hold if heart rate is less than 60 BPM (beats per minute). Review of the resident's Medication Administration Record (MAR) dated February 2025 revealed Metoprolol 25 MG administered to the resident for the 6AM to 9AM dose on the following dates when the resident's systolic bp was less than 120: a. 2/1/25: blood pressure (bp) 104/62 b. 2/2/25: bp 113/76 c. 2/3/25: bp 95/65 d. 2/7/25: bp 118/72 e. 2/8/25: bp 118/74 f. 2/11/25: bp 92/54 The medication was also administered to the resident for the 4PM to 7PM dose on the following dates when the resident's systolic blood pressure was less than 120: a. 2/13/25: bp 91/53 b. 2/19/25: 81/60 On 3/5/25 at 11:16 AM, the facility's Director of Nursing (DON) confirmed nursing staff should follow parameters as guidance to whether given medication or not. Review of the facility policy titled Medication Administration-General, implemented 5/30/23 and revised 9/19/23, revealed the following: Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 3. Resident #23's MDS assessment dated [DATE], identified a BIMS score of 12, indicating moderately impaired cognition. The MDS included diagnosis of unspecified severe protein-calorie malnutrition. Review of Physician Orders revealed an order for weekly weights, start date of 2/11/25. Review of Clinic Weights and Vitals in the electronic health record (EHR) revealed a weight of 157.5 pounds on 2/14/25. No further documentation of weekly weights found in the EHR. During an interview on 3/5/25 at approximately 10:10 AM, the DON stated Resident #23 has an order to be weighed weekly and this is not being getting done. During an interview on 3/05/25 at 11:40 AM, the Consultant stated as the facility does not currently have a dietician she is one of two consultants covering for the position. She stated the last weight the facility documented for Resident #23 was on 2/14/25. The Consultant advised she would expect the facility to weigh a dialysis resident at least weekly. It is her expectation staff weigh the resident and not rely on the dialysis summary sheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interview, the facility failed to provide set up assistance for resident identified with an impaired ability to eat independently for 1 of 1 residents (Resident #23) in the sample. The facility reported a census of 65 residents. Findings include: 1. Review of Resident #23's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 12, which indicated a moderate cognitive impairment. The MDS included diagnoses of metabolic encephalopathy (brain function impairment), Crohn's disease, end stage renal disease and diabetes. Per the MDS, Resident #23 required set up or clean up assistance for eating. Review of the Care Plan, Date Initiated: 2/11/25 identified a Focus area to address Resident is at risk for or has actual IMPAIRED ABILITY TO EAT INDEPENDENTLY. The Intervention directed staff to EATING AND DRINKING: The resident usually requires a helper to provide SETUP ASSISTANCE prior to or following the eating activity (such as opening packages or cutting meat). Date Initiated: 2/11/25. During an interview on 02/25/25 at 12:35 PM, Resident #23 shared he has difficulty eating on his own and staff do not help him. He explained his hands are messed up and he can't cut up his food on his own. Resident #23 stated staff bring his plate to his room, set it down and then leave. During an interview on 2/26/25 at approximately 1:45 PM when queried about the assistance Resident #23 required to eat, Staff E, Certified Nurse Aide (CNA) stated sometimes he is assisted but not always. She explained sometimes staff help him cut up his food. Staff E stated on the days he has dialysis he doesn't usually eat very much. She stated the resident does not use special or adaptive silverware or plates. During an observation on 02/27/25 at 12:10 PM, Staff R, CNA delivered lunch to the resident's room, and left the room without offering or proving assistance. During an interview and observation on 02/27/25 at 12:30 PM, Resident #23 tray delivered to his room. The lunch meal consisted of ham and bean soup, green beans, and corn bread. The resident also had white milk and orange Kool-aid. The milk had been opened for him. The resident picked up the glass of juice and took a small drink. The resident spilled a spoonful of soup on his shirt. Resident #23 tried eating dessert with a fork which resulted in most bites falling back on to the plate. During an interview after the lunch meal on 2/27/25, Resident #23 stated staff dropped off his meal tray and left. He stated his hands are messed up and he can ' t eat like this. At approximately 12:50 PM Staff C, Registered Nurse (RN) entered the resident's room and asked the Resident if he was done. When he said yes she took the tray and left the room. During an interview on 2/27/25 at 12:52 PM when queried about the assistance Resident #23 required to eat, Staff C, RN stated he usually eats independently, and does not ask for assistance. Staff C stated she saw the resident did not eat much of the noon meal. She explained she did not ask if he needed assistance because she knew he ate a good breakfast. Staff C added she has occasionally assisted the resident depending on the meal. Staff C stated she was not sure if the resident's Care Plan had changed or been updated or if there is a physician's order to assist him. During an interview on 02/27/25 at 2:30 PM, the facility Director of Nursing (DON) stated she had only been at the facility for a couple of weeks and concerns about Resident #23 eating had not been brought to her attention. Review of a General Note in the electronic health record, dated 3/2/25 at 10:56 AM revealed CNA reports to this nurse she has noticed the resident doesn ' t eat very much of his tray. She reports concerns that he is unable to eat independently. Will pass concerns to NP (nurse practitioner). Review of Physician Orders revealed an order, start date of 3/3/25 to please get resident up with all meals and place in the dining room, will need to be fed as he is unable to feed self.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS dated [DATE] identified Resident #21 as cognitively impaired with a BIMS of 7. The MDS assessed Resident #21 required partial/moderate assistance to sit to stand and to transfer from chair/bed-to-chair. Review of the Care Plan, dated 10/19/23, revealed Resident #21 at risk for or has actual IMPAIRED ABILITY TO TRANSFER INDEPENDENTLY R/T Musculoskeletal impairment. The Intervention dated 12/6/24 revealed, TRANSFER: Resident requires assist of 1 staff using a GB (gait belt) et (and) walker for all functional transfers. During an observation on 2/25/25 at 11:02 AM, Staff D, CNA and Staff D, CNA assisted Resident #21 to stand and pivot to lie down in the bed without placing a gait belt around the resident. At 11:10 AM, both aides assisted resident to transfer from bed to wheelchair by holding resident underneath her arms and did not use a gait belt. Staff D reported the resident is usually one to one assist and usually independent. During an interview on 3/4/25 at 11:40 AM, Staff R, CNA reported Resident #21 was care planned to be transferred with the assist of one using a gait belt and walker. During an interview on 3/4/25 at 12:25 PM, Staff I, LPN reported Resident #45 was care planned to be transferred with the assist of two using the gait belt as she had a history of falls. A review of the facility policy titled: Safe Resident Handling/Transfers dated as last revised 12/17/24 had documentation of the following: Resident's lifting or transferring will be performed according to the resident's plan of care. Based on observation, staff interview, and clinical record review the facility failed to ensure wheelchair foot pedals utilized when residents assisted via wheelchair, and failed to ensure staff utilized a gait belt during transfer for 2 of 9 residents reviewed for accidents (Resident #12, #21). The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. Per this assessment the resident used a walker and wheelchair. Review of Resident #12's Care Plan dated 10/18/23 revealed, Resident is at risk for or has actual IMPAIRED ABILITY TO INDEPENDENTLY MOVE/NAVIGATE WHEELCHAIR R/T (related to) Limited Mobility, Musculoskeletal impairment. The Intervention dated 10/25/23 revealed, Foot pedals when push assist is given for navigating in wheelchair. On 2/24/25 at 11:23 AM, Staff F, Certified Nursing Assistant (CNA) pushed Resident #12 in their wheelchair while the wheelchair did not have foot pedals applied. At 11:25 AM, Staff F again pushed the resident into another resident room while Resident #12 did not have foot pedals applied to resident's wheelchair. On 2/24/25 at 12:19 PM, Staff F pushed Resident #12 in their wheelchair while the resident did not have foot pedals on the wheelchair. On 3/3/25 at 3:20 PM, Staff B, Registered Nurse (RN) queried if should have foot pedals on when resident assisted in wheelchair, and responded, yeah. On 3/4/25 at 11:58 AM, Staff H, CNA explained, in part, for anybody pushed, the only way could push was foot pedals on wheelchair. On 3/5/25 at 11:18 AM, the facility's Director of Nursing (DON) acknowledged should have on at all times if push resident in wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed secure the tubing for a urinary catheter in a position that prevented it from sitting on the floor for 1 of 2 residents reviewed for catheter care (Resident #45). The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #45 as cognitively impaired with a BIMS of 6 and had the following diagnoses: renal insufficiency (kidney failure), encephalopathy (a medical condition characterized by a general dysfunction of the brain) and malnutrition. The MDS also identified used an indwelling urinary catheter. On 12/23/22, the Care Plan identified Resident #45 with the problem of an Indwelling Catheter related to urinary retention, obstructive and reflux uropathy (a condition where urine flows backward from the bladder into the ureters). During an observation on 2/26/25, Resident #45 sat up in her wheelchair in the back dining room. The catheter tubing noted to be on the floor. Resident #45 self propelled her wheelchair with the tubing dragging on the floor. Resident #45 stepped on the tubing one time during this observation. During an interview on 3/4/25 at 11:40 AM, Staff R, Certified Nursing Assistant (CNA) stated if catheter tubing is on the floor it should be picked up and the nurse informed so the tubing can be changed. During an interview on 3/4/25 at 12:28 PM, Staff J, Registered Nurse reported if the CNA saw Resident #45's tubing on the floor, she would expect the aide to move the tubing up off the floor and let the nurse know about it. She would normally encourage the resident to wear a leg bag during the day and switch it out at night to the big bag. A review of the facility policy titled: Catheter Care and dated as last revised on 1/1/24 directed staff to ensure catheter tubing is secured to prevent touching the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to coordinate communication with the dialysis center for 1 of 2 residents reviewed for dialysis (Resident #18). The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated the resident received dialysis. The MDS revealed the medical diagnosis for renal insufficiency, renal failure, or end-stage renal disease (ESRD). The Care Plan revealed a Focus area dated 10/22/24 for hemodialysis related to ESRD. The Intervention dated 10/22/24 indicated encourage the resident to go for the scheduled dialysis appointments on Tuesday, Thursday, and Saturday every day shift at 9:30 . Review of the Physician Orders revealed the an order for Outpatient hemodialysis treatments: Day/s of the Week & Approximate Time: Tues (Tuesday)/Thur (Thursday)/Sat (Saturday) at 9:30 . Review of the clinical record revealed the most recent [Facility name redacted] Dialysis Communication Tool completed on 1/11/25 by the facility and the dialysis center. During an interview on 2/24/25 at 2:20 PM, Resident #18 stated she went to dialysis on Tuesday, Thursday and Saturday. Resident #18 stated she took a paper to dialysis and then the dialysis center faxed it back to the facility. During an interview on 2/26/25 at 2:28 PM, Staff B, RN (Registered Nurse) queried on Resident #18 communication with the dialysis center and she stated they sent a form printed off the computer and then the dialysis center should send back the form. Staff B stated the communication wasn't very good because Resident #18 would come back and tell Staff B, she had new orders and Staff B didn't get a call or fax. Staff B stated she thought it would work better if the dialysis center sent the paper back with the resident instead of waiting for a call or fax to come through. During an interview on 2/27/25 at 1:57 PM, the Director of Nursing (DON), queried on the communication between the dialysis center and the facility and she stated the staff filled out the initial portion and printed it out and sent the form to the dialysis center to fill out and send back to the facility. The DON stated it was a struggle to get the form back from the dialysis center. The DON informed the last form the facility provided for Resident #18 was dated 1/11/25 and her thoughts and she stated she knew the facility had them and it was just a matter of getting a copy of them and she could call the dialysis center for them. The DON asked how the facility knew if Resident #18 had changes in her care and she stated she didn't know, she only worked at the facility for a few weeks. The facility Hemodialysis Policy dated March 2022 directed: a. The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: 1. Ongoing assessment and oversight of the resident before, during, and after dialysis treatments . 2. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Based on clinical record review, staff interview, and facility policy review the facility failed to ensure timely follow up for medication regimen review recommendations identified by the Pharmacist for 1 of 5 residents reviewed for unnecessary medications (Resident #47). The facility reported a census of 65 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #47 dated 12/3/24 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident took antianxiety medication. The Pharmacist Review/Visit Progress Note dated 12/31/24 at 1:10 PM revealed, in part, Alprazolam PRN (as needed) and hydroxyzine PRN orders require stop dates - letter generated. The Pharmacist Review/Visit Progress Notes dated 1/28/25 and 2/24/25 stated the same recommendation and documented letters were generated/regenerated. On 3/4/25 at 2:40 PM, Resident #47's pharmacy recommendations and response communication requested for the following dates 12/31/24, 1/28/25, and 2/24/25. One Note to Attending Physician/Prescriber with print date 2/25/25 was provided by the facility for Resident #47. The form revealed the following: [Resident #47] currently has an order for Hydroxizine Hcl 50 MG (milligram) Q4HS (every 4 hours) PRN (as needed). Per regulatory guidelines, orders for psychotropic medications on a PRN basis must be limited to 14 days unless a stop date is noted. This order was implemented on 12/4/2024. This order needs to have a stop date of 12/18/2024 or a continuation duration noted to be in compliance with federal regulations. ***NURSING HAS REQUESTED THIS MEDICATION TO BE DISCONTINUE DUE TO NON-USE***. The following option had been selected on the form: Yes, extend the order with the following stop date (left blank). The Medication Regimen Review form was signed 3/4/25. On 3/5/25 at 10:50 AM, the facility's Director of Nursing (DON) explained they weren't done prior to DON getting to the facility, all she had were the original copies that wasn't sent to the Physician. On 3/5/25 at 11:12 AM, the DON acknowledged letters were not getting sent to the doctor, had received the February ones, and were waiting to get them back. Review of the Facility Policy titled Medication Regimen Review, dated 5/5/21 last revised 9/23, revealed the following: The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. The Facility Policy further revealed, Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #58 as cognitively impaired and did not have a BIMS score completed. The MDS also identified Resident #58 with the following diagnoses: stroke, renal insufficiency (kidney failure) and pneumonia and dependent on staff assistance for all activities of daily living. The MDS also identified Resident #58 had a feeding tube through which he received all his total calories. A review of the Physician Orders revealed the following: 1/3/25 may crush and mix medications for administration into GT 2/25/25 G-tube site- cleanse area with NS or wound cleaner, apply t-sponge dressing secure with tape every day shift for wound care and PRN 2/28/25 wound care to left buttock: cleanse with wound cleanser, apply Triad twice daily and as needed During an observation on 2/25/25 at 8:54 AM, Staff C, RN wound nurse, Staff B, RN and Staff A, Certified Nursing Assistant (CNA) entered the room, washed their hands and donned gloves. The nursing staff proceeded to complete wound care, GT (gastric tube) site care and incontinence cares. The staff did not don protective gowns during this observation. During on observation on 2/25/25 9:15 AM, Resident #58 door noted to have a sign for Enhanced Barrier Precautions with bin of Personal Protective Equipment well stocked with isolation gown and gloves outside the room. During an interview on 3/3/25 at 2:39 PM, Staff C, RN stated when providing cares to a resident in Enhanced Barrier Precautions, staff should wear a gown and gloves. She stated when providing care for Resident #58 on 2/25/25 she and the other two staff forgot to put on the isolation gowns. During an interview on interview on 3/4/25 at 9:59 AM, the DON/Infection Preventionist stated when staff provide cares for residents in Enhanced Barrier Precautions, they should don an isolation gown and gloves and mask if needed. A review of the facility policy titled: Enhanced Barrier Precautions dated as implemented 7/1/24 directed: Initiation of Enhanced Barrier Precautions: An order for Enhanced Barrier Precautions will be obtained for residents with any of the following: Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds or chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, etc). Implementation of Enhanced Barrier Precautions: a. Make gown and gloves available immediately near or outside the resident's room b. PPE (Personal Protective Equipment) is only necessary when performing high-contact care activities c. High contact resident care activities include: aa. Changing briefs or assisting with toileting bb. Device care or use for feeding tubes cc. Wound care: any skin opening requiring a dressing Based on observation, interview, clinical record record review, and facility policy review the facility failed to ensure enhanced barrier precautions (EBP) utilized for incontinence care, wound care, and gastrostomy tube site care for one of two residents reviewed for EBP, and failed to ensure appropriate infection control practices during medication administration for one of ten residents observed during medication administration (Resident #16) when a barrier was not utilized for the glucometer. The facility also failed to ensure the infection control policies were reviewed annually by the facility's Medical Director. The facility reported a census of 65 residents. Findings include: 1. On 2/27/25 at approximately 8:16 AM during an observation conducted for medication administration, Staff L, Registered Nurse (RN) had the glucometer directly on Resident #16's over the bed table. Staff L checked the resident's blood sugar and set the glucometer back on the table. At 8:19 AM, Staff L set the glucometer by the sink in the resident's room. At 8:20 AM, the glucometer was on the medication cart without a barrier present. At 8:29 AM, the glucometer was on the medication cart. Staff L queried when she cleaned the glucometer, and explained did so at the top and bottom of her shift. On 3/3/25 at 3:20 PM, Staff B, RN queried when glucometer cleaned, and responded between residents. When queried if barrier used if going to set glucometer down, and responded supposed to, yes. On 3/5/25 at 11:19 AM, the DON queried if barrier should be used for glucometer, acknowledged it should be, and acknowledged staff should be sanitizing the glucometer in between use. Review of the Facility Policy titled Infection Prevention and Control dated 7/1/24 revealed, This facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on record review, staff interview and policy review, the facility failed to provide immunizations to 3 of 5 residents reviewed. (Residents #23, #50 and #58). The facility reported a census of 65 residents. Findings include: A review of the immunization records revealed the following: Residents #23 and #48 did not have documentation of the pneumococcal vaccine given. Residents #23 and #50 did not have documentation of the influenza vaccine given in 2024. During on interview on 3/4/25 at 9:59 AM, the Director of Nursing/Infection Preventionist stated she had not had a chance to look at immunization status related to flu and pneumvax since she started at the facility a month ago. She stated currently, there is no one assigned to enter the immunization data when residents are admitted . A review of the facility policy titled: Influenza Vaccination dated as last revised 7/1/24 had documentation of the following: 1. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or the resident refuses to receive the vaccine. 2. The resident's medical record will include documentation that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of immunization and that the resident received or did not receive the immunization due to medical contradiction or refusal. A review of the facility policy titled: Pneumococcal Vaccine (Series) dated as last revised 12/9/24 had documentation of the following: 1. Each resident will be assessed for pneumococcal immunization. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders.

Based on observation, record review and staff interview, the facility failed to provide a homelike environment free of odors in 2 of 4 hallways, and failed to ensure the handrails of one of four hallways to be free of exposed sharp edges. The facility reported a census of 65 residents. Findings include: #1. During an interview on 2/24/25 at 10:59 AM, a resident representative for Resident #45 stated when she visited the facility the smell of urine was overpowering. She stated she could smell it as soon as she walked into the building. Observations of the A and B halls revealed the following: On 2/24/25 at 12:33 PM, the end piece to the handrails outside room B2 and B8 missing, exposed sharp edges noted. On 2/24/25 at 1:40 PM, hallway outside room B5 noted to have a strong odor of urine. On 2/25/25 at 8:00 AM, strong odor of urine noted in back dining room by A and B halls. During an interview on 3/4/25 at 11:00 AM, the Administrator reported the facility currently did not have a Maintenance Supervisor as the last one quit on 3/1/25. During an interview on 3/4/25 at 11:40 AM, Staff R, Certified Nursing Assistant (CNA) stated she is not sure what caused the odors in the A and B hallway, but thought it could be embedded in the flooring. During an interview on 3/4/25 at 12:50 PM, Staff I, Licensed Practical Nurse (LPN) reported she did not feel the odors in the A and B hallways and back dining room were caused by the linen bins and thought it could be caused by the flooring. During an interview on 3/4/25 at 12:28 PM, Staff J, Registered Nurse (RN) reported she felt the odors in the A and B hallways and back dining room were caused by flooring that should be replaced. #2. During an observation on 2/26/25 at 9:13 AM while in room B9 with the Director of Nursing (DON) and Staff F, RN for wound care a dried red substance was observed on the wall near the end of the bed. The red substance was smeared and ran down the wall. During an observation on 2/27/25 at 8:35 at AM, the red substance remained on the wall in room B9. During an interview on 2/27/25 at 8:40 AM Staff F, RN stated she had not seen the red substance on the wall. She stated if she would have seen it she would have had it cleaned off immediately. During an interview on 2/27/25 at 8:54 AM, the DON reported she had not seen the red substance on the wall. While in room B9, the DON stated she certainly had not seen this yesterday when in the room for wound care. During an interview on 03/04/25 at 11:00 AM the Administrator advised it is his expectation all staff members immediately clean up any visibly soiled surfaces when observed. It is his expectation that all resident rooms are cleaned and disinfected routinely A review of the Facility Policy titled: Routine Cleaning and Disinfection dated as last revised 6/25/24 had documentation of the following: a. Routine cleaning and disinfection of the frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms and at the time of discharge. b. Routine cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces. c. Cleaning of walls, blinds and window curtains will be conducted when visibly soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to maintain a safe, palatable temperature of foods served at the noon meal on 2/25/25. The facility reported a census of 65 residents. Findings include: On 2/25/25 at 12:11 PM, the State Agency requested a test tray for the noon meal. At 12:17 PM, the Dietary Manager took food temperatures of the refried beans with a result of 134.2 degrees F (Fahrenheit); and of jello cake with whipped topping with a result of 69.2 degrees F. During an interview on 2/25/25 at 12:20 PM, the Dietary Manager reported he expected temperatures for hot food items be at least 135 degrees F, and cold food items be under 41 degrees F. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated the resident required supervision or touching assistance with eating. During an interview on 2/24/25 at 11:44 AM, Resident #47 stated she ate in her room and the food being hot was a hit or miss and all of last week the food was cold. During an interview on 2/24/25 at 11:58 AM, Resident #47 food delivered to his room and he commented the fries were ice cold. 3. The MDS assessment dated [DATE] revealed Resident #31 scored a 12 out of 15 on the BIMS exam, which indicated cognition moderately impaired. The MDS indicated the resident needed set up or clean up assistance with eating. During an interview on 2/24/25 at 1:21 PM, Resident #31 stated the food tasted okay, but usually cold. A review of the facility policy titled: Food Safety Requirements, last revised April 2024 directed the following: a. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards. b. Cooking - foods shall be prepared as directed until recommended temperatures for the specific foods are reached. Staff shall refer to the current FDA Food Code and facility policy for food temperatures needed. c. Holding - staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code and facility policy for food temperatures needed.

Based on observation, staff interviews, and the facility policy, the facility failed to ensure 1 of 5 dietary staff covered their hair while in the kitchen. The facility reported a census for 65 residents. Findings include: During a kitchen observation on 2/25/25 at 11:00 AM, Staff G, Dietary Aide hairnet covered part of her hair. Staff G had multiple long braids of hair not covered by the hairnet and braids hung down her back. During an interview on 2/26/25 at 11:52 AM, Staff G only had part of her hair covered with 2 hairnets. Staff G had part of her braids hang down her back not in the hairnet. Staff G asked about wearing hairnets in the kitchen and Staff G stated they needed to wear them and she had 2 of them on. Staff G queried if all her hair needed to be in the hairnet and she stated yes, all of her needed covered. Staff G informed part of her hair not covered by the hairnet and she tried to put her hair in the hairnet and was unsuccessful and commented she had a lot of hair and had a hard time getting all of it in her hairnet. During an interview on 2/27/25 at 9:41 AM, the Dietary Manager queried about hairnet use and he stated the staff needed to all wear them in the kitchen and in the kitchenette in the back dining room. The Dietary Manager queried if all their hair needed covered by the hairnets and he stated yes and confirmed he had one staff member with weaves they had trouble with her hair not all being in the hairnet. The Facility Kitchen Personnel Hygiene-Attire Policy dated 11/14.24 revealed the following: a. Personal Hygiene-Proper Attire for food handlers should include hair covering (hair nets or caps) .Food employees shall wear hair restraints such as hats, hair coverings or nets .

Based on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies on the current survey previously identified in 2023 and 2024. The facility reported a census of 65 residents. Findings include: Review of the Department of Inspections, Appeals and Licensing (DIAL) website under the facility's visit history revealed deficient practices identified during the Recertification and Complaint Survey ending on 3/6/25 also cited during the following survey's: a. F689 cited during Recertification Surveys ending on 6/5/23 and 6/24/24, and a Complaint Survey on 10/21/23. b. F812 cited during Recertification Surveys ending on 6/5/23, and 6/24/24. c. F865 cited during Recertification Survey ending on 6/24/24. During an interview on 3/5/25 at 12:20 PM the Administrator reported awareness of repeated deficiencies cited during the past survey and the current survey. The Administrator revealed the kitchen processes is an ongoing project in collaboration with the Dietary Manager to provide staff education, re-education and staff retention. The Administrator revealed the facility continues to work on more efficient communication between floor staff and leadership and continue to implement new QAPI projects until proven successful. Facility management meet informally every month and officially every quarter. The facility policy titled, Quality Assurance and Performance Improvement (QAPI), revised 7/17/23, revealed expectation of the Quality Assessment and Assurance (QAA) Committee to meet at least quarterly and as needed, develop and implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.

Based on observation, clinical record review, and staff and physician interviews, the facility failed to follow physician orders directing treatment for pressure ulcers for 2 of 3 resident's reviewed for pressure ulcers (Resident's #1 and #2), and failed to follow standard infection control practices during wound care for 1 of 1 residents reviewed. (Resident #1.) The facility reported a census of 57 residents. Findings include 1. The Minimum Data Set (MDS) Assessment, dated 7/6/24, revealed Resident #1 diagnoses included multiple sclerosis, diabetes and cerebrovascular accident (a stroke). The resident's Brief Interview for Mental Status (BIMS) score of score 15 out of 15 indicated intact cognition. The MDS indicated Resident #1 required extensive staff support to reposition in bed, transfer to and from bed and chair, and for dressing, toileting and bathing. The assessment revealed the presence of a Stage 3 (a full-thickness ulcer that extends through the skin and into deeper tissue and fat, but does not reach muscle, tendon, or bone) pressure ulcer present on admission to the facility. A wound care Physician Progress note, dated 8/5/24, revealed the resident had a Stage 4 (full-thickness tissue loss that exposes bone, tendon, or muscle) pressure ulcer on the sacrum (tailbone) that measured 4.5 centimeters (cm) long by 2.1 cm wide by 0.4 cm deep. Physician orders dated 7/8/24 directed staff to cleanse the sacral wound with wound cleanser, apply medi honey to wound bed and cover with ABD pad (type of absorbent pad used to manage drainage from a wound) secured with tape. Mix a 1:1 ratio of house antifungal powder and zinc cream for peri wound area daily and as needed (PRN). Review of the resident's August, 2024 Treatment Administration Record revealed Staff C, Registered Nurse (RN) documented she changed the resident's sacral dressing on 8/9/24. During an observation on 8/10/24, started at 10:11 a.m., Staff A, RN stood at the treatment cart positioned in the hall outside the resident's room, squirted zinc oxide paste into a 1 ounce sized medication cup, added an approximate equal amount of antifungal powder and mixed with a wooden spoon. Staff A applied gloves, and carried wound care supplies into the room as Staff B, Certified Nursing Assistant (CNA) cleared an over the bed table in the resident's room. Without sanitizing the surface of the table or applying a barrier, Staff A placed the wound supplies directly on the table. Staff A moved the over the bed table to the resident's bedside, removed the resident's covers, Staff A and Staff B rolled the resident to her left side, Staff A rolled the resident's incontinence brief up and pulled it out from under the resident. Staff A removed her gloves, went to the isolation cart outside of the room for more gloves, returned with 4 gloves and said staff would bring more to the room. Staff A applied gloves, removed an approximate 4 inch by 4 inch foam island type of dressing from the sacrum that was dated 8/9, with Staff C, RN's initials on it. The dressing was approximately 70 percent saturated with red serosanguinous drainage. Staff A, without a change of gloves or hand hygiene continued with care. Staff A sprayed non-sterile gauze squares with wound cleanser, and wiped the left buttocks area near the wound 3 times without changing the surface of the gauze, folded the gauze and wiped over the wound bed two times without changing the surface, sprayed wound cleanser on another non-sterile gauze and wiped the wound, folded the cloth and continued to wipe the left buttocks near the wound without changing the surface of the gauze. Staff A, without a change of gloves or hand hygiene, positioned a medi-honey strip inside the wound, opened the package of the ABD gauze, removed the gauze, unfolded it, applied to the sacral area, Staff B held the gauze in place as Staff A obtained pieces of tape to secure the dressing. Staff A changed gloves, used cleansing wipes, positioned behind the resident and wiped from front to back over the resident's right groin and vaginal area, used a new cleansing cloth and wiped over the resident's vaginal and rectal area, folded the cloth and wiped the left groin area two times without changing the surface of the cloth. Staff A, without a change of gloves or hand hygiene, applied the zinc paste and antifungal mixture to the resident's groin area and stated there was a doctor's order to apply it to her peri area. Staff A did not apply the mixture to the area around the wound as directed by the doctor. During an interview on 8/12/24 at 4:13 p.m., the resident's Wound Care Physician stated staff were directed to apply the zinc oxide with antifungal powder mixture to the skin immediately next to the wound, and that what was meant by the peri-wound description. 2. The MDS Assessment tool dated 7/18/24 revealed Resident #2 had diagnoses that included paraplegia (paralysis of the lower half of the body), morbid obesity and encephalopathy. The residents BIMS score of 13 out of 15 indicated intact cognition. The MDS indicated the resident required extensive staff support to reposition in bed, transfer to and from bed and chair, dressing, toileting and bathing. A Wound Physician Progress note dated 8/5/24 revealed the resident had a Stage 4 pressure sore on the sacrum that measured 10.8 cm long by 15.6 cm wide by 1 cm deep, and had heavy sero-sanguinous drainage (yellow mixed with red colored). The Wound Physician transcribed orders on 8/5/24 Progress Note included: 1. Apply calcium alginate once daily and as needed. ABD pad apply once daily and as needed. Tape (retention) apply once daily and as needed. 2. Antibiotic choice: linezolid (an antibiotic) 600 mg PO (per mouth) BID (twice daily) for 6 weeks. 3. ID (Infectious Disease) consult. A review of the August 2024 MAR on 8/12/24 revealed the lack of a twice daily scheduled linezolid 600 mg, per the 8/5/24 physican order. A Wound Physician Progress note dated 8/12/24 revealed the resident's sacral wound measured 10 cm long by 15 cm wide by 1 cm deep, with heavy purulent drainage (pus mixed with blood), wound progress exacerbated due to infection, and the physician directed the resident's transfer to the hospital for antibiotics administered intravenously due to the wound infection. During an interview on 8/12/24 at 4:14 p.m., the Wound Physician stated staff had not contacted her with questions about the antibiotic ordered, and she was extremely concerned for the resident's condition if staff had not implemented the antibiotic order. During an interview 8/12/24 at 2:24 p.m., the Director of Nursing (DON) stated the Assistant Director of Nursing (ADON) rounds with the wound physician, and she would check with her about the antibiotic order. During an interview on 8/12/24 at 4:26 p.m. the DON stated the ADON did make the referral to the Infectious Disease doctor, but missed the antibiotic order, and the DON contacted the pharmacy and sent the order for the linezolid, it would be delivered that evening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility policy review, the facility failed to clarify and ensure a current copy of a resident's advance directive was in the medical record for 2 of 3 residents (Resident #253 and Resident #15) reviewed for advanced directives. The facility reported a census of 60 residents. Findings include: 1. The Order Summary for Resident #253, dated [DATE], revealed both an active Physician order for full code/cardiopulmonary resuscitation (CPR) with the start date of [DATE] and an active Physician order for Do Not Resuscitate (DNR) with the start date of [DATE]. The Electronic Health Records (EHR) lacked documentation of Iowa Physician Orders for Scope Of Treatment (IPOST). The EHR and Nursing Progress Notes additionally lacked documentation the facility offered or assisted with completion of advanced directives. The Care Plan, initiated [DATE] and revised [DATE], revealed Resident #253 had advanced directives on record with the goal that if the resident's heart stops or if resident stops breathing, CPR will not be initiated in honor on Resident's #253's wishes. 2. The Order Summary for Resident #15, dated [DATE], revealed both an active physician order for Full Code/Cardiopulmonary Resuscitation (CPR) with the start date of [DATE] and an active physician order for Do Not Resuscitate (DNR) with the start date of [DATE]. The Iowa Physician Order for Scope of Treatment (IPOST), dated [DATE], signed by Resident #15's Power of Attorney (POA) and Physician revealed the resident's preference for DNR status with comfort measures only. The Care Plan, initiated [DATE], revealed Resident #15 had advanced directives on record with a goal that if Resident #15's heart stops or if they stop breathing, CPR will be initiated in honor of Resident #15's full code wishes. On [DATE] at 08:37 AM, Staff F, Licensed Practical Nurse (LPN), revealed that advanced directives would be found in each resident's physician orders, located in the EHR, which informed staff of resident's preference for life saving measures. On [DATE] at 01:17 PM, Director of Nursing (DON) informed that until facility had advanced directives in place, new residents would receive full code/CPR life saving measures. DON revealed that Social Services Worker also assisted residents and families with IPOST and advanced directive which caused both CPR and DNR orders to be in place. DON planned to increase interdisciplinary communication and audit medical records to ensure appropriate advanced directives were in place. The facility policy titled, Advanced Directives, revised [DATE], revealed the expectation that the plan of care be consistent with the resident's documented treatment preferences and/or advanced directives and if resident had not established advanced directives, the facility staff would offer assistance to establish advanced directives and instructed nursing staff to document in the medical record the offer to assist with the resident's decision to accept or decline. The policy additionally revealed responsibility of the Director of Nursing or designee to notify the Attending Physician of advance directives so that appropriate orders could be documented in the resident's medical record and plan of care.

Based on record review, policy review, and staff interview the facility failed to have staff complete the Dependent Adult Abuse training within 6 months of hire for 1 of 6 employees reviewed, and to complete the Single Contact License & Background prior to the start date of a nursing staff for 1 of 6 employees reviewed. The facility reported a census of 60 residents. Findings include: 1. During employee file record reviews on 6/20/24 at 9:34 AM Staff C, Certified Nursing Assistant (CNA) was found to be hired on 3/30/23. The Dependent Adult Abuse (DAA) training certificate was absent from her employee file. On 6/20/24 at 11:30 AM, request made to facility administrative staff for documentation of DAA training completion for Staff C, A second request made at 1:36 PM. During an interview on 6/20/24 at 1:44 PM, the Director of Clinical services stated the facility did not have a DAA training certificate for Staff C. 2. During employee personnel file reviews on 6/20/24 at 9:34 AM Staff J, Licensed Practical Nurse (LPN) found to be hired on 5/23/24. A Single Contact License & Background (SING) background check found for Staff J with a completion date of 6/07/24. A review of time card records revealed Staff J worked directly with residents for 12 hour shifts, clocking in at 5:45 AM on 5/28/24, 5/30/24, 6/01/24, 6/02/24, 6/03/24, 6/04/24, and 6/05/24. During an interview on 6/20/24 at 12:56 PM Staff J confirmed she was hired on 5/23/24 and began working on the floor at the end of May. She was hired to work three 12-hour days per week. During an interview on 6/20/24 at 3:08 PM the Director of Clinical Services explained the DAA training must be completed prior to reaching the sixth month of employment. The SING for a new hire must be completed and reviewed prior to an employee's start date. These are per Iowa requirements. The facility lacked a policy regarding timelines for DAA training and SING completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview the facility failed to identify, assess and treat a skin tear in a timely manner (Res# 304). The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], documented Resident #304 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. The MDS included diagnoses: stroke, non-Alzheimer's dementia, and hemiparesis (inability to move one half of the body). The Care Plan updated 5/14/24 included goals to maintain or develop clean or intact skin. Interventions instructed staff to follow facility protocols for treatment of injury, monitor/document location, size and treatment of skin injury, and conduct weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The Physician Order dated 6/05/24 instructed staff to complete a weekly skin evaluation every 7 days. A review of the weekly skin notes, dated 6/13/24, revealed no documentation of a skin tear on the resident's left arm. During an observation on 6/17/24 at 2:40 PM, Resident #304 was sitting in her wheelchair with her left arm contracted toward her chest. There was a large dark brown scabbed area on the top of the forearm. In an interview on 6/18/24 at 3:20 PM Staff D, Registered Nurse (RN) reported the facility does not have skin sheets, wound sheets, or incident sheets. They chart in the Electronic Health Record (EHR). She looked and could not find any documentation for the resident's skin tear. In an interview on 6/19/24 at 8:10 AM Staff E, RN checked the EHR and could not find any documentation for the resident's skin tear. In an interview on 6/19/24 at 8:15 AM the Director of Nursing (DON) explained the facility didn't know the resident had a skin tear. She was just made aware of it last night. The nurses didn't know it had happened or how it happened. During an interview on 6/19/24 at 3:55 PM the DON explained the nurses are supposed to do a skin assessment upon falls and any new open areas. The facility policy titled Skin Assessment, updated 9/2023 instructed staff to: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 2. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview the facility failed to have a physician conduct the first resident assessment within 30 days of admission for three of five residents reviewed (Res #47, Res #5, Res #304). The facility reported a census of 60 residents. Findings include: 1. The Minimum Data Set (MDS) report dated 5/07/24 for Resident #47 documented a Brief Interview for Mental Status (BIMS) score of 9 out of 5 indicating moderately impaired cognition. The MDS diagnoses included: stroke, seizure disorder, and metabolic encephalopathy (chemical imbalance that damages the brain). The Electronic Health Record (EHR) indicated Resident #47 admitted to the facility on [DATE]. A review of the Physician Progress Note dated 2/19/24 at 10:36 AM revealed a new resident initial visit was conducted by a Nurse Practitioner (ARNP). 2. The MDS dated [DATE] for Resident #50 documented a BIMS score of 9 out of 15 indicating moderately impaired cognition. The MDS diagnoses included: fractures and other multiple trauma, renal insufficiency (kidney failure), and GERD (gastroesophageal reflux disease). The EHR indicated Resident #50 admitted to the facility on [DATE]. A review of the Physician Progress Note dated 4/26/24 at 1:23 PM revealed a new resident initial visit was conducted by an ARNP. 3. The MDS report for Resident #304 documented a BIMS score of 3 out of 15, indicating severely impaired cognition. The MDS diagnoses included: stroke, non-Alzheimer's dementia, and hemiparesis (inability to move one half of the body). The EHR indicated Resident #304 admitted to the facility on [DATE]. A review of the Physician Progress Note dated 4/03/24 at 4:31 PM revealed a new resident initial visit was conducted by a ARNP. In an interview on 6/20/24 at 3:08 PM the Director of Clinical Services explained she expected each resident to be seen by a physician within the first 30 days and then they can be seen by an ancillary provider. The facility policy titled Physician Visits and Physician Delegation, reviewed 12/22 instructed the physician to see the resident within 30 days of initial admission to the facility. At the option of the physician, required visits in Skilled Nursing Facilities, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist that is acting within scope of practice defined by State law and under the supervision of the physician.

Based on clinical record review, staff interview, and policy review the facility failed to ensure Certified Nursing Assistants (CNA) were provided routine competency evaluations for two of three employees reviewed. The facility reported a census of 60 residents. Findings include: 1. A review of the employee personnel files on 6/20/24 at 10:05 AM revealed Staff C, CNA did not receive routine competency evaluations. The employee was hired on 3/30/23. 2. A review of the employee education files on 6/20/24 at 10:45 AM revealed Staff K, CNA did not receive routine competency evaluations. Staff K was hired on 4/01/20. On 6/20/24 at 11:30 AM documentation of CNA competency evaluations requested. A second request made at 1:36 PM . On 6/24/24 the Director of Clinical Services reported she could not find a performance evaluation for Staff K. During an interview on 6/20/24 03:08 PM, the Director of Clinical Services explained she expected all staff to complete their core competency requirements for education, including the 12 hours of yearly education and the yearly competency evaluations. The facility knew they were behind. The facility policy titled Competency Evaluation, revised 3/23 instructed the facility to complete subsequent and/or annual competency evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. Checklists must be used to document training and competency evaluations. Employee competency forms must be maintained in the Staff Development Coordinator's office for current training year, then forwarded to the Human Resources Director for placing into the employee's personnel file.

Based on record review, staff interview, and policy review the facility failed to ensure Certified Nursing Assistants were provided the required minimum of 12 hours of in-service education yearly for one of three employees reviewed. The facility reported a census of 60 residents. Findings Include: A review of the employee education files including online training transcripts and in-service sign in sheets on 6/20/24 at 10:05 AM revealed Staff C, CNA did not have 12 hours of in-service education yearly. The employee was hired on 3/30/23. On 6/20/24 at 11:30 AM, a request made to the facility clinical administrative staff to provide documentation of the required education. A second request made at 1:36 PM. In an interview on 6/20/24 03:08 PM the Director of Clinical Service explained she expected all staff to complete their core competency requirements for education, including the 12 hours of yearly education and the yearly competency evaluations. The facility policy titled Required Training, Certification, and Continuing Education of Nurse Aides, revised 10/01/22 instructed the facility to provide at least 12 hours of in-service training annually, based on the employment date, not calendar year. Documentation of in-services must be forwarded to the HR Director and maintained in the employee's personnel file.

Based on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey previously identified during surveys completed in the last twelve months. The facility reported a census of 60 residents. Findings include: 1. Review of the facility's CMS-2567 form from a recertification survey which occurred 04/11/23 to 06/05/23 revealed the facility received immediate jeopardy level and harm level citations related to the following areas: a. Free of accidents, hazards, supervision, and devices b. Food procurement, storage/preparation/service and kitchen sanitation. c. Treatment and services to prevent or heal pressure ulcers The facility's plan of correction for this survey revealed documentation present at the end of the CMS-2567 form included the following: a.) Free of accidents and hazards: Residents were reviewed for elopement risk, interventions placed as appropriate with updated binders located at nurses station and front desk. Facility conducted environmental review of egress doors to ensure functionality and reviewed kitchen serving area to ensure keypad entry locks were in place and functioning. Staff were educated on elopement risk assessments, resident trigger identification, interventions, supervision, response procedures, routine mock drills, behavior alert and communication, and functionality of egress doors. Director of Nursing (DON), or designee, responsible for audits of resident elopement risk assessments and to ensure elopement binder kept up to date. Maintenance Director responsible for review of egress doors to ensure functionality. Administrator responsible for elopement drill documentation to ensure staff participation. b.) Food Procurement, store/prepare/serve-sanitary: Facility reported kitchen surfaces, refrigerator units, drawers, equipment, and floor were cleaned and added ceiling air return vents and AC vents to the routine cleaning schedule. Dietary staff completed food safety training. Dietary and Maintenance staff were educated on routine cleaning and disinfection standards, safe resident environment, personal hygiene, hand hygiene, hair nets, pest control program, and preventative maintenance. Dietary staff were educated on food safety, food handling, routine dietary duties, menus, and communication related to broken equipment. Facility Administrator responsible for conduction of audits to ensure food safety practices demonstrated, routine dietary duties carried out, and menus followed. Quality Assurance/Performance Improvement Committee recommended ongoing quarterly monitoring. c.) Services to prevent or heal pressure ulcers: Licensed staff were educated on the regulation with emphasis on prevention of the development and transmission of infection, clean dressing change process, and interventions to prevent development of pressure ulcers. Director of Nursing (DON), or designee, to conduct licensed staff audits of clean dressing change competency and audits of residents at risk for pressure ulcers to ensure preventative interventions in place. 2. The CMS-2567 form from a complaint survey dated 09/19/23 to 10/12/23 revealed the facility again issued a harm level deficient practice for free of accidents, hazards, supervision, and devices during this specific survey. 3. The facility's current recertification survey, entrance date 06/17/24, resulted in an Immediate Jeopardy level deficient practice for free of accidents and hazards and a harm level deficient practice for services to prevent or heal pressure ulcers. Additionally, the current recertification survey resulted in a deficient practice for food procurement, storage/preparation/service and kitchen sanitation. On 06/24/24 at 09:30 AM, Facility Administrator revealed that kitchen sanitation is an ongoing project in collaboration with Dietary Manager to provide staff education and re-education, and ensure that cleaning lists and temperature logs are completed. Administrator revealed ongoing collaboration with nursing department to determine residents at risk for elopement, and put interventions in place. Administrator stated an elopement drill, code silver, occurred once in past 2 months and had been successful. Administrator revealed that in light of recent elopement all staff educated on immediate communication to leadership if a resident is missing and felt current Quality Assurance Committee is headed in the right direction to resolve repeat deficiencies. The Facility provided documentation of QAPI sign in sheets from the following dates: 02/22/24, 02/28/24, 04/30/24, and 05/30/24. Facility unable to provide additional documentation of sign in sheets prior to the 02/22/24. The facility policy titled, Quality Assurance and Performance Improvement (QAPI), revised 07/17/23, revealed expectation of the Quality Assessment and Assurance (QAA) Committee to meet at least quarterly and as needed, develop and implement appropriate plans of actions to correct identified quality deficiencies, regularly review and analyze data, and act on available data to make improvements. The policy additionally instructs the facility to take action at performance improvement as documented in QAA Committee meeting minutes and action plans with success of the actions to be monitored and documented in subsequent QAA Committee meetings.

Based on personnel file review, staff interview, and policy review the facility failed to ensure staff members were provided mandatory education on the rights of residents and the responsibilities of the facility for 5 of 6 employees reviewed. The facility reported a census of 60 residents. Findings include: A review of the employee education files on 6/20/24 at 9:42 AM revealed the following staff did not have record of resident rights and facility responsibilities education: a. Staff H, Licensed Practical Nurse (LPN) b. Staff C, Certified Nursing Assistant (CNA) c. Staff K, CNA d. Staff A, Dietary Aide e. Staff J, LPN On 6/20/24 at 11:30 AM a request made to facility clinical administrative staff to provide documentation of the required education. A second request made at 1:36 PM. In an interview on 6/20/24 03:08 PM the Director of Clinical Service explained she expected all staff to complete their core competency requirements for education, including the 12 hours of yearly education and the yearly competency evaluations. The facility policy titled Orientation, revised 10/01/22 instructed the facility to create a general orientation plan that reflected the onboarding process for all newly hired employees, and reflected content that is applicable to all staff. It noted general orientation must be completed prior to the employee's formal contact with facility residents. Checklists must be used to document training and competency evaluations conducted during the orientation process. It required all documentation to support completion of the orientation process to be maintained in the employee's personnel file. The facility policy titled Required Training, Certification, and Continuing Education of Nurse Aides, revised 10/01/22 instructed the facility to provide education including resident rights and facility responsibilities.

Based on observations, interviews, facility document review and facility policy review, the facility failed to maintain sanitary conditions for the storage, preparation and handling of beverage cups during 1 of 1 meal services observed; and failed to maintain appropriate temperatures for frozen food stored in 1 of 3 freezers. The facility reported a census of 60 residents. Findings include: On 06/17/24 at 10:10 AM, during an initial tour of the main kitchen, the stand alone freezer thermometer indicated a temperature of 30 degrees Fahrenheit. The kitchen stove top appeared to be coated with a black substance and grease. During an observation of the noon meal on 6/17/24 from 12:15 PM to 12:38 PM Staff A, Dietary Aide served 10 glasses to 9 residents with bare fingers touching the drinking rim surface of the glass. On 06/18/24 at 11:00 AM, throughout lunch preparation the floor in kitchen noted to be heavily flooded around the dishwasher, continuing towards the front of the kitchen near the preparation sink, in front of the steam table, and in front of the food preparation counter. The water on the floor contained food particles, wrappers, dirt, and debris. [NAME] towels placed on the floor in the areas with the water appeared to be heavily saturated, and brown and black in color. The stove top appeared to have a thick yellow crusted substance, pushed towards the back of the stove. A collection of heavy dust visible under the center of a set of three connected refrigerator units. Areas of dust noted on the ceiling above the dishwasher and food preparation areas. On 06/18/24 at 11:30 AM, the stand alone freezer thermometer continued to read 30 degrees Fahrenheit. Freezer contained: 2 rolls of ground beef, box of hamburger patties, 2 packages of pre-made soup, a bag of French toast sticks, and a bag of sweet potato fries. The shelves of freezer felt slightly cool, but not cold. Noted French toast sticks soft to touch and one of the two rolls of ground beef had softened. Dietary Manager confirmed temperature read 30 degrees Fahrenheit, informed staff recently cleaned freezer, which resulted in higher temperature reading. On 06/18/24 at 12:25 PM, following lunch service, stand alone freezer thermometer continued to read 30 degrees Fahrenheit, Dietary Manager indicated thermometer may not be functioning appropriately and planned to change the thermometer. On 06/18/24 at 02:56 PM, a new thermometer placed in stand alone freezer, temperature read 10 degrees Fahrenheit, Dietary Manger revealed freezer not functioning appropriately and planned to notify maintenance staff. On 06/20/24 at 11:38 AM, Dietary Manager revealed the expectation that main kitchen is cleaned daily and for dietary staff to sign off checklist when cleaning tasks are completed. Dietary Manager additionally revealed the expectation of dietary staff to handle resident's drinking glasses in a way that prevents contamination to rim of glass. The facility document titled Freezer Temperature Log, dated June 2024, revealed the following freezer temperature entries: 1. June 6th at 07:00 PM= 20 degrees Fahrenheit 2. June 9th at 07:00 PM= 20 degrees Fahrenheit 3. June 11th at 07:00 PM= 20 degrees Fahrenheit 4. June 12th at 07:00 PM= 40 degrees Fahrenheit 5. June 13th at 07:00 AM= 20 degrees Fahrenheit 6. June 17th at 07:00 PM= 30 degrees Fahrenheit The facility provided dietary staff assignment checklist, not dated, revealed a daily expectation of the cook assigned to record refrigerator and freezer temperatures, clean grill or stove if used, and sweep the floor. The assignment checklist revealed a daily expectation of dietary aides to mop kitchen floor. The facility policy, titled Food Safety Requirements, revised November 2022, instructed staff to monitor food temperatures and functioning of refrigeration equipment daily and at routine intervals during all hours of operation. Policy revealed that all equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. This policy additionally revealed expectation of staff to adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. In an observation on 6/19/24 at 9:02 AM Staff B, Housekeeper noted resident clothes and linens are in a plastic bag upon pickup. She explained staff wore gloves to separate and place the soiled laundry into the washing machines. She further explained staff are not required to wear any other protective equipment when handling soiled laundry. They are to transport all items in a clean, covered bin. A pile of linens were directly on the floor by the dryer. During an observation on 6/19/24 at 11:55 AM Staff B failed to wear a gown and wore only gloves, opened a resident linen bag, and placed towels, linens, and pads in the washer. She placed a personal item on a pile on the floor. She then grabbed linens from a second resident's bag and placed them in the washer. Soiled laundry came into direct contact with Staff B's clothing. In an interview on 6/19/24 at 4:01 PM, the Director of Maintenance explained there's really nothing set in place for what staff are expected to wear when handling soiled laundry. The facility policy titled Handling Soiled Linen, updated 12/05/23 directed staff to: 1. Linen can become contaminated with pathogens from contact with intact skin, body substances, or from environmental contaminants. Transmission of pathogens can occur through direct contact with linens or aerosols generated from sorting and handling contaminated linen. 2. All used linen should be handled using standard precautions (i.e., gloves) and treated as potentially contaminated. Other protective equipment may be required. 3. Linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. 3. The Minimum Data Set (MDS), dated [DATE], for Resident #25 revealed severe cognitive impairment. Diagnoses included cerebral palsy and dysphagia (difficulty swallowing) The Care Plan, revised 07/12/23, revealed Resident #25 required feeding tube related to dysphagia and instructed staff to provide local care to Gastronomy Tube (G-Tube) site as ordered and monitor for signs and symptoms of infection. Care Plan lacked instruction for Enhanced Barrier Precautions or additional Personal Protective Equipment (PPE) to prevent the spread of infection related to chronic internal device. The Medication Administration Record (MAR) revealed current orders for Nothing Per Oral route (NPO), and administration of 45 milliliters (mL) Jevity Liquid Supplement via G-Tube one time a day for dependence on enteral feed with a total run time of 16 hours each day. MAR orders instructed staff to check G-Tube residual and placement and flush with 30 mL of water before and after medication administration. On 06/19/24 at 08:37 AM, Staff F, Licensed Practical Nurse (LPN) prepared, crushed, and mixed with water, Resident #25's morning medications, following Physician orders. Staff F entered Resident #25's room applied hand sanitizer and donned gloves, no additional PPE (i.e. gown) applied prior to medication administration via Gastronomy Tube. No additional signage, staff instruction, or PPE observed upon entrance to Resident #25's room. She paused, clamped, and removed tubing for continuous Jevity feeding from G-Tube site. Staff F flushed G-Tube with water, administered crushed medication mixture, then flushed tube again with water prior to restarting the Jevity tube feeding. She removed gloves and applied hand sanitizer. Based on observations, clinical record review, staff interviews and facility policy review the facility failed to implement Enhanced Barrier Precautions (EBP) for 2 of 2 resident reviewed for EBP (Resident #9, #25). The facility failed to handle laundry with Personal Protective Equipment (PPE) for 2 out of 2 observations. The facility reported a census of 60 residents. Findings include: 1. The MDS for Resident #9 dated 5/1/24, listed diagnoses of venous insufficiency and diabetes mellitus. The MDS reflected she scored 11 out of 15 on the Brief Interview for Mental Statues (BIMS), indicating moderately impaired cognition. The MDS reflected 2 venous ulcers. The Diagnoses Sheet for Resident #9 dated 6/20/24, listed diagnoses resistant to multiple antimicrobiales drugs (MDRO), venous insufficiency and diabetes mellitus. The Care Plan for Resident #9 revised on 5/20/24, lack her MDRO diagnosis and lack intervention related to EBP. The facility Matrix dated 6/12/24, listed Resident #9 with a stage 4 pressure ulcer (a deep tissue injury that involves full-thickness skin loss and exposure of bone, tendon, or muscle). The Order Summary Report for Resident#9 dated 6/17/24, failed to direct EBP. The Wound Evaluation & Management Summary dated 6/3/24, described a Stage 4 pressure wound of the right heel full thickness 1.2 centimeters (cm) by 1.2 by 0.1 cm. Surface 1.44 cm. Thick black necrotic tissue 100%. wound improved decreased surface size. Apply Betadine once daily for 30 days. On 6/17/24 at 11:50 AM, Resident# 9's room door held (PPE) personal protective equipment that included gowns. On 6/19/24 10:22 AM Staff F Licensed Practical Nurse (LPN) used alcohol based hand sanitizer and applied gloves. Staff F completed treatments to Resident #9's left great toe, left shin and her left heel wound. Staff F failed to apply a gown while she completed the wound care. On 6/20/24 at 09:54 AM Staff F reported Resident # 9 room door held the PPE because of Carbapenem-resistant Acinetobacter baumannii (CRAB) in the urine. On 6/20/24 at 1:16 PM, the Infection Preventionist (IP) reported she expected staff to use the EBP with tube feedings, wounds, catheter, and IV (intravenous). She said she's put a system in place for the staff to know when to use EBP. She reported the doors need a sign and the PPE hung. She stated she's done some education on the PPE needed. On 6/20/24 at 1:24 PM, the IP at R#9's room confirmed the facility failed to indicate the needed for EBP. She reported she has the signs on order and has the PPE needed for EBP. The facility provided a policy titled Enhanced Barrier Precautions dated 10/4/23, directed it is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms (MDROs). Enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. Novel or targeted MDROs are organisms that are resistant to all or most antibiotics tested, are uncommon in a geographic area, or have special genes that allow them to spread their resistance to other germs. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheotomy/ventilator) regardless of MDRO colonization status. 2. On 6/20/24 at 9:33 AM, Staff B Housekeeping/Laundry delivered clothes on the A wing hall with the hung laundry cart open on the side to remove the hung clothes by A16. The hung laundry cart remained open as staff moved the cart to the other end of the hall as she delivered clothes. Nursing staff passed by as they picked up meal trays from resident's rooms. At 09:53 AM Staff B by room A3 covered the cart. On 6/20/24 at 1:16 PM, the Infection Preventionist (IP) reported she expected the linen covered in the hall while transported. 06/20/24 12:15 PM the policy titled Infection Prevention and Control Program revised 7/1/23, reflected; This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy failed to address the Enhanced Barrier Precautions (EBP). The Linens section of the policy included: a. Laundry and direct care staff should handle, store, process, and transport linens to prevent the spread of infection. b. Clean linen shall be separated from soiled linen. c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. d. Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. f. Environmental services staff shall not handle soiled linen unless it is properly bagged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and resident and staff interviews the facility failed to keep the facility free from vermin. The facility reported a census of 60 residents. Findings include: 1. During an observation on 6/17/24 at 2:40 PM a hole in the outside soffit (underside of roof overhang) measuring roughly 2 feet by 2 feet on the right side of the entrance was found. In an interview on 6/18/24 at 11:59 AM Staff D, Registered Nurse (RN) remarked she had heard things in the ceiling and assumed they were raccoons. In an interview on 6/18/24 at 12:31 PM Staff I, Occupational Therapist noted she had heard residents complain about raccoons in the ceiling. She reported there is a crawl space attic above the front of the building. In an interview on 6/18/24 at 1:30 PM the Director of Maintenance stated he started working at the facility about three months ago. At that time, he put all the soffit back up that had fallen down. He reported there were raccoons in the facility before he started. He was just made aware of the hole on the right side of the entrance yesterday. He thought it was probably squirrels this time. He stated the pest control service did come yesterday to set and move mouse traps in the building. In an interview on 6/20/24 at 10:07 AM the vermin control professional reported there were two holes in the outside soffit. He noted there was an actual raccoon entrance hole on the [NAME] of the front entrance. He explained the only thing that makes holes like that are raccoons and reported the facility definitely had raccoons going up there. In an interview on 6/20/24 at 12:42 PM the Director of Maintenance explained the pest control company had been there every month, twice this month putting mouse traps out and moving them around the building. He noted mice have been in the building since he started in March. 2. The MDS dated [DATE] for Resident #20 revealed a BIMS score of 15 out of 15, indicating intact cognition. On 06/17/24 at 11:20 AM Resident #20 stated I have seen mice. I saw them down where we go out to smoke in the dining room going under a heater vent. I think it is because people drop their food on the floor. 2. The MDS dated [DATE] for Resident #154 revealed a BIMS score of 15 out of 15 indicating intact cognition. On 06/17/24 at 11:46 AM Resident #154 stated there are mice in the building and I see them everyday. He pointed out a mouse trap in the corner of his room in the corner. There is a hole by the front door. You can hear the raccoons up in the room. Mice run out in front of you at night. On 06/20/24 12:09 PM Staff L, Certified Nursing Assistant ( CNA) stated I saw a mouse in the women's bathroom on L hall just on Saturday. They have had the problem a while, I have seen exterminator in the building and there also one down in a residents room. I seen a mouse on L hall and also on C hall. On 06/20/24 12:17 PM Staff H, Registered Nurse (RN) stated I saw a mouse one about a week ago on A hall. I reported it to the Administrator I haven't seen anything being done that I am aware of but only here two days a week. The facility provided a policy titled Pest Control with a revision date of 4/5/21 revealed staff facility- wide pest-control strategies are developed emphasizing kitchens, cafeterias, laundries, central sterile supply areas, loading docks, construction activities, and other regions prone to pest infestations. Guidelines included: 1. On-going measures are taken to prevent, contain, and eradicate common household pests such as roaches, ants, mosquitoes, flies, mice, and rats. 2. General measures to decrease pests include the elimination of cracks and crevices, proper lighting and ventilation, use of screens on windows and doors, and use of self-closing doors. 3. Monitor for breaks in screens and doors on a routine basis. 4. Food stored in the dietary area is kept in a designated area in securely covered containers, is off the floor and away from the walls. 5. Any food items kept in residents ' rooms stored in covered containers or sealed bags, except uncut fruits such as bananas or oranges. Review resident plan of care for non-compliance with food storage and provide education as needed. 6. Maintain garbage storage area(s) in a sanitary condition to prevent the harborage and feeding of pests. 7. A contract with a pest control company may be elected to assure regular inspection and application of chemical pesticides. 8. The facility will contract for routine pest control service by a credentialed pest-control specialist. The pest control contractor shall have knowledge of pest control treatment methods for healthcare facilities. 9. Facility employees shall not handle or apply pesticides. 10. Regular inspections by the local and county sanitation departments are part of the pest control program. 11. The facility will follow applicable state and local regulations on regular pest control. 12. Maintenance Director or designee will maintain records of pest control program and applicable contracts with pest control services, including applicable SDS (Safety Data Sheets) for pesticides applied. 13. The facility shall maintain a method for staff to notify the Maintenance department when pests are identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and the facility policy, the facility failed to ensure the resident's urinary catheter bag and tubing didn't touch the floor for 1 of 3 residents reviewed for incontinent cares (Resident #14). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #14 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated cognition moderately intact. The MDS revealed the resident used an indwelling catheter. The MDS revealed medical diagnoses of neurogenic bladder and obstructive uropathy. The Care Plan revealed a focus area dated 12/23/22 for indwelling catheter related to urinary retention, obstructive and reflux uropathy. The intervention dated 12/23/22 revealed position catheter bag and tubing below the level of the bladder. The EMR (Electronic Medical Record) revealed the following medical diagnoses: a. flaccid neuropathic bladder, not elsewhere classified b. retention of urine, unspecified The Physician Orders revealed the following orders: a. Routine catheter change with Foley size 16 F (french) and 10 ml (milliliters). May go up in size catheter diameter and/or balloon size as needed to fit resident's needs- ordered on 2/14/24. b. Monitor for Foley catheter output every shift- ordered on 5/29/23. The Progress Note dated 1/26/24 at 2:50 PM, revealed resident returned from Urology appointment related to hypotonic bladder , chronic urinary retention and history of UTI's (urinary tract infections). No new orders. Continue daily Keflex, oxybutynin, and Foley catheter changes every 4 weeks. Follow up in 6 months. During an observation on 3/18/24 at 2:02 PM, Resident #14's catheter tubing laid on the floor under her wheelchair. The catheter bag hung on the inside of the wheelchair below the bladder. During an observation on 3/19/24 at 12:04 PM, Resident #14's catheter bag hung under the wheelchair seat of the resident. The bottom of the catheter bag touched the floor. During an observation on 3/19/24 at 2:53 PM, Resident #14 sat in her wheelchair in the dining room and her urinary catheter bag hooked under the wheelchair seat and the catheter bag touched the floor. During an observation on 3/19/24 at 3:05 AM, Resident #14 self propelled herself down the hallway. The catheter bag drug on the floor as she self propelled down the hallway. During an observation on 3/19/24 at 3:07 PM, Resident #14 entered her room and stood up and got into her bed. The catheter bag remained under the wheelchair seat. During an observation on 3/19/24 at 3:36 PM, a staff member escorted Resident #14 out to the dining room table. Resident sat in her wheelchair and the urinary catheter bag hooked under the seat. The catheter bag touched the floor when the resident sat at the table. During an observation on 3/20/24 at 8:22 AM, Resident #14 sat in her wheelchair in the dining room. Her catheter bag hung under the wheelchair and the catheter tubing touched the floor when the resident self propelled in her wheelchair. During an observation on 3/20/24 at 12:14 PM, Resident #14's urinary catheter tubing touched the floor under the resident ' s wheelchair. During an observation on 3/20/24 at 4:15 PM, Resident #14 sat in her wheelchair in the dining room. The catheter bag and tubing touched the floor. During an interview on 3/19/24 at 4:32 PM, Staff A, CNA (Certified Nurse Aide) queried if the catheter bag could touch the floor and she stated no. Staff A was asked if the catheter tubing could touch the floor and she stated no. During an interview on 3/20/24 at 1:29 PM, Staff B, CNA confirmed the urinary catheter bag and the catheter tubing never should touch the floor. During an interview on 3/20/24 at 4:33 PM, Staff C, LPN (Licensed Practical Nurse) queried on where the catheter bag needed placed on a resident and she stated under the chair below the waist line. Staff C was asked if the catheter bag and tubing could touch the floor and she stated no, they couldn't. During an interview on 3/20/24 at 5:09 PM, the Director of Nursing (DON) queried on where the catheter bag needed placed on a resident and she stated below the height of the bladder. The DON was asked if the catheter bag and tubing could touch the floor and she stated no, they shouldn't be on the floor. The Facility Catheter Care Policy dated 1/1/24 revealed the following information: a. Ensure catheter tubing secured to prevent touching the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, Pharmacist and staff interviews, and facility policy review, the facility failed to receive and administer medications for a newly admitted resident as prescribed and ordered by the physician for 1 of 3 Residents reviewed (Resident #1). The facility reported a census of 59 residents. Findings include: A Daily Skilled Progress Note dated 12/7/23 at 7:18 PM, documented Resident #1 admitted to the facility for skilled services. The note recorded the resident with the following conditions: GU (genitourinary, referring to the reproductive or urinary system), neurological (brain or nerve related), and mood condition. Hospital records for the prior hospitalization from 11/23/23 to 12/7/23 revealed the diagnosis for the visit as seizure and stroke risk. A review of hospital records for the 11/23/23 admission revealed prior to discharge the resident last received the anti-epileptic medications as following: a. Lamotrigine 100 milligrams (mgs) 1 tab at 12/7/23 at 9:24 AM. b. Levetiracetam, intravenous (IV) 1000 mg/ml (milliliter) per 10 ml on 12/6/23 at 10:11 PM. c. Lacosamide 100 mg 12/7/23 at 9:15 AM. d. Valproic acid via intravenous 750 mg/7.5 ml. Hospital Discharge Instructions dated 12/7/23 included the following orders: a. Lamotrigine 100 mg by mouth twice daily (drug class anti-epileptic medication). b. Levetiracetam 500 mg by mouth twice daily (drug class anti-epileptic medication). c. Stop taking Valproic Acid 150 mg Twice daily (drug class anti-epileptic medication). A Progress Note dated 12/8/23 at 8:00 AM, by Staff A, Registered Nurse (RN) revealed the resident had seizure activity and went to the emergency room (ER) via medics, the Director of Nursing (DON) and family notified. Hospital records dated 12/8/23 revealed a Neurological Consultation Note documenting Assessment/Plan included Status epilepsy - based on multiple seizures during 30 minutes. The note stated the seizures occurred due to lack of medications, please restart all of her medications. The Electronic Medication Administration Record (EMAR) for December 2023 documented: a. Lamotrigine 100 mg: 1. On 12/7/23, during the 7:00 PM medication pass documented given by Staff B, Licensed Practical Nurse (LPN). 2. On 12/8/23, during the 6 AM to 9 AM medication pass documented a 6 by Staff A, Registered Nurse (RN). The Chart Code on the EMAR revealed a 6 is used to indicate hospitalization. b. Levetiracetam 500 mg: 1. On 12/7/23 during the 7:00 PM medication pass documented an X. 2. On 12/8/23 during the 6 AM to 9 AM medication pass documented a 3 by Staff A. The Chart Code on the EMAR revealed a 3 is used to indicate absence from the home. During an interview on 12/12/23 at 1:29 PM, the DON stated the resident's admission occurred late in the day on 12/7/23. She explained the medications were never received from the Pharmacy the night of admission. The DON stated the discharge instructions were faxed to the Pharmacy on 12/7/23. She talked to the Pharmacy and they reported to her they never received any orders for medications. The DON stated a nurse should have called the Pharmacy to follow up. During an interview on 12/18/23 at 2:34 PM, Staff A stated during the morning nurse to nurse report on 12/8/23 she learned Resident #1's medications had yet to be delivered from the Pharmacy. Staff A stated she would use the facilities Electronic Medication Management Assistant [NAME]) when this happens. The [NAME] is an emergency kit containing stock medications that can be used if a resident has an order for a medication that can not be immediately delivered by the Pharmacy. Staff A stated the [NAME] went down the night before [12/7/23] so medications could not be pulled for the resident. Staff A reported she had not administered any medication to the resident prior to the seizure activity starting. During an interview on 12/18/23 at 2:48 PM, the Consulting Pharmacist stated the facilities [NAME] mediation list does not include Lamotrigine or Levetiracetam. The Pharmacist stated the half life for Lamotrigine is 12 hours and for Levetiracetam it is 8 hours. The Pharmacist stated it is difficult to say missing one dose of each medication would cause seizure activity. The Pharmacist stated the Pharmacy did receive the fax after 5:00 PM, when the Pharmacy closed. He stated the Pharmacy would not know a new order had been faxed unless the facility called the on-call number. The Pharmacist stated per the on-call record for 12/7/23, the on-call did not receive a call from the facility about the new orders submitted for Resident #1. During an interview on 12/19/23 at 11:24 AM, Staff B, Licensed Practical Nurse (LPN) stated she worked 6:00 PM to 6:00 AM on 12/7/23. She stated Resident #1 arrived prior to the start of her shift. She stated during nurse to nurse report she learned the orders had been faxed to the Pharmacy, and entered into the electronic record. Staff B stated she believed the on-call Pharmacist had been contacted prior to her shift about the new orders faxed for the resident. She denied being informed the need to follow up with the on-call Pharmacist. She stated she did not expect the medication to be delivered due to the late hour, and planned to pull medications form the [NAME]. Staff B stated she attempted to pull medications from the [NAME], but the machine locked up and no medications were able to be pulled. Staff B stated she did not administer any medications to the resident during her shift. Staff B stated she cannot explain why she documented the administration of Lamotrigine on the evening 12/7/23 medication pass. Staff B stated she completed an assessment on the resident and had no concerns. She noted the resident to be stable during the night. In the early morning the resident reported feeling sick. Staff B stated staff sat the resident up in bed and gave her an emesis basin During an interview on 12/19/223 at 2:20 PM, the DON stated a mistake had been made in failing to secure the medications for Resident #1. She presented a facility Action Plan dated 12/8/23 to address medications not delivered in a timely manner. The Action Plan indicated a Root Cause Analysis had been completed. The outcome identified with two potential causes for the problem: a. Pharmacy and facility communicated ineffectively. b. Pharmacy failed to deliver medication in a timely manner. The Action Plan indicated employee education for the process for new admissions which included: a. Entering orders into the electronic health record, then contacting the pharmacy. b. Document the person spoken to at the Pharmacy and validate receipt and anticipated delivery time of medications. The education started on 12/13/23 and is ongoing. The Action Plan called for the DON to review each new admission to validate the arrival of medication from Pharmacy for 30 days, then reevaluate the effectiveness of the process. The facility policy, dated 9/27/23, titled admission of a Resident, failed to address processing resident medication orders upon admission.

Based on clinical record review, personnel record review, the Iowa Board of Nursing and staff interviews, the facility failed to ensure that nursing staff had appropriate competence to administer intravenous (IV) medications, fluids and assessment skills related to care for 2 residents with central IV lines (Resident's #3 and #4), and compliance with mandated regulations that included those set forth by the Iowa Board of Nursing for 2 nursing staff, Staff F, Licensed Practical Nurse (LPN) from a staffing agency, and Staff G, facility LPN. The facility reported a census of 56 residents. Findings include: 1. The 7/6/23 Minimum Data Set (MDS) Assessment tool revealed Resident #3 had diagnoses that included renal failure, intestinal malabsorption, anxiety and long term use of antibiotics. The MDS documented the resident required assistance of 1 staff to reposition in bed, transfer to and from bed and chair, dressing, toileting, personal hygiene, and unable to ambulate. The Nursing Care Plan included the following problem: Resident is receiving TPN (total parenteral nutrition) Initiated 9/27/2023, and directed staff: a. If IV is infiltrated, stop infusion and thoroughly examine the site. If the catheter appears to be lodged in the tissues, an attempt to aspirate any fluid remaining in the catheter can be made in order to lessen the amount of drug at the site. After removing the cannula, elevate the affected arm, notify the physician (for large infiltrations and extravasations), and apply cool compresses. Initiated 9/27/2023 b. IV DRESSING: Observe dressing every shift. Change dressing and record observations of site. Change and dress per doctor orders. Initiated 9/27/2023 c. Monitor/document/report any signs or symptoms of infection at the site: Drainage, Inflammation, Swelling, Redness, Warmth. Initiated 9/27/2023 d. Monitor/document/report signs or symptoms of leaking at the port site: Edema at the insertion site, Taut, shiny or stretched skin, whitening/blanching or coolness of the skin, slowing or stopping of the infusion, leaking of fluid out of the insertion site. Initiated 9/27/2023 e. TPN dedicated central line: Dressing Change Weekly on Wednesdays and PRN one time a day every Wed for maintenance. Initiated 9/27/2023 The hospital Physician Progress Note dated 10/2/23 revealed the resident had a peripherally inserted central catheter (PICC) intravenous (IV) line (a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart, utilized for long-term administration of IV fluids, medications and nutrition) inserted to the right arm on 9/1/23. The Physician Order dated 9/27/23 directed staff to flush the PICC line with 10 milliliters (ml) Sodium Chloride IV every day and night shift. Documentation in the resident's September, 2023 and October, 2023 Medication Administration Record's (MAR's) revealed Staff F, LPN, contracted through a staffing agency, documented she flushed the PICC line on the 9/28/23, 10/6/23 and 10/10/23 day shifts. Documentation provided by the staffing agency revealed Staff F had a multi-state LPN with LPN Expanded IV Therapy nursing license effective 1/26/17 to 12/31/23, without state of origin or curriculum provider referenced. The facility's IV Therapy policy dated 8/2/22 stated the facility would follow accepted standards of practice regarding infusion practices. Regulations specific to nursing care and intravenous (IV) therapy, mandated by the Iowa Board of Nursing (IBN) and posted on their website (https://nursing.iowa.gov), with the most recent changes effective 12/22/21, directed the following: A licensed practical nurse (LPN), under the supervision of a registered nurse (RN), may engage in the limited scope of practice of intravenous (IV) therapy. The LPN shall be educated and have documentation of competency in the limited scope of practice of IV therapy. Limited scope of practice of IV therapy may include: a. Administration of a prefilled heparin or saline syringe flush, prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or RN, to an established peripheral lock, in a licensed hospital, nursing facility or a certified end-stage renal dialysis unit. An LPN shall be permitted to perform, in addition to the functions set forth in sub-rule 6.3(5), procedures related to the expanded scope of practice of IV therapy upon completion of the IBN-approved expanded IV therapy certification course and in accordance with the following: a. The course must be offered by an approved IBN provider of nursing continuing education. Documentation of course completion shall be maintained by the LPN and employer. b. The IBN-approved course shall incorporate the responsibilities of the LPN when providing IV therapy via a peripheral IV catheter, a midline catheter and a peripherally inserted central catheter (PICC) to children, adults and elderly adults. c. Upon completion of the course, when providing IV therapy, the LPN shall be under the supervision of a RN. Procedures which may be performed if delegated by the RN include: (1) Administration, via a peripheral IV catheter, midline catheter, and a PICC line, of IV antibiotic solutions prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or RN. The first dose shall be administered by the RN. Staff interviews revealed: On 9/28/23 at 4:10 p.m., the Director of Nursing (DON) and Administrator, interviewed together, stated Staff G, LPN, was IV certified in Florida, currently in the process of obtaining a copy of the certificate, the Administrator stated the staffing agency utilized by the facility was to provide LPN's that were IV certified. The DON stated there was always an RN in the building when IV medications and care were administered, she returned to the facility to administer IV care when an RN wasn't on duty. On 10/5/23 at 9:46 a.m., an IBN staff member stated LPN's must complete an IV therapy course that was approved by the IBN in order to provide IV therapy and care in Iowa, the multi-state nursing compact rules for nursing licensure did not include certification for IV therapy practice obtained in other States unless the curriculum was approved by the IBN, and a full listing of the approved providers for the IV therapy curriculum was listed on their website. On 10/10/23 at 3:27 p.m. Staff F, agency LPN, stated she attended a nursing program that included IV therapy for the expanded LPN role in the state of Mississippi, where she was originally licensed as an LPN. She had a multi-state nursing license, her IV certification information has transferred with her nursing license information every place she has worked and she could provide IV care through her multi-state nursing license. Staff F stated she had flushed IV PICC lines when she worked at the facility, and was unaware the curriculum and program where she received her IV education was not approved by the IBN, she was not licensed and did not have the authority to provide IV therapy or care in the state of Iowa. On 10/11/23 at 2:42 p.m. the Administrator stated she was not aware of the specific requirement by the IBN that IV training had to be in the state of Iowa, she spoke with the IBN yesterday and learned this information, and both Staff F, agency LPN and Staff G, LPN were instructed on 10/10/23 they could not provide IV care at the facility. 2. The 9/25/23 MDS Assessment tool revealed Resident #4 had diagnoses that included diabetes, renal insufficiency, urinary tract infection and renal calculi (kidney stone). The MDS documented the residednt required extensive assistance of at least 1 staff to reposition in bed, transfer to and from bed and chair, dressing, toileting, bathing and personal hygiene. The Nursing Care Plan included the following problem: Frequent incontinence of bowel and bladder, initiated 10/27/2022, directed staff: a. Monitor/document for signs or symptoms of a urinary tract infection (UTI) such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temperature, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Initiated 10/27/2022 The hospital Discharge Summary report dated 9/21/23 directed the nursing home staff to administer Ceftriaxone (a very strong antibiotic) 2 Grams IV daily for 5 days. The resident's September 2023 MAR revealed Staff G, facility LPN, administered the Ceftriaxone on 9/24/23. A copy of Staff G's IV certification revealed the education was completed 5/9/06 by a Florida continuing education provider. Staff interviews revealed: On 10/11/23 at 10:36 a.m., Staff G, facility LPN, stated she has administered IV medications including flushes and antibiotics at the facility, her IV certification was from Florida, and acknowledged she administered the resident's Ceftriaxone in September. Staff G was not aware of the requirement for the IV certification course to be completed at a continuing education provider approved by the IBN.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The 3/9/23 MDS Assessment Tool listed diagnoses for Resident #63 which included diabetes, burns, and unspecified fall and listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The MDS identified the resident admitted to the facility on [DATE]. During an observation on 4/12/23 at 7:41 a.m., Resident #63 had a garbage receptacle in her room near her bed which overflowed with refuse. The bathroom contained no garbage can and the resident stated she did not have one for the bathroom and had not had one since she admitted on [DATE]. She stated she was incontinent and when she had to change her brief, she had to carry the soiled brief out of the bathroom into her room and stated this was not sanitary. Care Plan entries, stated 3/13/23, stated the resident had occasional bladder incontinence and stated she utilized incontinence briefs. The facility policy Resident Rooms Furniture reviewed March 2023, documented the facility would furnish rooms with functional furniture arranged according to resident needs and preferences. The policy did not include information regarding garbage cans in bathrooms. Based on observations, clinical record review, staff interviews and policy review, the facility failed to provide items in residents' rooms to meet resident needs for 2 of 26 residents reviewed (Residents #52 and #63). The facility reported a census of 69 residents. Findings Included: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #52 as cognitively intact with a Brief Interview for Mental Status score of 12 out of 15 and had the following diagnoses: end stage renal disease (required Dialysis), heart failure and coronary artery disease. The MDS also identified the resident extensive staff assistance with bathing and required limited staff assistance with transfers, walking in and out of his room, toileting and personal hygiene. Observations of the resident's room revealed the following: a. On 4/11/23 at 11:09 AM, the resident lying in bed with several plastic zippered bags on the floor next to his bed which contained food. The room did not have a nightstand and he reported he had not had a nightstand since he moved in (1/31/23). b. On 4/11/23 at 2:23 PM, assessment unchanged, currently in the therapy room. Remains without nightstand in his room and Ziploc bags containing food on the floor beside his bed. c. On 4/12/23 at 9:40 AM, room remains without a nightstand and plastic zippered bags on the floor beside his bed d. On 4/12/23 at 12:18 PM, assessment unchanged. e. On 4/13/23 at 7:18 AM, asleep in bed and room remains without a nightstand. f. On 4/17/23 at 8:06 AM, currently not in his room, out at Dialysis. Room remains without nightstand and bags of potato chips on the floor next to his bed. The Care Plan with the last revision date of 2/8/23 identified the resident with the problem of an activities of daily living (ADL) performance deficit and did not identify the need to ensure his room had been equipped to meet his needs. Interviews with staff revealed the following: a. In an interview on 4/24/23 at 1:46 PM, the Social Worker reported every resident should have a nightstand and that the facility just received a lot of new nightstands. b. In an interview on 4/25/23 at 9:06 AM to 9:23 AM, Staff OO, Certified Nursing Assistant/Certified Medication Aide (CNA/CMA) reported Housekeeping is supposed to make sure the room is all set up before the resident moves in, then the Nurse and CNA need to follow up if anything is missing. She did not know why Resident #52's room did not have a nightstand. c. In an interview on 4/25/23 at 10:24 AM, Staff PP, CNA reported all staff, including Housekeeping had the responsibility to ensure the resident's room had the items needed, such as a nightstand. She had not been aware that Resident #52 did not have a nightstand in his room. d. In an interview on 4/25/23 at 3:04 PM , the Director of Nursing (DON) reported she would expect the following items to be placed in all resident rooms: basic hygiene needs, night stand and trash can. Both housekeeping and nursing staff had the responsibility to ensure all items had been placed in the residents' rooms. The facility policy titled: Resident Rooms Furniture dated as last revised March 2023 had documentation of the following: 1. Each resident will have: a. Functional furniture appropriate to the resident's needs. 2. The facility shall request and/or maintain variances from the survey agency if the room variances: a. Are in accordance with the special needs of the resident; b. Will not adversely affect the residents' health and safety. 3. Resident rooms will be furnished with functional furniture and arranged according to resident needs and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS Assessment Tool, dated 5/16/22, listed diagnoses for Resident #121 which included heart failure, high blood pressure, diabetes, and cerebral vascular accident (which is an interruption in the flow of blood to cells in the brain), and aphasia resulted (when a person has difficulty with their language or speech), and listed the BIMS score as 7 out of 15, indicating severely impaired cognition. The Care Plan dated 4/13/22 showed the resident had communication problems related to Expressive Aphasia (a condition where a person may understand speech, but they have difficulty speaking fluently themselves). On 5/9/22 the Care Plan was updated to include behaviors of confabulation in regard to not getting medications, food, and believing things that are not true. During an interview on 4/17/23 at 8:20 AM, the resident's POA stated not being notified when the resident had been transferred to an emergency room (ER) for evaluation on 5/16/22. Review of the Iowa Physician for Scope of Treatment (IPOST) dated 4/14/22 showed the interviewee had been the POA since the date signed. Review of Resident #121 electronic health record lacked documentation of the POA notification when the resident transferred on 5/16/22 for an ER evaluation. A review of the facility policy titled: Notification of Changes dated as last reviewed March 2023 documented the following: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents a. Resulting in injury. b. Potential to require physician intervention. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include life-threatening conditions, or clinical complications, circumstances that require a need to alter treatment. This may include: new treatment. discontinuation of current treatment due to: adverse consequences, acute condition or exacerbation of a chronic condition. 3. A transfer or discharge of the resident from the facility. 4. A change of room or roommate assignment. 5. A change in resident rights. Based on clinical record review, staff and resident representative interviews and facility policy review, the facility staff failed to document the residents' Power of Attorney (POA)) had been notified of room changes, physician appointments and transfers to the hospital for two of two residents reviewed (Residents #9 and #121). The facility reported a census of 69 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #9 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 2 out of 15 and had the following diagnoses: Renal Insufficiency, Non-Alzheimer's Dementia and Bipolar Disorder. The MDS also identified the resident required extensive staff assistance with bed mobility, transfers, dressing, toileting and hygiene. In an interview on 4/13/23 at 3:49 PM, the resident's POA reported the resident had been moved to different rooms four different times and the facility did not notify her of the room changes and of a doctor's appointment they made for her to be seen by a doctor in Iowa City for a spot on her nose that she constantly picks at daily. The POA also reported there has been a total lack of communication from the facility to inform her of different issues. On 1/31/22 the Care Plan identified the resident with the problem of being at risk for COVID, however did not address the need to notify the POA/family of room changes. A review of the Social Worker and Nurse's Progress Notes in the past year revealed no documentation that the POA notified of the room changes or of the doctor's appointment. A review of the electronic medical record revealed resident lived in the following rooms: a. On 3/23/22 room A 15-2. b. On 5/6/22 room B 8-1. c. On 7/5/22 room [ROOM NUMBER]-1. d. On 1/6/23 room [ROOM NUMBER]-1. e. On 1/6/23 room A 11-2. f. On 1/18/23 room [ROOM NUMBER]-1. In an interview on 4/25/23 at 9:43 AM, Staff D, Licensed Practical Nurse (LPN) reported the resident's POA should be notified with any changes in the resident's condition, orders or behaviors. The nurses are responsible for contacting the POA and this should be documented in the progress notes. In an interview on 4/25/23 at 9:53 AM, Staff K, Registered Nurse (RN) reported the resident's POA should be notified with any changes in the resident's condition, injuries or if the resident is sent to the hospital. The nurse working the floor is responsible for notification and should document in the progress notes. In an interview on 4/25/23 at 3:05 PM, the Director of Nursing (DON) reported she would expect nurses to notify family with any change of condition, if there is a reportable incident or a room change and document it in the progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and policy review, the facility failed to report an allegation of abuse for 3 of 10 residents reviewed for abuse (Residents #12, #21,and # 70). The facility reported a census of 69 residents. Findings Include: 1. The Minimum Data Set(MDS) Assessment Tool, dated 1/3/23, listed diagnoses for Resident #70 which included heart failure, paraplegia (paralysis from the waist down), and anxiety disorder. The MDS documented the resident required supervision assistance of 2 staff for personal hygiene, limited assistance of 2 staff for transfers, extensive assistance of 1 staff for dressing, extensive assistance of 2 staff for toilet use, and depended completely on 2 staff for bathing. The MDS listed the resident's Brief Interview for Mental Status Score (BIMS) of 14 out of 15, indicating intact cognition. A 5/30/22 Behavior Note for Resident #70 stated Resident #70 rammed her wheelchair into Resident #21 and then Resident #21 stood up to hit Resident #70. A 5/31/22 Physician Note for Resident #70 documented the resident admitted to punching a [AGE] year old (Resident #21) resident and no injuries were sustained. A 6/2/22 Physician Note for Resident #21 stated the resident denied being punched. A 8/27/22 General Note documented Resident #70 and her roommate (Resident #12) threw water at each other and the resident changed rooms. A 7/19/22 Care Plan entry stated the resident could be verbally aggressive related to ineffective coping skills and poor impulse control. An 11/25/22 revision of the entry stated on 11/10 the resident was physically aggressive and required 1:1 monitoring. The Care Plan lacked documentation of alleged physical altercations prior to 11/25/22. In an interview on 4/25/23 at 8:35 a.m., Staff JJ, Licensed Practical Nurse (LPN) stated Resident #70 had physical altercations with other residents. She stated once Resident #70 smoked outside and she threw a lit cigarette on another resident. She stated she did not see this but heard about it. In an interview on 4/25/23 at 1:00 p.m., the Director of Nursing (DON) stated she heard about the allegation that the resident threw a lit cigarette. She stated staff should report physical altercations between residents and the facility would separate the residents and interview residents and staff. She stated the Care Plan should address the resident's behaviors. In an interview on 4/27/23 at 10:50 a.m., the Administrator stated staff should report allegations of abuse within 2 hours. She stated the facility would investigate the allegation and would separate the residents. The facility lacked documentation of an investigation related to the above altercations and lacked documentation they reported the allegations to the State Agency or separated the resident from other residents. The facility policy Abuse, Neglect, and Exploitation, dated March 2023, stated the facility would provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident property. The policy stated the facility would complete an immediate investigation and ensure all residents were protected upon a suspicion of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review staff interviews and facility policy review, the facility failed to document a complete investigation of allegations of abuse for 3 of 10 residents reviewed (Residents #12, #21 and #70). The facility reported a census of 69 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 1/3/23, listed diagnoses for Resident #70 which included heart failure, paraplegia (paralysis from the waist down), and anxiety disorder. The MDS documented the resident required supervision assistance of 2 staff for personal hygiene, limited assistance of 2 staff for transfers, extensive assistance of 1 staff for dressing, extensive assistance of 2 staff for toilet use, and depended completely on 2 staff for bathing. The MDS listed the resident's Brief Interview for Mental Status Score (BIMS) of 14 out of 15, indicating intact cognition. A 5/30/22 Behavior Note for Resident #70 stated Resident #70 rammed her wheelchair into Resident #21 and then Resident #21 stood up to hit Resident #70. A 5/31/22 Physician Note for Resident #70 documented the resident admitted to punching a [AGE] year old (Resident #21) resident and no injuries were sustained. A 6/2/22 Physician Note for Resident #21 stated the resident denied being punched. A 8/27/22 General Note documented Resident #70 and her roommate (Resident #12) threw water at each other and the resident changed rooms. A 7/19/22 Care Plan entry stated the resident could be verbally aggressive related to ineffective coping skills and poor impulse control. An 11/25/22 revision of the entry stated on 11/10 the resident was physically aggressive and required 1:1 monitoring. The Care Plan lacked documentation of alleged physical altercations prior to 11/25/22. In an interview on 4/25/23 at 8:35 a.m., Staff JJ Licensed Practical Nurse (LPN) stated Resident #70 had physical altercations with other residents. She stated once Resident #70 smoked outside and she threw a lit cigarette on another resident. She stated she did not see this but heard about it. In an interview on 4/25/23 at 1:00 p.m., the Director of Nursing (DON) stated she heard about the allegation that the resident threw a lit cigarette. She stated staff should report physical altercations between residents and the facility would separate the residents and interview residents and staff. She stated the Care Plan should address the resident's behaviors. In an interview on 4/27/23 at 10:50 a.m., the Administrator stated staff should report allegations of abuse within 2 hours. She stated the facility would investigate the allegation and would separate the residents. The facility lacked documentation of an investigation related to the above altercations and lacked documentation they reported the allegations to the State Agency or separated the resident from other residents. The facility policy Abuse, Neglect, and Exploitation, dated March 2023, stated the facility would provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident property. The policy stated the facility would complete an immediate investigation and ensure all residents were protected upon a suspicion of abuse. A review of the facility policy titled: Abuse, Neglect and Exploitation dated as last reviewed March 2023, had documentation of the following: Investigation of Alleged Abuse, Neglect and Exploitation: a. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. b. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: a. Responding immediately to protect the alleged victim and integrity of the investigation; b. Removal of the alleged perpetrator until the conclusion of the investigation; c. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; d. Increased supervision of the alleged victim and residents; e. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; f. Protection from retaliation; g. Providing emotional support and counseling to the resident during and after the investigation, as needed; Reporting/Response a. The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: b. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or c. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. d. Assuring that reporters are free from retaliation or reprisal; e. Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service; f. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: aa. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; bb. Defining how care provision will be changed and/or improved to protect residents receiving services; cc. Training of staff on changes made and demonstration of staff competency after training is implemented; dd. Identification of staff responsible for implementation of corrective actions; ee. The expected date for implementation; and ff. Identification of staff responsible for monitoring the implementation of the plan. g. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility policy review, the facility failed to address the Preadmission Screening and Resident Review (PASARR)) Level II on the Care Plan for 2 of 2 residents reviewed for PASARR Level II (Resident #16, Resident #41). The facility reported a of 69. Findings Include: 1. The Annual Minimum Data Set (MDS) Assessment Tool, dated 7/20/22 documented Resident #41 did not require a Level II PASARR. The MDS assessment dated [DATE] revealed Resident #41 scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderate impairment cognition. The MDS revealed the medical diagnosis of schizophrenia and anxiety. The MDS indicated the resident received antipsychotic medications 7 out of 7 days and antipsychotic medications received on routine basis. The PASARR Level II completed on 9/2/20 and revealed the resident had a diagnosis of schizophrenia. The PASARR Level II identified the following: a. Specialized Services: Ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders and evaluate ongoing need for additional behavioral health services. b. Rehabilitative Services: Obtain archived psychiatric records to clarify history and to provide to treating physicians c. Rehabilitative Services: A guardian/conservator or POA for healthcare to assist with decision-making, health and safety The Physician Medication Orders are the following: a. Benztropine mesylate tablet- ordered 9/17/20- Give 1 tablet by mouth two times a day b. Olanzapine 20 mg tablet- ordered 5/28/22- Give 1 tablet at bedtime with 10 mg tablet to equal 30 mg The Electronic Medical Record revealed the following Medical Diagnosis: a. Schizophrenia, unspecified b. Anxiety disorder, unspecified The Care Plan dated 3/3/23 revealed a focus problem of a PASARR Level II for person with a Mental Health Disorder or Intellectual Disability. The interventions dated 1/7/21 included resident used psychotropic medications related to schizophrenia and anxiety. The Care Plan dated 3/3/23 failed to document the PASARR Level II Specialized and Rehabilitative Services. During an interview on 4/20/23 at 10:46 AM, Staff Y, Social Services queried on the expectations of PASARR level II being addressed on the care plan and she responded they needed to be care planned with their medical diagnosis. Staff Y asked if the resident's specialized services should be addressed and she responded they should be on the care plan. Staff Y informed Resident #41 PASARR Level II specified resident needed a guardian and he didn't have one documented and she responded the State was really behind on finding them and it needed to be done. She stated he had a payee through the corporation. She reviewed Resident #41 chart and stated she didn't see anything for his PASARR and needed corrected. During an interview on 4/24/23 at 4:01 PM, the Director of Nursing (DON) queried on the expectations of a a PASARR Level II being addressed on the Care Plan and she responded the MDS Coordinator entered the initial Care Plan. The Facility Policy titled Resident Assessment - Coordination with PASARR Program dated March 2023 revealed the following: a. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. 2. The Minimum Data Set(MDS) assessment tool, dated 10/26/22, documented Resident #16 did not require a Level II PASARR. The Notice of PASARR Level II Outcome, dated 10/8/22, documented the resident required a Level 2 assessment and included the following specialized services: a. Ongoing psychiatric medication management by a psychiatrist or psychiatric Advanced Registered Nurse Practitioner (ARNP). b. Individual therapy by a licensed behavioral health professional. c. A designated Power of Attorney (POA) for healthcare and financial matters. The Care Plan lacked documentation of the implementation of the above interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS Assessment Tool, dated 8/29/22, listed diagnoses for Resident #71 which included non-Alzheimer's dementia, unspecified dementia with behavioral disturbance, and anxiety disorder. The MDS documented the resident was independent with transfers, and required supervision for walking and eating, extensive assistance of 1 staff for dressing, extensive assistance of 2 staff for toilet use and personal hygiene, and depended completely on 2 staff for bathing. The MDS listed the resident's BIMS score as 1 out of 15, indicating severely impaired cognition and stated he had wandering behaviors 4-6 days out of the 7 day review period and stated his behaviors placed the resident at significant risk of getting to a potentially dangerous place. An 8/23/22 Elopement Risk Evaluation stated the resident displayed exit seeking behaviors and was a high risk to elope. A 9/6/22 Social Service Note stated facility staff called the resident's sister to discuss possibly having to find a different placement for the resident due to exit seeking behaviors. A 9/12/22 Physician Note stated the nursing staff reported on 8/23/22 that the resident stated he wanted to leave and be with his brother and that the resident tried to go out the doors twice last night. The note stated staff discussed the possible risk for elopement and they would keep an eye on him. A 9/19/22 1:45 p.m., General Note stated the resident sat quietly eating lunch and denied pain or the need for analgesia (pain medication) at this time. A 9/19/22 4:44 p.m., General Note stated the resident got out of the facility and the police were contacted. The note stated the resident was found shortly after by a Certified Nursing Assistant (CNA) outside of the facility. A 9/21/22 Physician Note stated the resident had an elopement on 9/19/22 and was found a few blocks away from the facility. Care Plan entries, dated 9/19/22, stated the resident was an elopement risk and wanderer related to disorientation to place. The resident had a history of attempts to leave the facility unattended and had impaired safety awareness and wandered aimlessly. Further 9/19/22 entries stated the resident's safety would be maintained through the review date and directed staff to: a. Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. b. Monitor for fatigue and weight loss. c. Provide structured activities such as toileting, walking inside and outside, and reorientation strategies including signs, pictures and memory boxes. d. Identify a pattern of wandering. The Care Plan lacked documentation of the resident's risk/history of eloping or interventions directed at the prevention of elopement prior to the 9/19/22 incident. The National Weather Service Climatological Data retrieved from https://www.weather.gov/wrh/Climate?wfo=dvn on 4/19/23 listed the high and low temperatures on 9/19/22 as 83 degrees Fahrenheit and 63 degrees Fahrenheit. During a phone interview on 4/18/23 at 4:11 p.m., Staff I, CNA stated she remembered the resident leaving the facility. She stated while staff were in a meeting, the resident got out and they looked for him. She stated she found him on [NAME] and [NAME] streets. She stated the resident was walking on the sidewalk and it was about an hour from the time they realized he was missing to the time they located him. She stated they found him about a 5 minute walk away. During a phone interview on 4/18/23 at 4:33 p.m., Staff J, former Director of Nursing (DON) stated when the resident eloped the door alarm was not engaged. She stated staff observed the door opened and immediately did a count and noticed the resident was not there. She stated the B Hall door was broken and had been intermittently problematic when she worked there. She stated because of Resident #71's past history, when the door was open, they immediately thought of him. She stated the resident had exit seeking behaviors and was constantly walking. She stated he eloped from the Group Home he was at previously. Staff J stated it was 30 minutes by the time they found him. She stated some interventions they utilized to address his wandering were redirection and maintaining a visual on the resident. She stated the resident was in the Elopement Book which had his picture and basic information. She stated the Elopement Book was a tool used if someone eloped but would not prevent an elopement. Staff J explained the doors were supposed to be locked and stated they requested a wanderguard (a device which alerted when residents were near exits)for Resident #71 multiple times because the resident should absolutely have one. During an observation on 4/19/23 at 9:49 a.m., the Administrator demonstrated the door alarm mechanisms on the left hall door, right hall door, front dining room door, back dining room door, B Hall door, and A Hall door. The Administrator pushed on the door for 15 seconds and the door alarmed and the light turned red. In order to rearm the doors, the Administrator utilized a key. A Receptionist sat next to the front door so the door was unarmed. She stated the door was armed when the receptionist was not present and required a code to be silenced. During an interview on 4/19/23 at 7:45 a.m., Staff F, Certified Medication Aide (CMA) stated prior to the resident's elopement he kept getting out and they brought him back in. She reported on the day of the elopement, she did not hear the alarm. During an interview on 4/19/23 at 8:22 a.m., the Assistant Director of Nursing (ADON) stated if one pushed on the B Hall door, the light would turn red and the alarm would be disabled. She stated staff did not rearm the door after the resident touched the door. She stated prior to the elopement, the resident touched the door and they removed him and disabled the door but did not re-arm the door. She reported if the door was green, that indicated the door alarm was armed. The ADON reported it was her practice to look at the doors and after the elopement, the facility completed education related to the door locks. During an interview 4/19/23 at 10:05 a.m., the Administrator stated prior to the elopement, the resident was agitated and staff had disarmed the door but not rearmed it. She stated it was staff error. During an observation on 4/20/23 at 7:20 a.m., when the facility front door was pushed, it was locked and would not open. During an interview on 4/20/23 at 9:13 a.m., Staff N, CNA stated she did not know how the resident got out of the facility but she heard a Code Silver. She stated staff were trying to figure out who eloped but she knew it was him because of his history of wandering. During a phone interview on 4/20/23 at 9:44 a.m., Staff O, former Administrator stated the biggest concern he had with the resident was that he would pace. He stated the day before the elopement, the facility shut off the door annunciator due to complaints but stated the doors also had local alarms staff could still hear. He stated the resident left the facility and they completed a search and found the resident within the hour near a park sitting on some bleachers. He reported if the door opened, the light at the top would turn red to indicate the door was not engaged. He stated a key was needed in order to re-arm the door and stated more than likely, the door opened prior to the elopement and staff failed to re-arm the door After the elopement, he stated the facility turned the annunciators back on and completed staff education regarding elopement and door locks. The undated facility document Cognitively Impaired and Independently Mobile, provided on 4/25/23 listed 26 cognitively impaired and independently mobile residents. During an interview on 4/26/23 at 2:04 p.m., the DON stated a resident's history of elopement and related interventions should be included on the Care Plan. The facility policy Elopements and Wandering Residents reviewed 1/2023, stated the facility ensured that residents who exhibited wandering behavior and were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Based on observations, clinical record review, staff interviews and policy review, the facility failed to address continuous oxygen for one resident (Residents #48) and identify a resident as at risk for elopement (Resident #71) for a total of 2 of 26 residents reviewed for Comprehensive Care Plans. The facility reported a census of 69 residents. Findings Include: 1. The MDS dated [DATE] identified Resident #48 as cognitively intact with a BIMS score of 15 out of 15 and with the following diagnoses: Cancer, Atrial Fibrillation (an abnormal heart rhythm) and chronic obstructive pulmonary disease (COPD). The MDS also identified the resident required extensive staff assistance with all activities of daily living except with eating (she had been independent) and with walking where she had been totally dependent on staff for assistance. The MDS failed to identify the resident required continuous oxygen. Observations of the resident revealed the following: a. On 4/11/23 at 11:02 AM asleep in bed with continuous oxygen maintained at 2.5 liters per nasal cannula per concentrator. Respirations even and unlabored. b. On 4/12/23 at 9:36 AM sitting up in bed with continuous maintained at oxygen maintained at 2.5 liters per nasal cannula per concentrator. Respirations even and unlabored. c. On 4/13/23 at 7:18 AM asleep in bed with oxygen maintained at 2.5 liters per nasal cannula per concentrator. Respirations even and unlabored. A review of the Care Plan identified the resident with the problem of Emphysema/COPD on 3/14/23, however the interventions did not address the use of continuous oxygen. A review of the undated policy titled: Comprehensive Care Plans revealed the following documentation: a. The Care Planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the Comprehensive Care Plan, shall be culturally-competent and trauma-informed. b. The Comprehensive Care Plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. c. The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. d. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review and facility policy review the facility failed to have Physician's Orders for the placement of indwelling catheters 2 out of 3 resident reviewed (Resident # 11 and # 49). The facility failed to have 1 out of 3 resident's catheter tubing secured off the floor (Resident #33). The facility reported a census of 69 residents. Findings Include: 1. The Minimum Data Set Assessment (MDS) for Resident #33 dated 1/25/23, included diagnosis of diabetes mellitus(DM), and rheumatoid arthritis. The MDS listed Resident # 33's Brief Interview for Mental Status score as 11 out of 15, indicating moderately impaired cognition. The MDS indicated Resident #33 required extensive assist of 1 staff for toileting and personal hygiene. The MDS identified a catheter placed for Resident # 33. The Care Plan for Resident #33 dated 12/23/22, reflected Resident #33's indwelling catheter placed related to fluid retention at recent hospitalization. The Care Plan directed position catheter bag and tubing below the level of the bladder and away from entrance room door. Monitor, record, report to Physician signs or symptoms of urinary tract Infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Updated Care Plan dated 12/30/22, Resident #33 will show no signs or symptom of Urinary infection through review date. Resident #33's Care Plan dated 7/19/21, reflected a history of dehydration/fluid deficit related to a history of UTI and poor oral intake. Staff G, Advanced Registered Nurse Practitioner (ARNP), Physician Note dated 4/13/23, reflected UTI. Hospital course - Urine culture grew Aerococcus urinae (a rare organism isolated from urine cultures). On 2/13/23 saw by Urology, who stated they could not proceed with her cystoscopy (a procedure that allows your doctor to examine the lining of your bladder and the tube that carries urine out of your body) due to having high suspicion for active UTI. Recent urine culture positive for 2 bacteria that were both susceptible to Macrobid. The note continued on 2/17/23 the Urology office faxed over recent urine culture results showed Klebsiella pneumoniae (bacteria), e.coli (bacteria) and actinotignum schaalii (bacteria), ESBL (enzymes produced by some bacteria that may make them resistant to some antibiotics) positive. Susceptible to Gentamycin. The Urologist ordered Gentamycin 80 milligrams (mg) intramuscular (IM) everyday for 5 days. The facility Matrix provided on 4/11/23, reflected Resident #33 with an active UTI. The Medication Administration Record (MAR) dated 4/23, directed Cephalexin Oral Tablet 250 milligrams (mg), give 1 tablet by mouth at bedtime for UTI. On the following days noted the catheter tubing for the resident dragging on the floor: a. On 04/11/23 at 1:05 PM, Resident #33 sat in her wheel chair (w/c) with 10 inches of her catheter tubing sitting on the floor under her. b. On 4/11/23 at 2:51 PM, Resident #33 sat in her w/c in the lunch room next to a table with 4-6 inches of her catheter tubing drug on the floor under her w/c as she took herself back down to her room (approximately 100 feet). c. On 4/12/23 at 1:03 PM, Resident #33 wheeled herself into the dining room and up to the table by the restroom door as 8 inches of her catheter tubing drug on the floor under her w/c. Resident #33 lacked a dignity bag over her catheter bag under the w/c. The catheter bag held amber urine. d. On 4/13/23 at 7:45 AM, Resident #33 sat in her w/c in the dining room while 4 inches of her catheter drug on the floor under her w/c and she moved he feet. e. On 4/13/23 at 8:37 AM, Resident #33 propelled herself in the wheelchair in A hallway to dining room as her catheter tubing drug on the floor. As Resident #33 moved herself back and forth at the table in her w/c her catheter tubing drug back and for on the floor. f. On 4/13/23 at 9:04 AM, Resident #33 walked herself in the w/c from the edge of the A hall to the kitchen doorway asked staff for coffee as 5 inches of the catheter tubing drug on the floor under her w/c. Resident # 33 moved herself back to her seating spot in the dining room. g. On 4/13/23 at 11:35 AM, Resident #33 wheeled herself from the nurses station by A hall, into her room as her catheter tubing drug on the floor under her w/c. h. On 04/13/23 at 1:09 PM, Resident #33's catheter bag hung on the grab bar on the right side of her bed above the height of her shoulder as she laid in the bed. i. On 04/17/23 at 11:52 AM, Resident #3 sat at an activity while 8 inches of her catheter tubing sat on the floor under her. j. On 04/17/23 at 1:00 PM, Resident #33 sat at the dining room table as 8 inches of her catheter tubing sat on the floor under her. The facility failed to utilize a dignity cover over Resident #33's catheter bag under her w/c in the dining room. k. On 4/18/23 at 12:37 PM, Resident #33 sat in her w/c in her room as the room door sat open, her catheter bag laid flat out on the floor. Resident #33 wheeled herself over the catheter bag that laid on the floor. On 4/18/23 at 12:42 PM, Staff DD, Certified Medication Aid (CMA), placed Resident #33's catheter bag in a dignity bag. On 4/18/23 at 12:42 PM, Staff DD stated she just emptied the catheter bag. Staff DD, reported staff are expected to keep catheter tubing off the floor. On 04/18/23 at 2:15 PM, the Director of Nursing (DON) stated her expectation is catheter tubing is up off the floor and not drug all over the building. She stated she expected all catheter bags covered with a dignity bag. The facility provided titled Catheter Care dated 3/2023, documented the following directive: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: a. Catheter care will be performed every shift and as needed by nursing personnel. b. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. c. Privacy bags will be changed out when soiled, with a catheter change or as needed. d. Leg bags may be used for ambulatory residents or per resident request. e. Legs bags may be worn during the day, but need to be removed and a bedside drainage bag replaced on the catheter at night. f. Legs bags will be attached to the resident ' s thigh or calf making sure to have slack on the tubing to minimize pressure and tension. Ensure straps are snug but not tight. g. Leg bags may be stored in a clean, plastic bag when not in use or as per facility policy. h. Empty drainage bags when bag is half-full or every 3 to 6 hours. i. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. The facility policy failed to address the storage of the catheter tubing. 2. The MDS dated [DATE] identified Resident #11 as cognitively intact with a BIMS score of 15 out of 15, and identified with the following diagnoses: Atrial Fibrillation, UTI and Diabetes Mellitus. The MDS identified the resident required extensive staff assistance with all activities off daily living (ADL's)) except for eating and that he had an indwelling catheter. Observations of the resident revealed the following: a. On 4/11/23 at 11:25 AM lying in his bed with a Foley (indwelling catheter) bag below bladder which had not been placed in a dignity bag. b. On 4/11/23 at 1:10 PM asleep in bed with the Foley bag that remained without a dignity bag. c. On 4/11/23 at 2:23 PM assessment unchanged d. On 4/12/23 at 10:30 AM asleep in bed with Foley bag which remained without a dignity bag and visible to anyone walking into his room. e. On 4/12/23 at 11:15 AM assessment unchanged. f. On 4/12/23 at 12:20 PM sitting up in bed eating lunch, Foley bag remains without dignity bag visible to anyone walking into his room, door to room cracked open The hospital Discharge summary dated [DATE] revealed documentation that the resident had a chronic indwelling Foley. A review of the current Physician Orders did not have orders for indwelling catheter. On 4/5/23, the Care Plan identified the resident with the problem of an indwelling catheter (the resident had been admitted to the facility on [DATE]) Interventions had been documented as follows: a. Catheter: last changed: (Specify Date). Change catheter (frequency). (Specify Size) (Specify Type) Date Initiated: 04/05/2023 b. Catheter: The resident has (Specify Size) (Specify Type of Catheter). c. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Date Initiated: 04/05/2023. The Care Plan did not address the size and type of catheter and how often to change the catheter. 3. The MDS dated [DATE] identified Resident #49 as cognitively intact with a BIMS score of 15 out of 15 and had the following diagnoses: Multiple Sclerosis, neurogenic bladder and paraplegia. It also identified the resident required extensive staff assistance with repositioning in bed, and totally dependent on staff for bathing. Observations of the resident revealed the following: a. On 4/11/23 at 12:09 PM sitting up in power chair with the Foley which had not been placed in a dignity bag. b. On 4/11/23 at 1:16 PM sitting up in power chair, assessment unchanged. c. On 4/11/23 2:11 PM sitting up in power chair with Foley bag which remained without a dignity bag. d. On 4/12/23 at 3:36 PM, during an observation of wound care, the Foley bag had not been placed in a dignity bag and found lying on the floor along with the Foley tubing also on the floor. e. On 4/13/23 7:21 AM asleep in bed, door to room wide open. Foley bag below bladder in full view of anyone walking past the room and not in dignity bag. No tubing noted on the floor. f. On 4/13/23 8:36 AM assessment unchanged g. On 4/13/23 9:15 AM Foley bag remains in full view of anyone walking by his room as door wide open, not in dignity bag, no tubing on the floor. h. On 4/17/23 8:10 AM sitting up in bed, holding wound vac and Foley bag (not in dignity bag) over his groin area. Properly positioned and appears comfortable. On 2/20/23 the Care Plan identified the resident with the problem of having an Indwelling Foley Catheter: size - 14FR (French)/10 cubic centimeters (cc) with interventions to position catheter bag and tubing below the level of the bladder and away from entrance room door. The Hospital Discharge summary dated [DATE] revealed documentation that the resident had a neurogenic bladder with chronic indwelling urinary catheter A review of the current Physician Orders revealed no orders for the indwelling catheter. In an interview on 4/19/23 at 10:02 AM, Staff H, Nurse Practitioner reported the following: 1. Residents with indwelling catheters should have physician orders to include: monitor I&O, empty the catheter, size of the catheter and type and peri care 2. When asked why Resident #11 and #49 did not have orders for their Foley catheters, she reported the facility had an admissions nurse here in charge of double checking all admission orders and she was terminated 4 to 6 weeks ago. She also reported none of the floor nurses knew how to put in admission orders in, they only put in orders for medications in the computer. A review of the facility policy titled: Catheter Care and dated as last revised January 2023 did not have documentation to address the need to obtain a physician order for an indwelling catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff and resident interviews, the facility failed to provide administered oxygen and other respiratory treatments in accordance with Provider Orders and each resident's individual Care Plan for 3 of 6 residents reviewed (Residents #12, #46 and #48) . The facility had reported a census of 69. Findings include: 1. Review of Resident #12 Minimum Data Set (MDS) dated [DATE], listed the resident with a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating the resident with intact cognition. Resident #12 used a manual wheelchair and had been dependent on staffs for toileting, picking up dropped objects from the floor, and needed substantial assistance rolling side to side while lying in bed. The MDS listed Resident #12 with active medical diagnosis of sleep apnea, chronic obstructive pulmonary disease (COPD), and oxygen dependent. Resident #12's Care Plan dated 2/12/23 included COPD interventions, but failed to include oxygen as ordered by the residents' provider. The Care Plan listed Resident #12 with Advance Directives in place that included if respiratory breathing stopped, then staff needed to proceed with full respiratory resuscitation. The Care Plan further identified the resident with a focus area of sleeplessness and insomnia which had included interventions, however failed to identify oxygen needs. The Care Plan identified a focus area that stated the resident had oxygen therapy related to congestive heart failure. The intervention listed had been to apply 3 liters humidified oxygen by nasal prongs/nasal cannula. The Care Plan failed to identify any respiratory diagnosis for oxygen. Review of the Electronic Health Record (EHR) on 4/11/23, shown the Advanced Registered Nurse Practitioner (ARNP) ordered on 2/9/23 for Resident #12 to have nightly BIPAP (Non-Invasive Mechanical Respiratory Ventilator); therapy with IPAP of 25, EPAP 13 using full face mask and heated humidifier (reference to machine settings), bleed daytime oxygen into machine, use at bedtime and during naps. An observation on 4/12/23 at 2:00 PM, shown Resident #12 lying in bed without the head of bed elevated and no BIPAP machine observed at the bedside. The resident had an oxygen concentrator at the bedside with oxygen tubing connected to the oxygen concentrator, however Resident #12 observed not wearing the oxygen. Again, on 4/13/23 at approximately 9:30 AM, Resident #12 observed lying in bed without the head of bed elevated and no BIPAP machine observed at the bedside, with an oxygen concentrator at the bedside with oxygen tubing connected to the oxygen concentrator at the bedside however Resident #12 observed not wearing the oxygen. The oxygen concentrator observed to not be on. Further observation on 4/13/23 at 10:41 AM, shown Resident #12 sitting in a wheelchair in the North Dining Room. Staff BB, Registered Nurse (RN) observed removing an oxygen tank from the back of Resident #12's wheelchair and placing a new oxygen tank into the wheelchair. Staff BB then observed turning the oxygen tank on and assisting Resident #12 to place the oxygen nasal cannula in her nares. An observation of Resident #12 on 4/17/23 at 7:24 AM, shown the resident lying on her left side in bed, dressed in a hospital gown, and oxygen on at 2 liters per nasal cannula per the oxygen concentrator and no BIPAP machine observed at the bedside. During an interview on 4/17/23 with Staff E, Licensed Practical Nurse (LPN) at 7:30 AM, the residents respiratory orders reviewed. Staff E stated being unaware of Resident #12's BIPAP orders when asked why the machine had not been in the residents' room. Staff E also reviewed the EHR and the Electronic Medication Administration Record (EMAR )and shown facility staff repeated daily documentation of the number 9 at 8:00 P.M. on the EMAR. The directions on the form instructed staff when the number 9 charted there should have been a note in the EHR progress note why, but no explanations were found. During an interview with the Resident #12 on 4/17/23 at 8:50 AM, the resident had acknowledged completing testing for sleep apnea however when asked about a BIPAP machine the resident stated there had not been a machine for her to try. The resident further stated utilizing oxygen when needed however not using oxygen at all times. During an interview on 4/17/23 at 4:05 PM, the facility Director of Nursing (DON) and Assistant Director of Nursing (ADON) discussed Resident #12's BIPAP. The DON and ADON had both verbalized the resident had not wanted to use the BIPAP. When asked if the BIPAP machine had been obtained then the ADON had stated, yes. The ADON had further stated the BIPAP machine had been rented and had been removed from the resident room and moved to an office within the facility for security reasons. When asked further questions about the order being current then the ADON had stated no knowledge of the order being current. When asked if the provider made aware of the resident refusal to use the BIPAP, the DON and ADON stated the Nursing Staff would have to let the provider know. The DON and ADON asked where the Provider Communication would be located, then both stated in the EHR Progress Note Section. The DON and ADON made aware there no Provider Communication found and there had been no communication by Nursing Staff when a daily 8:00 PM documentation of number 9 made. 2. The MDS dated [DATE] identified Resident #46 as cognitively intact with a BIMS score of 13 out of 15 and with the following diagnoses: Multiple Sclerosis, Coronary Artery Disease and Respiratory Failure. The MDS also identified the resident required extensive staff assistance with all activities of daily living (ADL's) except for eating and totally dependent on staff for showers/baths. The MDS failed identify the resident had continuous oxygen. Observations of the resident revealed the following: a. On 4/11/23 10:59 AM resident lying in bed without continuous oxygen on. b. On 4/12/23 9:34 AM lying in bed with continuous oxygen maintained at 3.5 liter per minute per nasal cannula per concentrator. c. On 4/13/23 7:13 AM asleep in bed with door to room open. Continuous oxygen maintained at 3.5 liters per nasal cannula per concentrator. d. On 4/17/23 8:20 AM lying in bed without continuous oxygen on. A review of the physician orders for March and April did not show orders for continuous oxygen. The Care Plan identified the resident with the problem of shortness of breath on 10/29/22, however, interventions did not include continuous oxygen. 3. The MDS dated [DATE] identified Resident #48 as cognitively intact with a BIMS score of 15 out of 15 and with the following diagnoses: Cancer, Atrial Fibrillation (an abnormal heart rhythm) and Chronic Obstructive Pulmonary Disease (COPD). It also identified the resident required extensive staff assistance with all activities of daily living except with eating (she had been independent) and with walking where she had been totally dependent on staff for assistance. The MDS failed to identify the resident required continuous oxygen. Observations of the resident revealed the following: a. On 4/11/23 at 11:02 AM asleep in bed with continuous oxygen maintained at 2.5 liters per nasal cannula per concentrator. Respirations even and unlabored. b. On 4/12/23 at 9:36 AM sitting up in bed with continuous maintained at oxygen maintained at 2.5 liters per nasal cannula per concentrator. Respirations even and unlabored. c. On 4/13/23 at 7:18 AM asleep in bed with oxygen maintained at 2.5 liters per nasal cannula per concentrator. Respirations even and unlabored. A review of the Care Plan identified the resident with the problem of Emphysema/COPD on 3/14/23, however the interventions did not address the use of continuous oxygen. In an interview on 4/25/23 at 9:43 AM, Staff D, Licensed Practical Nurse (LPN) reported residents with continuous oxygen should have a Doctor's Order for it. If a resident admitted with continuous oxygen and did not have an order, the nurse who admitted the resident should have clarified and obtain an order from the doctor. When asked why there were no orders for Resident #46, Staff D explained the resident did not have oxygen unless Hospice placed it on her and did not tell us. Currently Resident #46 does not have oxygen. Staff D could not recall why Resident #48 did not have orders. In an interview on 4/25/23 at 9:53 AM, Staff K, Registered Nurse (RN) reported residents with continuous oxygen should have a Doctor's Order for it. The nurse is responsible for ensuring orders are received. She also reported the facility used to have a Corporate Person (who is not a nurse) to ensure admission Physician Orders had been verified. The nurse who admitted the resident had the responsibility to verify if any orders needed to be obtained from the provider. In an interview on 4/25/23 at 3:16 PM, the Director of Nursing (DON) reported she would expect the nurse to obtain a Doctor's Order for a resident with continuous oxygen.

Based on personnel file review, policy review, and staff interview, the facility failed to ensure 1 of 5 staff members (Staff K, Registered Nurse/RN) possessed the proper licensing to ensure residents safety. There was no documentation in staff K's file that she was a licensed nurse in the state of Iowa. The facility reported a census of 69 residents. Findings Include: On 4/17/23 at 2:27 PM, Record review of Staff K, RN employee file completed and the file failed to contain proof of RN licensure in the state of Iowa. On 4/19/23 at 2:30 PM, record review of additional employee file information shown the facility provided written proof of RN licensure in the state of Iowa for staff K. The print date on the Verification Form was 4/18/23. The license approval date for RN licensure in Iowa was 8/25/22. Staff K's hire date was 5/20/22 On 4/20/23 at 8:07 AM, review of facility policy titled Abuse, Neglect and Exploitation stated: a. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. b. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. c. Screenings may be conducted by the facility itself, third-party agency or academic institution. d. The facility will maintain documentation of proof that the screening occurred. On 4/19/23 at 2:35 PM, an interview with Assistant Director of Nursing (ADON) and the Administrator of the facility revealed the following: The Administrator was not employed at the facility in 2022 and deferred to the ADON for questions on staff K. The ADON reported Staff K hired in May of 2022, but Staff K did not work at the facility until they received verbal confirmation she had an Iowa License in August of 2022. The Administrator verified no written proof of licensure was contained in Staff K's file prior to 4/18/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and family member interviews, the facility failed to address a resident's history of drug abuse for one of one residents reviewed. (Resident #46). The facility reported a census of 69 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #46 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 13 out of 15 and with the following diagnoses: Multiple Sclerosis, Coronary Artery Disease and Respiratory Failure. The MDS also identified the resident required extensive staff assistance with all activities of daily living (ADL's) except for eating and totally dependent on staff for showers/baths. The MDS failed to identify the resident had continuous oxygen. A review of the Hospital History and Physical Report dated [DATE] documented the following: Chief complaint: Unresponsive and cardiac arrest. It seems there is a history of a family member or ex-husband bringing drugs in the past. Currently resident is intubated, most of history from record review and nurse interviews. Resident received 3 rounds of Cardiopulmonary Resuscitation (CPR). When she came to the emergency room (ER), 2 doses of Narcan ( a medicine that rapidly reverses an opiod overdose) were given. The resident hypotensive and pressors were started. Urine drug screen came back positive for THC (tetrahydrocannabinonol- primary psychoactive cannabinoid extracted from the cannabis (marijuana) and opiates (chemicals extracted from natural plant matter, ie: opium, morphine, codeine and heroin) Critically ill and in ICU. The Care Plan with the last revision date of [DATE] failed to identify the resident with the problem of history of drug abuse and failed to implement interventions to address it. The diagnoses listed on the Care Plan included cannabis use. In an interview on [DATE] at 2:57 PM, the resident's family member reported the resident was able to purchase drugs at the Nursing Home. That was the 2nd time within 2 weeks that she got drugs somewhere. The 2nd time, Resident #46 got a hold of a Fentanyl patch, chewed it and then became unresponsive. Then that's when they sent her to the ER. She has a drug history of taking pretty much anything she can get her hands on, meth, cocaine. The resident claimed she can buy drugs at the home. Her husband was bringing in illegal drugs and giving it to her. One time she was sent to the ER and tested positive for marijuana. He was bringing her CBD gummies and another family member was bringing vape pens with marijuana. In an interview on [DATE] at 9:53 AM, Staff G, Nurse Practitioner (NP), reported people came in from outside and brought her drugs. Resident #46 does have a history of drug abuse - methamphetamines and marijuana, and has had substance abuse overdose in the past. In an interview on [DATE] at 10:02 AM, Staff H, NP reported the following: a. The staff notified me in December that they found the resident unresponsive and sent to the hospital. Before she went, she was on a low dose Fentanyl patch that Staff H had ordered. The day Resident #46 went to the ER, she had a visit from her husband who told her she could tear her Fentanyl patch in pieces and chew it up. Resident #46's Power Of Attorney (POA) voiced concerns that family members were bringing in drugs in to the resident, however, did not say what kind of drugs. b. When the resident was admitted to the hospital, they had to give her two or three doses of Narcan and the resident was in the hospital for a week. c. Resident #46 had history of using meth, cocaine and marijuana before she came to this facility. She would have family members, sister, husband and Mom would want to bring in CBD oil in for her, we told her we could not allow that here. The staff told me they found a bag of white powder in her room, don't know if anyone tested it. She was told numerous times that she could not use them. d. The staff would catch Resident #46 vaping with marijuana at least once a day. Before her family member became the official POA, the staff could not restrict family members from bringing in marijuana vape pens to her. In an interview on [DATE] at 9:43 AM, Staff D, Licensed Practical Nurse (LPN) reported the resident had a history of drug use before admission to the facility and her spouse would bring in illicit drugs. She had an addiction to crack cocaine. This should be addressed on her Care Plan. In an interview on [DATE] at 9:53 AM, Staff K, Registered Nurse (RN) reported not sure if the resident had a history of drug use prior to admission and not sure it should be addressed on the Care Plan. In an interview on [DATE] at 3:19 PM, the Director of Nursing (DON) reported if a resident had a history of drug abuse, she would expect that to be addressed on the resident's Care Plan. If any of the staff suspected any of the residents had illicit drugs in the room, she would expect them to report it to her, the Administrator, then the police, Nurse Practitioner and the Physician. The family is blaming the husband for bringing in illicit drugs in and is no longer allowed to visit unless it's a supervised visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility policy review, the facility failed to document Pharmacy Consultant Visits monthly for two of two residents reviewed (Residents #9 and #46). The facility reported a census of 69 residents. Findings included: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #9 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 2 out of 15 and had the following diagnoses: Renal Insufficiency, Non-Alzheimer's Dementia and Bipolar Disorder. The MDS also identified the resident required extensive staff assistance with bed mobility, transfers, dressing, toileting and hygiene. A review of the Physician Orders revealed the following: a. On 7/5/22, Risperidone tablet 0.5 mg (milligrams) Give 1 tablet by mouth two times a day for bipolar. b. On 9/22/22, Eliquis Tablet 2.5 mg (Apixaban) Give 2.5 mg by mouth two times a day for pulmonary embolism (PE). c. On 1/30/23, Sertraline Tablet 50 mg Give 1 tablet by mouth in the morning for anxiety, irritability. d. On 3/22/23, Lorazepam Tablet 1 mg Give 1 tablet by mouth every 24 hours as needed for anxiety for 60 Days. A review of the Pharmacy Medication Regimen Reviews revealed the last entry dated 2/28/23. On 10/27/22, the Care Plan identified the resident with the problem of using psychotropic medications antidepressant, anti anxiety, and anti psychotic medication and directed staff to discuss with the doctor and family regarding the ongoing need for use of medication. 2. The MDS dated [DATE] identified Resident #46 as cognitively intact with a BIMS score of 13 out of 15 and with the following diagnoses: Multiple Sclerosis, Coronary Artery Disease and Respiratory Failure. It also identified the resident required extensive staff assistance with all activities of daily living (ADL's)) except for eating and totally dependent on staff for showers/baths. It did not identify the resident had continuous oxygen. A review of the physician orders revealed the following: a. On 2/3/23 Lorazepam Concentrate 2 MG/ML *Controlled Drug* Give 0.25 ml by mouth every 4 hours for anxiety. b. On 2/20/23 Morphine Sulfate (Concentrate) Solution 20 MG/ML *Controlled Drug* Give 0.25 ml by mouth every 2 hours as needed for Pain. c. On 3/7/23 Hydrocodone-Acetaminophen Tablet 7.5-325 MG *Controlled Drug* Give 1 tablet by mouth three times a day for Pain. d. On 3/21/23 Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) *Controlled Drug* Give 0.25 ml by mouth every 2 hours as needed for Anxiety/restlessness. A review of the Pharmacy Medication Regimen Reviews revealed the last entry dated 2/28/23. On 10/29/22, the Care Plan identified the resident with the problem of using psychotropic medications anti anxiety anti depressant and anti psychotic and directed staff to discuss with the doctor and family regarding the ongoing need for use of medication. A review of the facility policy titled: Medication Regimen Review and dated as last reviewed March 2023 documented the following: a. Timelines and responsibilities for Medication Regimen Review: The Consultant Pharmacist shall schedule at least one monthly visit to the facility, and shall allow for sufficient time to complete all required activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility policy review, the facility failed to re-evaluate and re-order for as needed (PRN) antianxiety medications for two of two residents reviewed (Residents #9, and #46). The facility reported a census of 69 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #9 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 2 out of 15 and had the following diagnoses: Renal Insufficiency, Non-Alzheimer's Dementia and Bipolar Disorder. The MDS also identified the resident required extensive staff assistance with bed mobility, transfers, dressing, toileting and hygiene. A review of the physician orders revealed the following: a. On 1/30/23 Sertraline Tablet 50 milligrams (mg), give 1 tablet by mouth in the morning for anxiety, irritability. b. On 3/22/23 Lorazepam Tablet 1 mg, give 1 tablet by mouth every 24 hours as needed for anxiety for 60 Days. A review of attempted Gradual Dose Reductions (GDR)) from the Pharmacy Consultant to the Physician revealed the following: a. On 10/31/22 3:43 PM, Medication regimen review for October completed. No response yet regarding possible GDR on sertraline 50 mg from September 2022 Medication Regimen Review (MMR). b. On 11/30/22 2:21 PM, Medication regimen review for November completed. No new medication irregularities but no response yet from September MRR letter to prescriber regarding sertraline GDR. Will send note to DON (director of nursing). c. On 12/29/22 5:18 PM, Medication Regimen Review for December completed. GDR request from September pending. d. On 2/28/2023 21:31, February Medication Regimen Review completed. Lorazepam 1 mg daily as needed for anxiety/agitation is on the regimen with no length of therapy specified. A recommendation letter to prescriber will be created. 2. The MDS dated [DATE], identified Resident #46 as cognitively intact with a BIMS of 13 out of 15 and with the following diagnoses: Multiple Sclerosis, Coronary Artery Disease and Respiratory Failure. It also identified the resident required extensive staff assistance with all activities of daily living (ADL's) except for eating and totally dependent on staff for showers/baths. The MDS failed to identify the resident had continuous oxygen. A review of the Physician Orders revealed the following: a. On 2/3/23 Lorazepam Concentrate 2 MG/ML *Controlled Drug* Give 0.25 ml by mouth every 4 hours for anxiety b. On 2/20/23 Morphine Sulfate (Concentrate) Solution 20 MG/ML *Controlled Drug* Give 0.25 ml by mouth every 2 hours as needed for Pain c. On 3/7/23 Hydrocodone-Acetaminophen Tablet 7.5-325 MG *Controlled Drug* Give 1 tablet by mouth three times a day for Pain d. On 3/21/23 Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) *Controlled Drug* Give 0.25 ml by mouth every 2 hours as needed for Anxiety/restlessness The order for the give as needed (PRN) order for Lorazepam did not have a re-evaluation or re-order by the physician after 14 days. On 4/26/23 at 2:00 PM, when asked for a policy on antipsychotic medications ordered to be given as needed, the Administrator reported their policy titled: Medication Regimen Review policy had information requested. A review of the policy dated as last revised March 2023 failed to have documentation on the process to re-evaluate and re-assess the resident's need to have the order after fourteen days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The MDS Assessment Tool, dated 1/3/23, listed diagnoses for Resident #70 which included heart failure, paraplegia, and anxiety disorder. The MDS documented the resident required supervision assistance of 2 staff for personal hygiene, limited assistance of 2 staff for transfers, extensive assistance of 1 staff for dressing, extensive assistance of 2 staff for toilet use, and depended completely on 2 staff for bathing. The MDS listed the resident's BIMS score of 14 out of 15, indicating intact cognition. Care Plan entries, dated 4/20/22, stated the resident had a self-care performance deficit related to paraplegia and stated the resident required staff assistance for bathing, bed mobility, dressing, toilet use, and transfers. During an interview on 4/12/23 at 10:11 a.m. , Resident #70 stated a nurse told her that she needed to pick up the slack when it came to helping with cares. Resident stated that she was at the facility to have help and could not move. The facility policy Promoting/Maintaining Resident Dignity During Mealtimes reviewed March 2023, stated it was the practice of the facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintained or enhanced his or her quality of life. 3. The MDS for Resident #33 dated 1/25/23, included diagnoses of diabetes mellitus (DM), rheumatoid arthritis. The MDS listed Resident # 33's BIMS as 11 out of 15 (moderately impairment cognition). The Care Plan for Resident #33 dated 12/23/22, reflected Resident # 33's indwelling catheter placed related to fluid retention at recent hospitalization. The Care Plan directed position catheter bag and tubing below the level of the bladder and away from entrance room door. On 04/12/23 at 1:03 PM, Resident #33 sat in her wheel chair (w/c), staff failed to place a dignity bag over her catheter bag under the w/c. On 4/13/23 at 8:37 AM, Resident #33 propelled herself in the wheelchair in A Hallway all the way to dining room and the facility failed to place a dignity bag over Resident # 33's catheter bag. On 4/13/23 at 9:40 AM, Resident #33 walked her self up the hall as she sat in the w/c. The urinary catheter bag under her w/c lacked a dignity cover as she walked herself in the w/c in the hall to the Front DR area. On 4/13/23 at 11:35 AM, Resident #33 wheeled herself from the nurses station by A hall into her room as her catheter bag lacked a dignity cover. Observations of Resident #33 on 4/17/23 revealed the following: a. On at 8:29 AM, able to self propel from dining room back to her room with Foley bag without a dignity bag under the wheelchair seat and tubing dragging across the floor. b. On at 8:33 AM, able to self propel from her room to the activity room with Foley bag without a dignity bag and tubing dragging across the floor. c. On at 8:46 AM, able to self propel from activity room back to her room with Foley bag still without a dignity bag and tubing dragging across the floor. On 4/17/23 at 1:00 PM, Resident # 33 sat at the table in the dining room, the facility failed to utilize a dignity cover over Resident # 33 catheter bag under her w/c. On 4/18/23 at 12:42 PM, Staff DD, Certified Medication Aide (CMA), placed Resident # 33 catheter bag in a dignity bag. On 4/18/23 at 12:42 PM, Staff DD reported, she finished fixing her dignity bag cover for Resident # 33's privacy. Staff DD stated, catheter bags needed a dignity cover place all the times. On 04/18/23 at 2:15 PM, the Director of Nursing (DON) stated, her expectation is all catheter bags covered with a dignity bag. The facility policy titled Catheter Care dated 3/2023, revealed the following: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 1. Catheter care will be performed every shift and as needed by nursing personnel. 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. 3. Privacy bags will be changed out when soiled, with a catheter change or as needed. Leg bags may be used for ambulatory residents or per resident request. The facility admission Agreement included Exhibit B Residents Rights undated, directed each resident shall have the right: a. To privacy in treatment and personal care. Based on observations, clinical record review and staff interviews, the facility staff failed to ensure residents' dignity upheld for 4 of 14 residents reviewed (Residents #11, #33, #49, and #70). The facility reported a census of 69 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15, and had the following diagnoses: Atrial Fibrillation, UTI and Diabetes Mellitus. The MDS also identified the resident required extensive staff assistance with all activities off daily living (ADL's)) except for eating and that he had an indwelling catheter. Observations of the resident revealed the a Foley catheter bag hanging off the bed frame without a dignity bag and visible to anyone walking into the room at the following times: a. On 4/11/23 at 11:25 AM, while the resident lying in bed b. On 4/11/23 at 1:10 PM, assessment unchanged. c. On 4/11/23 at 2:23 PM, assessment unchanged. d. On 4/12/23 at 10:30 AM, asleep in bed. e. On 4/12/23 at 11:15 AM, assessment unchanged. f. On 4/12/23 at 12:20 PM, assessment unchanged, door to room open. A review of the Care Plan identified the resident with the problem of having an indwelling Catheter on 4/5/23 (resident admitted to facility on 3/8/23) and directed staff to position catheter bag and tubing below the level of the bladder and away from entrance room door. 2. The MDS dated [DATE] identified Resident #49 as cognitively intact with a BIMS score of 15 out of 15 and had the following diagnoses: Multiple Sclerosis, neurogenic bladder and paraplegia. It identified the resident required extensive staff assistance with repositioning in bed, and totally dependent on staff for bathing. The MDS also identified the resident with an indwelling urinary catheter. Observations of the resident revealed a Foley catheter bag not placed in a dignity bag at the following times: a. On 4/11/23 at 12:09 PM, sitting up in a power chair. b. On 4/11/23 at 1:16 PM, sitting up in power chair, assessment unchanged. c. On 4/11/23 2:11 PM, sitting up in power chair in the main dining room, underneath his seat. d. On 4/12/23 at 3:36 PM, during an observation of wound care, also found the catheter bag and tubing lying on the floor. e. On 4/13/23 7:21 AM, asleep in bed, door to room wide open, the Foley catheter bag hung on the bed frame in full view of anyone walking past the room. f. On 4/13/23 8:36 AM, assessment unchanged. g. On 4/13/23 9:15 AM, resident in bed with Foley catheter bag in full view of anyone walking by his room as door left wide open. h. On 4/17/23 8:10 AM, sitting up in bed, holding the wound vac and Foley bag (without being placed in a dignity bag) over his groin area. On 2/20/23, the Care Plan identified the resident with the problem of having an indwelling catheter and directed staff to position the catheter bag and tubing below the level of the bladder and away from entrance room door.

Based on clinical record review, policy review, and staff interview, the facility failed to act promptly to Resident Council concerns with regard to call light response times. 5 of 5 residents who attended the April 2023 Resident Council interviewed reported call light wait time of more than 15 minutes. The facility knew about the call light concern since January 2023. The facility reported a census of 69 residents. Findings Include: Review of the Resident Council Minutes revealed the following concerns: a. The January 2023 Resident Council Meeting Minutes revealed call lights were not answered timely. It took more than 30 minutes to get a response. Certified Nursing Assistant's (CNA) were on cell phones and used ear buds. The Director of Nursing (DON) was at the meeting and was made aware of the concern. b. The February 2023 Resident Council Meeting Minutes revealed call lights were not being answered. CNA wore ear buds and was on the phone during care. The DON was at the meeting and agreed to address the concern. c. The March 2023 Resident Council Meeting Minutes revealed call lights were not being answered and staff wore earbuds and used phones. A Grievance Paper was filled out and was given to the DON. Review of policy titled Resident Council Meetings revised March 2023 stated the facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. The facility failed to provide any written information during the survey regarding the call light Grievance Form submitted by Resident Council in March 2023. On 4/11/23 at 1:00 PM, call lights were identified as a concern for 5 of 5 residents who attended the April Resident Council Group interview. Call light concerns were reported to facility staff and the group was told that the facility was trying to get the call light wait time down to a half hour. The group provided examples of residents waiting 2 hours in soiled pants and linens. Residents tracked time by watches and clocks. The Resident Council reported that staff shut call lights off and did not provide the requested care. Group members agreed that the average wait time for a response was more than 30 minutes. No one answered call lights at shift change according to one member. On 4/19/23 10:55 AM, the DON was asked about the facility response to the Resident Council's Call Light Grievance. The Assistant Director of Nursing (ADON) began inservice training with staff on call light response times. The ADON completed training with 5 staff. The DON was asked about plans to reduce call light times and reported she and the Social Worker developed a training on call lights on 4/18/23. The training began on 4/19/23 to inform staff they must answer all call lights. A no tolerance policy was implemented for use of cell phone and ear buds on the job. Those expectations were included in the new training. The DON stated that one problem was that staff were not answering call lights for residents that they were not assigned to assist during their shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. On 4/12/23 at 10:08 AM, Staff A, Housekeeping Supervisor, stated supplies of linens decreased recently. Soiled linens were not brought into the laundry room. Due to the delay before washing, the linens stained and were thrown away and not replaced. The supply shelf in the laundry room held 4 fitted sheets and 9 flat sheets. There were 0 linen incontinence pads and 0 bedspreads. The supply closet on Unit B had 0 linen incontinence pads. Staff A stated the facility lacked linens, especially linen incontinence pads. Staff A stated there was not enough linens for the facility and CNA's were waiting on linens that were in the laundry. 5. During an observation on 4/11/23 at 11:07 AM, revealed white powder on the floor in Resident #24 room. During observation on 4/11/23 at 4:11 PM, the floor under the dining room table in the dining area had a dried spilled area. The table had an empty cup, milk carton, an empty plastic cup on it. No residents occupied the table. Multiple tables observed dirty and not wiped down. During an observation on 4/18/23 at 12:59 PM, a sticky floor in Resident #24 room. Shoes stuck to the floor when ambulating throughout room. During an interview on 4/24/23 at 1:17 PM, Staff GG, Housekeeping queried how often the resident's rooms cleaned and she stated everyday. Staff GG asked how often the floors in the hallways and resident's rooms are mopped and she stated everyday. During an interview on 4/25/23 at 1:03 PM, the Administrator queried on how often they clean the resident's room and mopped the floors and she stated they cleaned, mopped, and took out the trash in the resident's room daily and mopped the floors in the hallways at least daily and they also did spot cleaning. 6. During an observation on 04/18/23 at 10:21 AM, Resident #41 laid on his bed with no linens on it. During an observation on 4/18/23 at 10:22 AM, no linens present on Resident #3 bed. During an observation on 4/18/23 at 11:33 AM, Resident #41 laid on his bed without a pillow case or linens covering the mattress. During an observation on 4/18/23 at 12:47 PM, no linens on Resident #3 and Resident #41 beds. During an observation on 4/18/23 at 2:58 PM, no linens on the Resident #3 and Resident #41 beds. Both residents laid on their beds. During an interview on 4/18/23 at 2:59 PM, Resident #3 queried why he didn't have linens on his bed and he stated because no sheets were available. He stated they threw them away when they got soiled. He stated the facility ordered new ones, but they hadn't come in yet. Resident #3 asked when they removed the linens from his bed and he stated yesterday afternoon. During an observation on 4/18/23 at 4:16 PM, no noted linens on Resident #3 and Resident #41 beds. During an interview on 4/19/23 at 10:30 AM, Staff A, Housekeeping Supervisor queried on the process of linen changes and she stated the Certified Nurse Aide (CNA) took them off and changed them. She stated Housekeeping wiped down the mattress and let it dry or sometimes the CNA came and got the spray and did it. The CNA or Housekeeping made them when the linens available. She stated no supplies available to hurry up and get beds made and they waited for Laundry to wash them. Staff A asked if linens not on residents beds happened frequently and she stated no, the CNAs stripped the beds, Laundry washed the linens and put them in a closet, and Laundry informed the CNAs the linens available to make beds. Staff A stated it could take 2 to 3 hours for beds to be made. During an interview on 4/20/23 at 9:27 AM, Staff HH, CNA queried if she ever saw beds without linens on them and she stated sometimes when she came on shift. Staff HH queried if the facility short on linens and she stated yes, she found out last night because no sheets were found in the closet in the back hallway. During an interview on 4/20/23 at 9:52 AM, Staff II, CNA queried if the facility short on linens and she stated yes, they are really short on linens. Staff II asked how long it took between removing linens on the bed and replacing them and she stated it depended on availability of sheets and at times it took a couple of hours. Staff II, queried if enough sheets were available with routine laundering/incontinent issues and she stated no, not all the time. During an interview on 4/24/23 at 1:21 PM, Staff B, Laundry Aide queried how often they changed the linens and she stated they were supposed to be changed daily but if they were not dirty they didn't get changed. She stated they had no linens and didn't have a lot of fitted sheets. She stated a lot of beds in the halls didn't have linens on them. During an interview on 4/25/23 at 1:03 PM, the Administrator queried on the expectations of linens being changed on the resident's beds after the removal of soiled linens and she stated she didn't have a time frame but they should definitely know the resident's routine and it should be done quickly. 7. During random observations of the facility, noted areas with strong odors smelling of urine, body odor and garbage: a. On 4/11/23 at 11:03 AM revealed Resident #24 room smelled of urine and body odor. b. On 4/12/23 at 12:31 PM, Hall B smelled of urine near Resident #24 room. c. On 4/13/23 at 12:53 PM, Hall B smelled of urine near Resident #24 room. d. On 4/17/23 at 1:21 PM, smelled urine when entering Resident #24 room. e. On 4/18/23 at 12:59 PM, walked by Resident #24 room and smelled a strong odor of urine. During an interview on 4/20/23 at 9:12 AM, Staff CC, Licensed Practical Nurse (LPN) queried if she noticed odors when she started her shift and she stated yes, at the front of the building from garbage bags lined up to be taken out. Staff CC asked if she noticed odors in B Hall and she stated she didn't know, she usually wore a face mask. During an interview on 4/20/23 at 9:52 AM, Staff II, Certified Nursing Assistant (CNA) queried if she noticed odors when she started her shift and she stated yeah, typically it stunk of urine especially in the back. Staff II asked if she noticed an odor in B Hall and she stated the back usually smelled of urine especially when one CNA worked because of the trash and incontinent briefs. Staff II queried if she ever smelled an odor in Resident #24's room and she stated urine, definitely. Staff II asked what she thought caused it and she stated his roommate took himself to the bathroom and didn't have good aim and the urinals in the room didn't get dumped very often or might get spilled. During an interview on 4/24/23 at 1:17 PM, Staff GG, Housekeeping queried if she noticed an odor in the facility and she stated an urine smell, just in B Hall. Staff GG asked when she smelled urine and she stated she guessed in the mornings. Staff queried if she noticed it more in any of the resident's rooms and she stated they were all about the same to her. During an interview on 4/25/23 at 1:03 PM, the Administrator queried if she noticed odors in the resident's rooms or hallways and she stated not specifically but if she did she got hold of housekeeping and got it cleaned up. She stated she noticed B hallway that had an urine odor and looked into ways to eliminate the problem. The undated Facility Policy titled Routine Cleaning and Disinfection revealed the policy ensured the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and preventing the development and transmission of infections to the extent possible. The facility indicated routine cleaning and disinfection of frequently touched or visibly soiled surfaces would be performed in common areas, resident rooms, and at the time of discharge. 11. During an observation on 4/11/23 at 9:44 a.m., Resident #56's room had a crumpled bed pad and hospital gown in the middle of the floor. There were pieces of paper and refuse on the floor near the resident's bed. During an observation on 4/13/23 at 8:13 a.m., the Central Hall near the Activity Room door had 2 pieces of crumpled up white paper. Near the door to the north dining room, there was a blue piece of paper on the floor and smashed raisins. 12. In an interview on 4/11/23 at 10:10 a.m., the Administrator stated odors were better in the facility and stated when she first started at the facility she thought the odors were stronger. She stated she would like to redo some flooring and that the removal of garbage was not just a housekeeping responsibility. An observation on 4/11/23 at 11:40 a.m. revealed a strong odor of urine in the center hall. Based on observations, resident and staff interviews and facility policy review the facility failed to maintain clean floors, empty trash, clean resident equipment, prevent urine odors in resident rooms and the hallways, noted cigarette butts are littered on the ground in the smoking area and failed to provide linens for 7 out of 26 residents reviewed (Residents # 3, #15, #9, # 24, #41, #46, and# 56). The facility reported a census of 69 residents. Findings Include: 1. On 4/11/23 at 10:58 AM, Resident # 15 reported housekeeping cleans daily. Resident # 15 stated, she's failed to know if housekeeping cleaned the bathroom. On 4/11/23 at 10:58 AM, the bathroom floor in Resident # 15's room held a dried 4 by 4 inch brown substance and smears of brown on the toilet riser. The resident's son stated the bathroom floor appeared disgusting. 2. On 4/12/23 at 10:50 AM, a night gown, incontinent pad and wash cloth sat on the floor in Resident # 56's room. 3. On 4/12/23 at 12:23 PM, the smoking area out the door on the North side of the building revealed cigarette butts in the grass and a large number sat on the sidewalk. 4. On 4/13/23 at 11:25 AM, Staff L, Housekeeping, used her foot and cloth towel to dry up the ice spilt and melted on the floor. The white cloth appears black/gray in color as she picked it up off the floor and carried down the hall to the dirty linen cart room. On 4/20/23 at 10:50 AM, Staff M, Housekeeping, reported she started here 7 months ago. She stated the facility provided training on the use of chemicals for the cleaning. The facility provided a policy titled Preventative Maintenance Program dated 3/2022, reflected a Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The facility provided an undated policy titled Routine Cleaning and Disinfection, the policy revealed the facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. The policy directed: Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. The policy included direction for: Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: a. Toilet flush handles; b. Bed rails; c. Tray tables; d. Call buttons; e. TV remote; f. Telephones; g. Toilet seats; h. Monitor control panels, touch screens and cables; i. Resident chairs; j. IV poles; k. Blood pressure cuffs; l. Sinks and faucets; m. Light switches; n. Door knobs and levers. The policy listed, horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine resident-care areas should be cleaned: a. On a regular basis. b. When soiling and spills occur. c. When a resident is discharged from the facility. 9. The Minimum Data Set (MDS) dated [DATE] identified Resident #9 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 2 out of 15 and had the following diagnoses: Renal Insufficiency, Non-Alzheimer's Dementia and Bipolar Disorder. It also identified the resident required extensive staff assistance with bed mobility, transfers, dressing, toileting and hygiene. Observations of the resident revealed the following: a. On 4/13/23 at 8:43 AM the resident ambulated independently in the hall wearing only pajamas and no footwear. The Assistant Director of Nursing (ADON) redirected her away from the exit door at end of hall. Multiple areas of brown residue noted on the carpeting. The resident began to walk the other way. Neither the ADON nor Staff F, Certified Medication Aide (CMA) in hallway placed any gripper socks or shoes on the resident's feet b. On 4/13/23 at 8:48 AM the resident remained ambulating independently in hall without any socks or shoes on her feet, had pushed the bar on the exit door at end of hall, but did not attempt to go outside. Staff F stood in the hallway and did not encourage her or assist her with putting socks or shoes on her feet. c. On /13/23 at 9:06 AM female therapy staff member assisted the resident to change into clean clothing and gripper socks and walked her down to therapy room. A review of the Care Plan identified the resident on 8/27/21 with the problem with being at risk for falls and directed staff to ensure the resident wore appropriate footwear when ambulating. It also identified her on the same date with the problem of an activities of daily living (ADL) self-care performance deficit and directed staff to assist of 1 to move between surfaces and as necessary. make sure she has shoes on will often refuse/take off. In an interview on 4/24/23 at 1:46 PM, the Social Worker reported the resident did have a history of wandering the halls independently and the staff should make sure she has her feet covered with gripper socks or shoes when walking in the hallways as the carpeting is not the cleanest. In an interview on 5/1/23 at 10:07, Staff QQ, CNA, reported Resident #9 had a history of walking in the halls independently and did so frequently. She also reported if staff saw her walking around in her bare feet, they should take her back to her room and put socks and shoes on her. When asked what she thought the brown spots were on the carpeting, she reported it could be feces as she had actually witnessed Resident #9 removing a bowel movement (BM) from her pants and throw it on the carpeting. In an interview on 5/1/23 at 10:19 AM, Staff E, Licensed Practical Nurse (LPN) reported Resident #9 had a history of walking in the halls independently and did so frequently. She also reported if staff saw her walking around in her bare feet, they should take her back to her room as she is easily re-directed and put socks and shoes on her. In an interview on 5/1/23 at 11:03 AM, the Director of Nursing (DON) reported Resident #9 did have a history of walking in the halls independently several times a day. If staff saw her walking around in her bare feet, she would expect the staff to take her to her room and put on socks, shoes or slippers on her feet. When asked what she thought the brown spots may be on the carpeting, she thought it might be food that the resident spit out and not BM. 10. A review of the MDS dated [DATE] identified Resident #46 as cognitively intact with a BIMS score of 13 out of 15 and with the following diagnoses: Multiple Sclerosis, Coronary Artery Disease and Respiratory Failure. It also identified the resident required extensive staff assistance with all ADLs (activities of daily living) except for eating and totally dependent on staff for showers/baths. Observations of the resident's room revealed the following: a. On 4/11/23 at 1:12 PM, asleep in bed, no side rails up. Floor mat beside bed covered with liquid residue. b. On 4/11/23 at 2:21 PM, assessment unchanged. c. On 4/13/23 at 7:13 AM, asleep in bed with door to room open and the floor mat beside the bed had a sticky residue, debris of tissues and food particles on floor beside bed. d. On 4/13/23 at 7:40 AM, The floor to the resident's room remains with food particles and tissues beside bed. e. On 4/13/23 at 9:32 AM, Staff C, CNA walked into the resident's room, provided cares and left the room without picking up food particles and tissues by the bed. f. On 4/17/23 at 8:20 AM, resident now in room in the A hall. The resident's floor appeared very sticky and the floormat next to bed covered with food particles. Clothing and blankets were also observed lying on the floor at the foot of the bed. The Care Plan identified the resident with the problem on 1/25/23 of being at risk for falls due to decreased mobility and directed staff to ensure her room was free of clutter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident interviews, staff interviews, and facility policy review, the facility neglected residents when they failed to provide required nursing services to residents who needed assistance wtih grooming, bathing, incontinence care and failed to provide housekeeping and laundry services for 16 out of 26 residents reviewed for activities of daily living assistance and homelike environment (Resident #35, #2, #10, #4, #46, #56, #61, #63, #70, #15, #9, #24, #41, #3). The facility reported a census of 69 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #35 dated 1/18/23, listed diagnoses of dementia and cancer. The MDS identified the Brief Interview of Mental Status (BIMS) score of of 00 (indicating severe cognitive impairments), and showed Resident #35 required extensive assist of 1 staff for personal hygiene and bathing. The Care Plan dated 10/28/19, identified Resident #35's activities of daily living (ADL) self-care performance deficit related to Dementia. The Care Plan intervention included to keep fingernails short and keep skin clean and dry. The Bath Record dated 4/18/23, showed Resident #35 received 3 baths in 30 days. The record reflected baths given to Resident #35 on 3/21/23, 3/28/23 and 4/11/23. The Hospice Communication log at the Nurses Station included notes from the nurses and lacked documentation of bathing. The Hospice Care Plan dated 3/16/23, failed to reflect bathing provided for Resident #35. During the following observations of Resident #35, noted dirty fingernails on both hands: a. On 4/11/23 at 12:50 PM, the resident's right and left hands under her fingernails noted a dark substance. b. On 4/12/23 at 12:26 PM, Resident #35 finger nails on her left hand continued with a dark colored substance under the nails. c. On 4/12/23 at 12:15 PM, under all five finger nails on Resident #35's right hand contained dark substance. d. On 4/13/23 at 8:42 AM, Resident #35's fingernails to her right hand remained with dark colored substance under the nail. e. On 4/17/23 12:54 PM, Resident #35's right hand under her finger nails held dark black colored substance as she sat at the dining room table. f. On 4/18/23 at 12:34 PM, Resident #35's sat at the dining room table and her right hand under her fingernails held a dark colored substance. The facility provided a policy titled Nail Care dated 3/2023, identified The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. The policy directed at point # 3: routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. The policy included at point #4: Routine nail care, to include trimming and filing, will be provided on a regular basis. Nail care will be provided between scheduled occasions as the need arises. 2. The MDS assessment dated [DATE], revealed Resident #2 scored 14 out of 15 on a BIMS exam, which indicated cognition intact. The MDS indicated the resident independent and bathed with no set up or physical help from staff. During an interview on 4/11/23 at 12:07 PM, Resident #2 stated they only showered him once and they were supposed to give him bed baths because of his pressure ulcers but they never asked if he wanted one. He stated his last bath happened 2 or 3 months ago. Resident #2 stated he waited for the staff to ask him to shower and didn't. Resident sat in his wheelchair and the resident disheveled wearing camo pants and a shirt. During an interview on 4/12/23 at 3:44 PM, Resident #2 stated he received one bed bath while he resided in the front hall and when they moved him to the back hall he stated didn't receive a bath. The Care Plan dated 3/1/23 revealed a focus problem of an Activities of Daily Living (ADL) performance deficit related to impaired mobility, paraplegia. The interventions dated 9/22/23 indicated Resident #2 required extensive assistance by (1) staff with bathing/showering. The Documentation Survey Report for March 2023 and April 2023 revealed the resident scheduled showers/baths on Tuesdays and Fridays between 6:00 AM and 2:00 PM and contained no documentation indicating the resident received a shower/bath. Task Sheet for Bathing/Shower for the last 30 days documented 1 shower on 4/18/23. During an interview on 4/20/23 at 9:27 AM, Staff HH, Certified Nurse Aide (CNA) queried how often Resident #2 showered and she stated she never provided his shower before and no one told her he took showers in rounds. During an interview on 4/20/23 at 09:52 AM, Staff II, CNA queried if refusals of showers are documented and she states yes and the resident signed the refusal on a Shower Sheet if able. Staff II asked how often Resident #2 showered and she stated she didn't work with him and personally not sure. During an interview on 4/24/23 at 4:31 PM, Staff L, CNA queried how often Resident #2 received a shower and she stated she didn't know, she didn't usually work B Hall, she usually worked A Hall. 3. The MDS assessment dated [DATE] revealed Resident #10 scored 9 out of 15 on a BIMS exam, which indicated moderate cognitive impairment. The MDS revealed the resident needed physical help in part of the bathing activity with a one person assist. The MDS revealed the needed extensive assistance with one person physical assist with personal hygiene. During an observation on 4/12/23 at 10:20 AM, Resident #10 wore a white shirt with a stain on it and his hair not combed. Resident grabbed a comb out of his drawer and started to comb his hair. The Care Plan 2/16/23 revealed a focus problem of ADL self performance deficit related to impaired balance, limited Range of Motion (ROM), stroke with right-sided deficits. The interventions dated 6/11/19 revealed to check the nail length and trim and clean on bath day and as necessary; provide sponge bath when a full bath or shower cannot be tolerated and resident will often refuse shower; resident required extensive assistance by staff with bathing/showering and as necessary; resident required extensive to limited assistance by staff with personal hygiene and he preferred facial hair and will often refuse grooming; and preferred long nails and would at times allow cleaning but would refuse trim. The Documentation Survey Report for March 2023 and April 2023 revealed Resident #10 scheduled for showers on Monday and Thursday on the PM shift. The report lacked documentation to indicate any showers received during the 2 months. The Task Record Report for ADL- Bathing/Shower for April 2023 lacked documentation after the date of 4/6/23 for Resident #10's shower completion. During an observation on 4/17/23 at 12:15 AM, Resident #10 sat in his wheelchair with a blanket over him in the common area. Hair not combed. During an interview on 4/18/23 11:20 AM, Resident #10 queried how often he preferred to shower and he stated once a week. Resident #10 asked if he ever refused to shower and he stated no, well yeah sometimes. During an observation on 4/18/23 at 4:17 PM, Resident #10 sat in the common area in his wheelchair. Fingernails were long. The resident asked how often they clipped his nails and he made a sound and stated he didn't know. During an interview on 4/20/23 at 9:52 AM, Staff II, CNA queried how often resident's showered and she stated they are short staffed and she got them done as soon as she could. She stated she came in on her days off and provided showers and bed baths to the residents. She stated the showers are not being completed regularly and the residents received a shower maybe once a week. Staff II queried how often Resident #10 offered a shower and she stated she believed his shower scheduled on the PM and he took his shower for her but refused with certain aides. During an interview on 4/24/23 at 4:01 PM, the Director of Nursing (DON) queried how often residents are showered and she stated they have a shower schedule and the residents should be showered on the scheduled days. The DON queried what it meant if the shower date was left blank on the task sheet in the computer and she responded like it not charted, either they forgot to do their charting or the shower not given. During an interview on 4/24/23 at 4:31 PM, Staff L, CNA queried how often residents are showered and she stated daily on their scheduled shower days at least a majority of the time they received their showers on their scheduled shower days. She stated except for days they are short staffed like that day. Staff L queried if the residents received showers that day and she stated no. 4. The MDS dated [DATE] for Resident #4 identified a BIMS score of 12 which indicated moderate cognitive impairment. The MDS revealed the resident dependent on staff for toileting and the resident needed substantial assistance rolling side to side while lying in bed. The MDS listed diagnosis of congestive heart failure (CHF), type two diabetes, chronic obstructive pulmonary disease (COPD), sleep apnea and morbid obesity. On 4/11/23 at 10:00 AM, the resident observed sitting in bed, with greasy hair, incontinence brief showing at the waist, and overall disheveled look. Resident #4's speech difficult to understand however able to answer yes and no questions by shaking head. When asked if a shower had been taken recently the resident shook her head no. A 10/31/22 Care Plan entry directed only female staff to provide personal care and stated the resident required extensive assistance in the shower and to provide a sponge bath when a shower could not be tolerated. Review of the Electronic Health Care Record showed the resident last received a shower on 3/22/23 and documented the activity did not occur on 3/29/23. Dates of 4/1/23 and 4/12/23 documented the activity was not applicable. The electronic reports lacked documentation of further showers/bath assistance given during the time period. 5. The MDS dated [DATE] identified Resident #46 as cognitively intact with a BIMS score of 13 out of 15 and with the following diagnoses: Multiple Sclerosis, Coronary Artery Disease and Respiratory Failure. It also identified the resident required extensive staff assistance with all ADL's except for eating and totally dependent on staff for showers/baths. In an interview on 4/12/23 at 10:50 AM, the resident's family member reported she would visit the resident once or twice a week. The family member reported they were supposed to reposition the resident every 2 hours. She reported she would be at the facility for 5 hours and not see anyone come in to reposition her. Observations of the resident's room on 4/11/23 at 1:12 PM revealed the floor mat beside bed covered with liquid residue and remained on the floor mat at 2:21 PM. Observations of the resident revealed the following on 4/12/23: a. At 1:30 PM remained lying on her back in bed, both resident and her mother verified it had been 2.5 hours and no one had been in to reposition the resident. b. At 2:45 PM remained lying on her back in bed, she and her mother both reported no staff member had been in to reposition the resident for the past 3.75 hours. Continuous observations of the resident on 4/13/23 from 7:13 AM to 9:32 AM revealed the following: a. At 7:13 AM asleep in bed with door to room open and the floor mat beside the bed had a sticky residue, debris of tissues and food particles on floor beside bed. b. At 7:20 AM no staff in hall c. At 7:40 AM remained asleep in bed lying on back, bells used to call staff on tray table out of the resident's reach. The floor remained with food particles and tissues beside bed. d. At 8:09 AM Staff C entered resident's room, and placed her breakfast tray on the tray table. e. At 8:12 AM resident asleep again, tray remained on tray table, untouched. f. At 8:29 AM, the ADON entered room and assisted the resident with breakfast. g. At 8:45 AM, the ADON left the resident's room. The resident reported the ADON did not provide cares, that it had been several hours since anyone had washed her private parts. h. At 8:49 AM, Staff F, entered room to administer medications. No cares provided i. At 8:56 AM, Staff C walked by the resident's room and removed linens from linen closet and walked down the other way; no cares provided j. At 9:13 AM, housekeeping staff entered the room to move belongings to another room. k. At 9:25 AM, Staff C walked into the resident's room and refilled resident's water pitcher with ice water but provided no cares. At 9:29 AM, Staff C walked by the resident's room but provided no cares. l. At 9:31 AM resident ringing her bells to call staff, no staff in the hallway. North Dining Room Alarm sounding overhead and bells could not be heard above alarm sounding. The resident did not have peri cares for 2 hours and 18 minutes. m. At 9:32 AM Staff C entered room to provide peri cares. Staff C left the room without picking up food particles and tissues by the bed. Observations of the resident on 4/17/23 revealed the following: a. The resident now resided in room on A hall. At 8:20 AM, the resident's floor appeared very sticky and the floormat next to bed covered with food particles. Clothing and blankets observed lying on the floor at the foot of the bed. The resident laid in bed with the call light wrapped around frame of her bed behind her head, and the resident stated I've been calling out for over an hour now, I can't find my call light, I need my brief changed. Surveyor turned on the call light for the resident. Staff BB, Registered Nurse (RN) stood out in the hallway by a medication cart, did not check on resident. b. At 8:25 AM the call light remained on, audible, Staff BB in the hall and walked into another resident's room. Staff L, CNA walked into another resident's room at the end of the hall. c. At 8:27 AM, Staff BB walked by this resident's room as her call light remained lit and did not check on her. d. At 8:28 AM, Staff L walked into the resident's room and turned off the call light and left the room and brought two bags of linens down the hall. e. At 8:30 AM, the surveyor asked the resident if Staff L addressed her needs, she reported I asked her to change my brief and she left my room without doing it. f. At 8:37 AM, the resident's cell phone rang, resident called out can someone help me get my phone No staff provided assistance. g. At 8:54 AM, Staff BB entered the room to check on resident, did not provide peri cares. The resident had been waiting 24 minutes to have someone provide peri care. h. At 10:00 AM, the resident's call light remained on. She reported no one ever came to change her incontinent brief. Then Staff BB entered the room to ask what she needed, she said I need my brief changed. Staff BB responded let me get someone to help you and left the room. The resident reported the day before she turned on her call light from 8:30 AM to get her brief changed and no one changed her brief until 2:30 AM that night. I'll turn on my call light, they keep coming in to turn it off and don't help me and I have to keep turning my call light on again i. At 10:08 AM Staff L entered the room to provide cares as requested 1 hour and 48 minutes later. On 10/29/22, the Care Plan identified the resident with the problem of bowel and bladder incontinence and directed staff to clean peri-area with each incontinence episode. The facility policy titled: Incontinence dated as last reviewed March 2023 had documentation of the following: 1. The facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. 6. The MDS, dated [DATE], listed diagnoses for Resident #56 which included heart failure, diabetes, and morbid obesity. The MDS documented the resident did not receive a bath during the review period and listed the resident's BIMS score as 14 out of 15, indicating intact cognition. During an interview on 4/12/23 at 9:44 a.m., the Resident #56 stated she missed baths but that was because she took them independently and forgot to go in and complete them. The resident's hair appeared greasy and unkempt. A 7/2/22 Care Plan entry directed staff to provide a sponge bath when a full bath or shower could not be tolerated. Care Plan entries, dated 11/3/22, stated the resident required assistance with ADL's due to impaired mobility and right hemiplegia (one-sided weakness). The March 2023 Documentation Survey Report documented the resident received a shower on 3/2/23 and 3/30/23 and documented the resident refused on 3/13/23 and the activity did not occur on 4/23/23. The April 2023 Documentation Survey Report documented the resident received a shower on 4/6/23 and 4/13/23. The 4/10/23 entry stated the resident was not available. The reports lacked documentation of further showers/bath assistance given during the time prior of 3/1/23-4/17/23. During an observation on 4/11/23 at 9:44 a.m., Resident #56's room had a crumpled bed pad and hospital gown in the middle of the floor. There were pieces of paper and refuse on the floor near the resident's bed. On 4/12/23 at 10:50 AM, a night gown, incontinent pad and wash cloth sat on the floor in Resident # 56's room. 7. The MDS, dated [DATE], listed diagnoses for Resident #61 which included malnutrition, morbid obesity, and weakness. The MDS documented the resident required extensive assistance of 2 staff for personal hygiene and bathing and listed the resident's cognition as moderately impaired. During an observation on 4/13/23 at 8:07 a.m., Resident #61 laid in bed. All of his nails were very long, extending past the fingers approximately 3 millimeters(mm). The resident was unshaven, had a long beard and his hair was unkempt. Observations on 4/17/23 at 12:29 p.m. and 4/18/23 at 7:38 a.m. revealed the resident's nails were the same length, he was unshaven, and his hair was unkempt. Care Plan entries, dated 4/6/23, stated the resident had a self-care performance deficit related to impaired mobility and stated the resident required extensive assistance of 1 staff for personal hygiene. 8. The 3/9/23 MDS listed diagnoses for Resident #63 which included diabetes, burns, and unspecified fall. The MDS identified the resident required extensive assistance of 1 staff for personal hygiene and completely depended on 1 staff for bathing. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The MDS documented the resident admitted to the facility on [DATE]. In an interview on 4/17/23 at 1:15 p.m., Resident #63 stated she only received 2 showers since admission to the facility. The March 2023 Documentation Survey Report stated the resident had partial baths on 3/4, 3/6, 3/8, 3/11/23, and 3/14, and had a shower on 3/21/23. The April 2023 Documentation Survey Report for stated the resident had a partial bath on 4/1/23 and 4/11/23. The record lacked documentation of further showers during the period of 3/3/23-4/17/23. A Care Plan entry, dated 3/13/23, stated the resident had a self-care performance deficit related to impaired mobility and stated the resident required total assistance of 1 staff for bathing and showering. 9. The MDS assessment tool, dated 1/3/23, listed diagnoses for Resident #70 which included heart failure, paraplegia, and anxiety disorder. The MDS stated the resident required supervision assistance of 2 staff for personal hygiene, limited assistance of 2 staff for transfers, extensive assistance of 1 staff for dressing, extensive assistance of 2 staff for toilet use, and depended completely on 2 staff for bathing. The MDS listed the resident's BIMS score as 14 out of 15, indicating intact cognition. The 4/7/23 entry MDS stated the resident admitted from an acute hospital on 4/7/23. In an interview on 4/12/23 at 10:11 a.m., Resident #70 stated she returned from the hospital Friday night(4/7/23) and stated she had not received a shower since. She stated she felt like she stinks. The April 2023 Documentation Survey Report lacked documentation the resident received a shower or bath from 4/7/23-4/12/23. A Care Plan entry, dated 4/20/22, stated the resident required extensive assistance of 1 staff for bathing/showering. 10. On 4/11/23 at 10:58 AM, Resident #15 reported housekeeping cleaned daily but did not know if housekeeping cleaned the bathroom. On 4/11/23 at 10:58 AM, the bathroom floor in Resident #15's room held a dried 4 by 4 inch brown substance and smears of brown on the toilet riser. The resident's son stated the bathroom floor appeared disgusting. 11. The MDS dated [DATE] identified Resident #9 as severely cognitively impaired with a BIMS score of 2 out of 15 and had the following diagnoses: Renal Insufficiency, Non-Alzheimer's Dementia and Bipolar Disorder. It also identified the resident required extensive staff assistance with bed mobility, transfers, dressing, toileting and hygiene. Observations of the resident revealed the following: a. On 4/13/23 at 8:43 AM the resident ambulated independently in the hall wearing only pajamas and no footwear. The Assistant Director of Nursing (ADON) redirected her away from the exit door at end of hall. Multiple areas of brown residue noted on the carpeting. The resident began to walk the other way. Neither the ADON nor Staff F, Certified Medication Aide (CMA) in hallway placed any gripper socks or shoes on the resident's feet b. On 4/13/23 at 8:48 AM the resident remained ambulating independently in hall without any socks or shoes on her feet. Staff F stood in the hallway and did not encourage her or assist her with putting socks or shoes on her feet. c. On /13/23 at 9:06 AM female therapy staff member assisted the resident to change into clean clothing and gripper socks and walked her down to therapy room. In an interview on 4/24/23 at 1:46 PM, the Social Worker reported the resident did have a history of wandering the halls independently and the staff should make sure she has her feet covered with gripper socks or shoes when walking in the hallways as the carpeting is not the cleanest. In an interview on 5/1/23 at 10:07, Staff QQ, CNA, reported Resident #9 had a history of walking in the halls independently and did so frequently. She also reported if staff saw her walking around in her bare feet, they should take her back to her room and put socks and shoes on her. When asked what she thought the brown spots were on the carpeting, she reported it could be feces as she had actually witnessed Resident #9 removing a bowel movement (BM) from her pants and throw it on the carpeting. In an interview on 5/1/23 at 10:19 AM, Staff E, Licensed Practical Nurse (LPN) reported Resident #9 had a history of walking in the halls independently and did so frequently. She also reported if staff saw her walking around in her bare feet, they should take her back to her room as she is easily re-directed and put socks and shoes on her. In an interview on 5/1/23 at 11:03 AM, the DON reported Resident #9 did have a history of walking in the halls independently several times a day. If staff saw her walking around in her bare feet, she would expect the staff to take her to her room and put on socks, shoes or slippers on her feet. When asked what she thought the brown spots may be on the carpeting, she thought it might be food that the resident spit out and not BM. 12. Observation on 4/11/23 at 11:07 AM revealed white powder on the floor in Resident #24 room. During random observations of the facility, noted areas with strong odors smelling of urine, body odor and garbage: a. On 4/11/23 at 11:03 AM revealed Resident #24's room smelled of urine and body odor. b. On 4/12/23 at 12:31 PM, Hall B smelled of urine near Resident #24's room. c. On 4/13/23 at 12:53 PM, Hall B smelled of urine near Resident #24's room. d. On 4/17/23 at 1:21 PM, smelled urine when entering Resident #24's room. e. On 4/18/23 at 12:59 PM, walked by Resident #24's room and smelled a strong odor of urine. Observation further revealed a sticky floor in Resident #24's room and shoes stuck to the floor when ambulating throughout the room. During an interview on 4/20/23 at 9:12 AM, Staff CC, Licensed Practical Nurse (LPN) queried if she noticed odors when she started her shift and she stated yes, at the front of the building from garbage bags lined up to be taken out. Staff CC asked if she noticed odors in B Hall and she stated she didn't know, she usually wore a face mask. During an interview on 4/20/23 at 9:52 AM, Staff II, Certified Nursing Assistant (CNA) queried if she noticed odors when she started her shift and she stated yeah, typically it stunk of urine especially in the back. Staff II asked if she noticed an odor in B Hall and she stated the back usually smelled of urine especially when one CNA worked because of the trash and incontinent briefs. Staff II queried if she ever smelled an odor in Resident #24's room and she stated urine, definitely. Staff II asked what she thought caused it and she stated his roommate took himself to the bathroom and didn't have good aim and the urinals in the room didn't get dumped very often or might get spilled. During an interview on 4/24/23 at 1:17 PM, Staff GG, Housekeeping queried if she noticed an odor in the facility and she stated an urine smell, just in B Hall. During an interview on 4/25/23 at 1:03 PM, the Administrator queried if she noticed odors in the resident's rooms or hallways and she stated she noticed B hallway that had an urine odor and looked into ways to eliminate the problem. 13. On 4/12/23 at 10:08 AM, Staff A, Housekeeping Supervisor, stated supplies of linens decreased recently. Soiled linens were not brought into the laundry room. Due to the delay before washing, the linens stained and were thrown away and not replaced. The supply shelf in the laundry room held 4 fitted sheets and 9 flat sheets. There were 0 linen incontinence pads and 0 bedspreads. The supply closet on Unit B had 0 linen incontinence pads. Staff A stated the facility lacked linens, especially linen incontinence pads. Staff A stated there was not enough linens for the facility and CNA's were waiting on linens that were in the laundry. During an observation on 4/18/23 at 10:21 AM, Resident #41 laid on his bed with no linens on it. During an observation on 4/18/23 at 10:22 AM, no linens present on Resident #3's bed. During an observation on 4/18/23 at 11:33 AM, Resident #41 laid on his bed without a pillow case or linens covering the mattress. During an observation on 4/18/23 at 12:47 PM, no linens on Resident #3's and Resident #41's beds. During an observation on 4/18/23 at 2:58 PM, no linens on the Resident #3's and Resident #41's beds. Both residents laid on their beds. During an interview on 4/18/23 at 2:59 PM, Resident #3 queried why he didn't have linens on his bed and he stated because no sheets were available. He stated they threw them away when they got soiled. He stated the facility ordered new ones, but they hadn't come in yet. Resident #3 asked when they removed the linens from his bed and he stated yesterday afternoon. During an observation on 4/18/23 at 4:16 PM, no noted linens on Resident #3's and Resident #41 s beds. During an interview on 4/19/23 at 10:30 AM, Staff A, Housekeeping Supervisor queried on the process of linen changes and she stated the Certified Nurse Aide (CNA) took them off and changed them. She stated Housekeeping wiped down the mattress and let it dry or sometimes the CNA came and got the spray and did it. The CNA or Housekeeping made them when the linens available. She stated no supplies available to hurry up and get beds made and they waited for Laundry to wash them. Staff A asked if linens not on residents beds happened frequently and she stated no, the CNAs stripped the beds, Laundry washed the linens and put them in a closet, and Laundry informed the CNAs the linens available to make beds. Staff A stated it could take 2 to 3 hours for beds to be made. During an interview on 4/20/23 at 9:27 AM, Staff HH, CNA queried if she ever saw beds without linens on them and she stated sometimes when she came on shift. Staff HH queried if the facility short on linens and she stated yes, she found out last night because no sheets were found in the closet in the back hallway. During an interview on 4/20/23 at 9:52 AM, Staff II, CNA queried if the facility short on linens and she stated yes, they are really short on linens. Staff II asked how long it took between removing linens on the bed and replacing them and she stated it depended on availability of sheets and at times it took a couple of hours. Staff II, queried if enough sheets were available with routine laundering/incontinent issues and she stated no, not all the time. During an interview on 4/24/23 at 1:21 PM, Staff B, Laundry Aide queried how often they changed the linens and she stated they were supposed to be changed daily but if they were not dirty they didn't get changed. She stated they had no linens and didn't have a lot of fitted sheets. She stated a lot of beds in the halls didn't have linens on them. During an interview on 4/25/23 at 1:03 PM, the Administrator queried on the expectations of linens being changed on the resident's beds after the removal of soiled linens and she stated she didn't have a time frame but they should definitely know the resident's routine and it should be done quickly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview and facility policy review, the facility failed to provide accurate documentation on the Minimum Data Set (MDS) for 1 of 3 residents for falls (Resident #22); for 2 of 2 residents reviewed for Preadmission Screening and Resident Review (PASARR) Level II (Residents #16 and #41); and for 1 of 8 for functional abilities for accuracy of the MDS (Resident #2). The facility reported a census of 69. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated the following documentation for Functional Abilities: a. Walked in room- how resident walked between locations in room- activity occurred only once or twice b. Walked in corridor- how resident walked in corridor on unit- activity occurred only once or twice c. Bathing- self performance- resident independent and no set up or physical help from staff d. Balance during transitions and walking- moving from seated to standing position- resident steady at all times. e. Balance during transitions and walking- walking (with assuasive device if used)- resident steady at all times f. Balance during transitions and walking- turning around and facing the opposite direction while walking- steady at all times. e. Mobility- walked 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space- resident independent f. Mobility- walked 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns- resident independent g. Mobility- walked 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space- resident independent h. Mobility- walked 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel- resident independent The Care Plan dated 3/1/23 revealed a focus problem of an Activities of Daily Living (ADL's) performance deficit related to impaired mobility, paraplegia. The interventions dated 9/22/23 indicated Resident #2 required extensive assistance by (1) staff with bathing/showering. The Electronic Medical Record revealed the following Medical Diagnosis of paraplegia. During an observation on 4/11/23 at 12:07 PM, Resident #2 sat with his legs crossed in his wheelchair playing a video game. The resident disheveled wearing camo pants and a shirt. During an interview on 4/20/23 at 10:29 AM, Staff MM, MDS Coordinator queried if she trained on how to do the MDS and she stated she yes, she completed MDS for many, many years and trained at different times. Staff MM asked how she obtained the information for the MDS and she stated information pulled over from the electronic medical record and what the staff charts. Informed Staff MM of discrepancies found for Resident #2, #22, and #41 and she stated remote staff helped with the MDS. She reviewed the MDS for the three residents and stated Resident #22 she completed and made the error. During an interview on 4/24/23 at 4:01 PM, the Director of Nursing (DON) queried on the expectations of the MDS accuracy and she responded it should be updated as changes happen. 2. The MDS assessment dated [DATE] revealed Resident #22 scored 5 out of 15 on a BIMS exam, which indicated severe cognitive impairment. The MDS revealed medical diagnosis of chronic obstructive pulmonary disorder (COPD) and heart failure. The MDS revealed the resident took antianxiety, antidepressant, opioid medications 7 out of 7 days. The MDS documented no falls since admission/entry or reentry or prior admission and failed to address the number of falls since admission/entry or reentry or prior admission. The Care Plan dated 2/20/23 revealed a focus problem of risk of falls related to decreased mobility for Resident #22. The interventions dated 12/15/21 included the call light within reach and encouraged the resident to use for assistance as needed and resident needed activities that minimized the potential for falls while providing diversion. During observation on 4/11/23 at 10:46 AM, Resident #22 laid in bed with no shirt on, wearing an arm sling on his left arm. Fall mat next to the bed, with the bed in the lowest position and bed rail up on the right side of the bed. During an interview on 4/24/23 at 4:01 PM, the DON queried on the expectations of the MDS accuracy and she responded it should be updated as changes happen. The Care Plan dated 4/25/23 revealed a focus problem of an actual fall with no injury related to unsteady gait on the following dates 6/10/22; 6/14/22; 7/7/22; 10/4/22; 2/26/23; 2/28/23; 3/9/23; 3/15/23; 4/10/23; and 4/21/23. 3. The MDS assessment dated [DATE] revealed Resident #41 scored 10 out of 15 on a BIMS exam, which indicated moderate impairment cognition. The MDS revealed the medical diagnosis of schizophrenia and anxiety. The MDS indicated the resident received antipsychotic medications 7 out of 7 days and antipsychotic medications received on routine basis. The PASARR Level II completed on 9/2/20 and revealed the resident had a diagnosis of Schizophrenia. The PASARR Level II identified the following: a. Specialized Services: Ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders and evaluate ongoing need for additional behavioral health services. b. Rehabilitative Services: Obtain archived psychiatric records to clarify history and to provide to treating physicians c. Rehabilitative Services: A guardian/conservator or POA (Power of Attorney) for healthcare to assist with decision-making, health and safety The Care Plan dated 3/3/23 revealed a focus problem of a PASARR Level II for person with a Mental Health Disorder or Intellectual Disability. The Care Plan dated 3/3/23 failed to document the PASARR Level II Specialized and Rehabilitative Services. During an observation on 4/11/23 at 10:36 AM, Resident #41 sat on his bed wore a flannel shirt, cap, and pajamas bottoms with a walker by the bed. During an interview on 4/20/23 at 10:46 AM, Staff Y, Social Services queried on the expectations of PASARR level II being addressed on the MDS and she responded she don't think she did that part of the MDS. She stated she addressed Section C, D, E, and part of Section Q. She stated she didn't do Section A. During an interview on 4/24/23 at 4:01 PM, the DON queried on the expectations of a a PASARR Level II being addressed on the MDS and she responded she honestly didn't know and would find out. During an interview on 4/26/23 at 2:34 PM, Staff MM, MDS Coordinator verified Social Services completed the PASARR on the MDS and she stated she also completed it when needed. 4. The MDS Assessment Tool, dated 10/26/22, documented Resident #16 did not require a Level II PASARR. The Notice of PASARR Level II Outcome, dated 10/8/22, documented the resident required a Level II assessment and included the following specialized services: a. ongoing psychiatric medication management by a psychiatrist or psychiatric Advanced Registered Nurse Practitioner (ARNP). b. individual therapy by a licensed behavioral health professional. c. a designated Power of Attorney (POA) for healthcare and financial matters The Care Plan lacked documentation of the implementation of the above interventions. The facility policy MDS 3.0 Completion reviewed March of 2023, stated the facility conducted accurate and standardized assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #4 Minimum Data Set (MDS) dated [DATE] listed a BIMS score of 12 out of 15, indicating the resident with moderate impairment of cognition. The MDS identified Resident #4 used a manual wheelchair and with partial assistance could wheel approximately 50 feet and make two turns and dependent on staff for toileting, picking up drooped objects from the floor, and Resident #4 needed substantial assistance rolling side to side while lying in bed, and dependent on staff for taking off and putting on footwear. Resident #4 documented with active medical diagnosis of sleep apnea, chronic obstructive pulmonary disease (COPD), Congestive Heart Failure (CHF) and Type Two Diabetes. Review of the Wound Notes on 1/16/23, shown the wound provider documented Resident #4 acquired a Stage III left heel in house pressure ulcer. The wound provider had ordered for Resident #4 to float heels in bed; off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able; and apply a sponge Pressure Relief Ankle Foot Orthosis (PRAFO) boot. The facility ordered PRAFO boot which is used for residents who spend a significant amount of time in bed and helps prevent pressure ulcers from developing on the back of the heel. Review of the Care Plan initiated on 10/31/22, shown the Care Plan updated on 1/30/23 to include a focus area for left heel pressure wound, however failed to include interventions to off-load pressure to the left heel when resident up in wheelchair (WC). Observations of Resident #4 while up in the WC had taken place on the following dates and times. The resident had been observed using the left foot heel with PRAFO boot on to propel the WC. The WC left leg rest had been in the down position: a. On 4/11/23 at 11:30 AM, the resident observed using left heel to propel WC in Hallway B. b. On 4/12/23 at 1:00 PM, the resident observed using left heel to propel WC in the North Dining Room. c. On 04/13/23 at 2:00 PM, the resident observed using left foot to propel WC in the South entry of the facility. d. On 04/17/23 at 9:00 AM, the resident observed using left foot to propel WC in the South hallway outside of conference room area. In an interview on 4/19/23 at 8:04 AM, Staff LL, Licensed Practical Nurse (LPN), stated the resident did not have the PRAFO boot on all night (4/18/23). Staff LL further stated the PRAFO boot had been on the floor when she entered the resident room and the residents left heel had not been positioned to float on a pillow either. During an interview on 4/19/23 at 10:02 AM, the Advanced Registered Nurse Practitioner (ARNP) for Resident #4 stated the expectations of use of the PRAFO boot while the resident was up in the wheelchair had been discussed. The ARNP stated the resident needed to wear the PRAFO boot and have the left leg rest elevated at all times when up in the wheelchair. ARNP was made aware the resident had been observed on more than one occasion using the left heel with PRAFO boot on to propel the wheelchair. Based on clinical record review, staff interviews and policy review, the facility failed to address oxygen use for 1 of 5 residents reviewed for oxygen (Resident #46), failed to create fall prevention interventions for 1 of 2 residents reviewed for falls (Resident #46), failed to create interventions to treat a pressure ulcer for 1 of 5 residents reviewed for pressure ulcers (Resident #4), failed to address drug use for 2 of 2 residents reviewed for alleged illicit drug use in the facility (Residents #46 and #70), and failed to address a history of physical altercations for 1 of 1 residents reviewed for a history of physical altercations with other residents(Resident #70). The facility reported a census of 69 residents. Findings Include: 1. The Minimum Data Set(MDS) Assessment Tool, dated 1/3/23, listed diagnoses for Resident #70 which included heart failure, paraplegia, and anxiety disorder and listed the resident's Brief Interview for Mental Status Score (BIMS) of 14 out of 15, indicating intact cognition. A 5/27/22 Physician Note stated the resident snorted Xanax (a medication for anxiety) and used a THC(tetrahydrocannabinol-a psychoactive component of cannabis) pen in the building and her urine tested positive for THC and opiates (narcotic pain medications). Care Plan entries, dated 4/20/23, documented the resident required a substance abuse evaluation with a treatment plan. The Care Plan did not address the resident's history of alleged illicit drug use in the facility. In an interview on 4/25/23 at 1:00 p.m., the Director of Nursing (DON) stated the Care Plan should include the resident's history of illicit drug use in the facility. 2. The MDS, dated [DATE], listed diagnoses for Resident #70 which included heart failure, paraplegia, and anxiety disorder. The MDS identified the resident required supervision assistance of 2 staff for personal hygiene, limited assistance of 2 staff for transfers, extensive assistance of 1 staff for dressing, extensive assistance of 2 staff for toilet use, and depended completely on 2 staff for bathing. The MDS listed the resident's BIMS of 14 out of 15, indicating intact cognition. A 5/30/22 Behavior Note for Resident #70 stated Resident #70 rammed her wheelchair into Resident #21 and then Resident #21 stood up to hit Resident #70. A 5/31/22 Physician Note for Resident #70 documented the resident admitted to punching a [AGE] year old (Resident #21) resident and no injuries were sustained. A 6/2/22 Physician Note for Resident #21 stated the resident denied being punched. A 8/27/22 General Note documented Resident #70 and her roommate (Resident #12) threw water at each other and the resident changed rooms. A 7/19/22 Care Plan entry stated the resident could be verbally aggressive related to ineffective coping skills and poor impulse control. An 11/25/22 revision of the entry stated on 11/10 the resident was physically aggressive and required 1:1 monitoring. The Care Plan lacked documentation of alleged physical altercations prior to 11/25/22. In an interview on 4/25/23 at 8:35 a.m., Staff JJ, Licensed Practical Nurse(LPN) stated Resident #70 had physical altercations with other residents. Staff JJ stated once Resident #70 smoked outside and threw a cigarette on another resident. She stated she did not see this but heard about it. In an interview on 4/25/23 at 1:00 p.m., the Director of Nursing (DON) stated she heard about the allegation that the resident threw a lit cigarette. She explained staff should report physical altercations between residents and the facility would separate the residents and interview residents and staff. She stated the Care Plan should address the resident's behaviors. In an interview on 4/27/23 at 10:50 a.m., the Administrator stated staff should report allegations of abuse within 2 hours. She stated the facility would investigate the allegation and would separate the residents. The facility lacked documentation of an investigation related to the above altercations and lacked documentation they reported the allegations to the State Agency or separated the resident from other residents. The facility policy Abuse, Neglect, and Exploitation, dated March 2023, stated the facility would provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident property. The policy stated the facility would complete an immediate investigation and ensure all residents were protected upon a suspicion of abuse. 4. The MDS dated [DATE] identified Resident #46 as cognitively intact with a BIMS score of 13 out of 15 and with the following diagnoses: Multiple Sclerosis, Coronary Artery Disease and Respiratory Failure. It also identified the resident required extensive staff assistance with all activities of daily living (ADL'S)) except for eating and totally dependent on staff for showers/baths. It did not identify the resident had continuous oxygen. Observations of the resident revealed the following: a. On 4/11/23 10:59 AM resident lying in bed without continuous oxygen on. b. On 4/12/23 9:34 AM lying in bed with continuous oxygen maintained at 3.5 liter per minute per nasal cannula per concentrator. c. On 4/13/23 7:13 AM asleep in bed with door to room open. Continuous oxygen maintained at 3.5 liters per nasal cannula per concentrator. d. On 4/17/23 8:20 AM lying in bed without continuous oxygen on. A review of the Physician Orders for March and April did not show orders for continuous oxygen. The Care Plan identified the resident with the problem of shortness of breath on 10/29/22, however, interventions did not include continuous oxygen. A review of the Incident Reports revealed the resident had falls on the following dates/times: a. On 8/25/22 at 00:03 AM - Resident is alert and oriented. Resident found lying on her back beside her bed. Resident stated that she did not hit her head. Resident stated that she was trying to turn over in bed and rolled onto the floor. No injuries noted at this time. Resident placed back into bed by 2 staff members and a gait belt. b. On 11/8/22 at 5:07 PM - The staff observed the resident laying on the floor of her room next to bed. The resident stated she was getting candy off bedside table. c. On 11/19/22 at 7:33 AM - Certified medication Aide (CMA), called nurse to room, resident was laying on floor next to bed d. On 1/12/23 at 8:00 AM - The resident had been observed sitting on her buttocks on floor next to her bed, stated she slipped out of bed. No new skin alterations or injuries noted at this time. e. On 2/6/23 at 6:28 PM - Resident found on the ground at 2:00 PM. She attempted to exit the bed. increased confusion to place. f. On 3/10/23 at 4:19 PM - Resident was found laying on floor on side of bed on floor mat. The Care Plan did not include any new interventions after the falls occurred starting August 2022. The record failed to have documentation of a Root-Cause Analysis of the falls. In an interview on 4/25/23 at 9:00 AM, the facility Chief Clinical Officer reported the staff had been discussing falls after they occurred, however, they did not document the completion of the Root Cause Analysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE], revealed Resident #2 scored 14 out of 15 on a BIMS exam, which indicated cognition intact. The MDS revealed three Stage 4 pressure ulcers. The MDS identified medical diagnosis of paraplegia. During an interview on 4/11/23 at 11:50 AM, Resident #2 stated pressure ulcers on each side of the buttock and on the lower back and the rods popped through the skin. He stated his pressure ulcers present on admission to the facility and stated the staff skipped dressing changes and he reminded them on Saturdays and Sundays the dressing changes needed completed. The Care Plan dated 3/1/23 revealed a focus problem of potential for and actual impairment to the skin integrity related to Stage 4 pressure sores on the sacrum, Stage 4 to the right ischium. The interventions dated 4/26/22 indicated to monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration, etc. to Medical Doctor (MD). The Physician Orders dated 3/3/23 revealed the following: a. Wound order for stage 4 pressure wound of the right and left ischium (present on admission: apply Dakins soaked gauze and cover with ABD pad and secure with tape twice daily. two times a day for wound orders b. Wound orders for stage 4 wound of the sacrum (present on admission : apply Dakins 0.125% soaked gauze and cover with ABD pad 2 x daily two times a day for wound orders The Electronic Medical Record identified the following Medical Diagnoses: a. Pressure ulcer of unspecified site, unspecified stage. b. Osteomyelitis of vertebra, sacral, and sacrococcygeal region. c. Paraplegia, unspecified. d. Pressure ulcer of sacral region, unstageable. The review of the Treatment Administration Record TAR) for April 2023 for wound dressing completion revealed the following documentation: a. April 1st- 7:00 PM, dressing change - 7 (sleeping) b. April 3rd- 12:00 PM, dressing change left blank c. April 3rd- 7:00 PM, dressing change- 7 (sleeping) d. April 5th- 7:00 PM, dressing change- 7 (sleeping) e. April 9th- 7:00 PM, dressing change- 2 (drug refused) f. April 10th- 7:00 PM, dressing change- 2 (drug refused) g. April 14th- 7:00 PM, dressing change- 9 (other/see progress notes) h. April 16th- 7:00 PM, dressing change- 2: (drug refused) i. April 17th- 7:00 PM, dressing change- 2: (drug refused) During an interview on 4/19/23 at 11:39 AM, Resident #2 stated he doesn't refuse the wound dressing changes, but it is too late at times and he is already in bed so he didn't want them at that time. He stated he didn't want them after 8:00-8:30 PM. He stated he didn't feel like its his choice when they completed the wound dressing changes. During the interview on 4/20/23 at 9:21 AM, Staff CC, Licensed Practical Nurse (LPN) queried if Resident #2 refused his wound dressings and she stated he doesn't refuse for me. During an interview on 4/24/23 at 4:01 PM, the Director of Nursing (DON) queried on the expectations nurse's performing dressing changes and she stated they should follow the TAR and if the resident refused, document the refusal and then notify the Physician. The DON asked if sleeping an acceptable reason for not performing dressing changes and she stated no, if the resident said no they needed to document appropriately. She queried if the resident continued to refuse or their wound dressing what interventions would be expected and she responded the Wound Doctor met with the resident and reinforced the importance of the dressing change. She stated they asked the resident if they wanted a specific time. She stated for continued refusal, it needed to be Care Planned. During an interview on 4/25/23 at 8:53 PM, Staff JJ, LPN queried if she ever completed dressing changes on Resident #2 and she stated no, she watched it once. She stated she asked him last night around 7:30 PM and he refused because his afternoon dressing change completed late in the afternoon. She stated he preferred to have it done at certain times and if it too late, he refused because he wanted to go to bed. 3. Review of the MDS for Resident #4 dated 1/31/23 listed a BIMS score of 12 out of 15, indicating the resident with moderate impairment of cognition. The MDS identified Resident #4 used a manual wheelchair and with partial assistance could wheel approximately 50 feet and make two turns, dependent on staffs for toileting, picking up dropped objects from the floor, and needed substantial assistance rolling side to side while lying in bed. Resident #4 identified with active medical diagnosis of sleep apnea, chronic obstructive pulmonary disease (COPD), and Congestive Heart Failure (CHF). Review of the Care Plan initiated on 10/31/22 showed the facility failed to document a focus Care Plan area for CHF. The Care Plan failed to include an intervention or update for daily weights. Review of provider orders showed on 1/24/23, the Advanced Registered Nurse Practitioner (ARNP) ordered Resident #4 to be weighed every day for CHF and for the provider to be notified if weight is +3 lb/1 day or 5 lb/1 week. Review of the Electronic Health Record (EHR) under the task category shown the facility failed to complete daily weights as ordered for Resident #4. Review of February 2023 weights had shown 14 days completed out of 28 days. March 2023 weights had shown 8 days completed out of 31 days. Review of the April 2023 record on April 17, 2023 shown only 3 days completed for the month. On 4/16/23 at 1:00 PM an interview with the facility Registered Dietician (RD), stated this was the third week of the month and 19 residents were missing a monthly weight. The RD stated she discussed monthly weights not being completed several times with the current Administrator. The RD further stated she emailed the providers to make weight changes known. On 4/17/23 at 4:05 PM, during an interview with the facility Director of Nursing (DON) and Assistant Director of Nursing (ADON) a discussion of weighing residents had taken place. The DON asked who was responsible to complete weights as ordered by providers and stated the process had been changed and the ADON further stated the Restorative Staff had been weighing the residents however due to tasks added to the Restorative Aides' duties, the Nursing Staff expected to make sure the resident weights are completed. When asked who would audit and review the resident charts to make sure the weights are completed, the DON and ADON stated who ever has time. Both the DON and ADON made aware of two residents that are to have daily weights #4 and #12 for CHF and daily weights had not been completed. The DON reviewed the computer task list for each resident and acknowledged the failure of provider orders not being followed. 4. Review of Resident #12's MDS) dated [DATE], a BIMS score of 14 out of 15, indicating the resident with intact cognition, used a manual wheelchair and had been dependent on staffs for toileting, picking up dropped objects from the floor, and Resident #12 had needed substantial assistance rolling side to side while lying in bed. The MDS identified Resident #12 with active medical diagnosis of sleep apnea, chronic obstructive pulmonary disease (COPD), Congestive Heart Failure (CHF), and dependent on oxygen. Review of the Care Plan initiated on 2/17/22, shown Resident #12 with a Focus Care Plan area for CHF which included an intervention that had been initiated 11/7/22 to weigh the resident daily and to report a +3 lb/1 day or 5 lb/1 week to the provider. Review of provider orders shown the Advanced Registered Nurse Practitioner (ARNP) reordered daily weights on 1/13/23 with direction to call a provider for +3 lb/1 day or 5 lb/1 week to the provider. Review of the Electronic Health Record (EHR) under the task category shown the facility failed to complete daily weights as ordered for Resident #12. Review of February 2023 weights shown 8 days completed out of 28 days. March 2023 weights shown 10 days completed out of 31 days. Review of April 2023 weights on April 17, 2023 shown only 4 days completed for the month. so far. On 4/16/23 at 1:00 PM, during an interview with the facility Registered Dietician (RD), the RD stated this was the third week of the month and 19 residents were missing a monthly weight. The RD stated she discussed monthly weights not being completed several times with the current Administrator. The RD further stated she emailed the providers to make weight changes known. On 4/17/23 at 4:05 PM, during an interview with the facility Director of Nursing (DON) and Assistant Director of Nursing (ADON), the discussion of weighing residents took place. The DON asked who had been responsible to complete weights as ordered by providers. The DON stated the process had been changed and the ADON had further stated the Restorative Staff had been weighing the residents however due to tasks added to the Restorative Aides' duties that now the Nursing Staff is expected to make sure the resident weights are completed. When asked who would audit and review the resident charts to make sure the weights are completed, the DON and ADON stated who ever has time. Both the DON and ADON made aware of two residents that are to have daily weights #4 and #12 for CHF and daily weights not completed. The DON reviewed the computer task list for each resident and acknowledged the failure of provider orders not being followed. Based on observation, clinical record review, staff and resident interviews and policy review, the facility failed to complete dressing changes as ordered for 2 of 5 residents reviewed for dressing changes (Residents #61 and #2) and failed to obtain weights as ordered for 2 of 5 residents reviewed for weights (Residents #4 and #12). The facility reported a census of 69 residents. Findings: 1. The MDS Assessment Tool, dated 3/15/23, listed diagnoses for Resident #61 which included malnutrition, morbid obesity, and weakness. The MDS documented the resident had a feeding tube and listed his cognition as moderately impaired. On 4/18/23 at 10:36 a.m., the resident laid in bed with a gauze dressing applied to his feeding tube site dated 4/11/23. Staff BB, Registered Nurse (RN) was present and confirmed the date of the dressing was 4/11/23. The facility policy Physician Orders reviewed March 2023, directed staff to enter orders into the Medical Record. A 4/6/23 Care Plan entry directed staff to provide local care to the gastrostomy tube (G-tube-a type of feeding tube) site as ordered. The April 2023 Treatment Administration Record (TAR) listed a 4/19/23 order for split gauze to G-tube, change daily. The TAR lacked documentation of a completed dressing change from 4/1/23-4/18/23. On 4/25/23 at 1:00 p.m., the DON stated staff should complete dressing changes as ordered and the nurse caring for Resident #61 should have obtained an order prior to putting the dressing on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE], revealed Resident #2 scored 14 out of 15 on a BIMS exam, which indicated cognition intact. The MDS indicated the resident independent and bathed with no set up or physical help from staff. During an interview on 4/11/23 at 12:07 PM, Resident #2 stated they only showered me once and they are supposed to give me bed baths because of his pressure ulcers but they never asked if he wanted one. He stated his last bath happened 2 or 3 months ago. Resident #2 stated he waited for the staff to ask him to shower and didn't. Resident sat in his wheelchair and the resident disheveled wearing camo pants and a shirt. During an interview on 4/12/23 at 3:44 PM, Resident #2 stated he received one bed bath while he resided in the front hall and when they moved him to the back hall he stated didn't receive a bath. The Care Plan dated 3/1/23 revealed a focus problem of an Activities of Daily Living (ADL) performance deficit related to impaired mobility, paraplegia. The interventions dated 9/22/23 indicated Resident #2 required extensive assistance by (1) staff with bathing/showering. The Documentation Survey Report for March 2023 and April 2023 revealed the resident scheduled showers/baths on Tuesdays and Fridays between 6:00 AM and 2:00 PM and documented the following information: a. 3/3/23- left blank b. 3/7/23- resident not available c. 3/10/23- not applicable d. 3/17/23- not applicable e. 3/21/23- left blank f. 3/24/23- left blank g. 3/28/23- Activity did not occur h. 3/31/23- left blank i. 4/4/23- left blank j. 4/7/23- left blank k. 4/11/23- left blank l. 4/14/23- left blank m. 4/21/23- left blank n. 4/25/23- left blank Task Sheet for Bathing/Shower for the last 30 days revealed the following information: a. 3/28/23- activity did not occur b. 4/18/23- documented resident showered During an interview on 4/20/23 at 9:27 AM, Staff HH, Certified Nurse Aide (CNA) queried how often Resident #2 showered and she stated she never provided his shower before and no one told her he took showers in rounds. During an interview on 4/20/23 at 09:52 AM, Staff II, CNA queried if refusals of showers are documented and she states yes and the resident signed the refusal on a Shower Sheet if able. Staff II asked how often Resident #2 showered and she stated she didn't work with him and personally not sure. During an interview on 4/24/23 at 4:31 PM, Staff L, CNA queried how often Resident #2 received a shower and she stated she didn't know, she didn't usually work B Hall, she usually worked A Hall. 3. The MDS assessment dated [DATE] revealed Resident #10 scored 9 out of 15 on a BIMS exam, which indicated moderate cognitive impairment. The MDS revealed the resident needed physical help in part of the bathing activity with a one person assist. The MDS revealed the needed extensive assistance with one person physical assist with personal hygiene. During an observation on 4/12/23 at 10:20 AM, Resident #10 wore a white shirt with a stain on it and his hair not combed. Resident grabbed a comb out of his drawer and started to comb his hair. The Care Plan 2/16/23 revealed a focus problem of ADL self performance deficit related to impaired balance, limited Range of Motion (ROM), stroke with right-sided deficits. The interventions dated 6/11/19 revealed to check the nail length and trim and clean on bath day and as necessary; provide sponge bath when a full bath or shower cannot be tolerated and resident will often refuse shower; resident required extensive assistance by staff with bathing/showering and as necessary; resident required extensive to limited assistance by staff with personal hygiene and he preferred facial hair and will often refuse grooming; and preferred long nails and would at times allow cleaning but would refuse trim. The Documentation Survey Report for March 2023 and April 2023 revealed Resident #10 scheduled for showers on Monday and Thursday on the PM shift. The report revealed the following information: a. 3/2/23- left blank b. 3/23/23- left blank c. 3/30/23- not applicable d. 4/6/23- left blank. The Task Record Report for ADL- Bathing/Shower for April 2023 did not provide documentation after the date of 4/6/23 for Resident #10's shower completion. During an observation on 4/17/23 at 12:15 AM, Resident #10 sat in his wheelchair with a blanket over him in the common area. Hair not combed. During an interview on 4/18/23 11:20 AM, Resident #10 queried how often he preferred to shower and he stated once a week. Resident #10 asked if he ever refused to shower and he stated no, well yeah sometimes. During an observation on 4/18/23 at 4:17 PM, Resident #10 sat in the common area in his wheelchair. Fingernails are long. The resident asked how often they clip his nails and he made a sound and stated he didn't know. During an interview on 4/20/23 at 9:52 AM, Staff II, CNA queried how often resident's showered and she stated they are short staffed and she got them done as soon as she could. She stated she came in on her days off and provided showers and bed baths to the residents. She stated the showers are not being completed regularly and the residents received a shower maybe once a week. Staff II queried how often Resident #10 offered a shower and she stated she believed his shower scheduled on the PM and he took his shower for her but refused with certain aides. During an interview on 4/24/23 at 4:01 PM, the Director of Nursing (DON) queried how often residents are showered and she stated they have a shower schedule and the residents should be showered on the scheduled days. She stated the shower schedule recently redone to fit acuity. She stated if the resident refused, CNA notified the nurse and the resident signed a paper. The DON asked if the facility had any issues with showers not being completed and she stated not to her knowledge. The DON queried what it meant if the shower date was left blank on the task sheet in the computer and she responded like it not charted, either they forgot to do their charting or the shower not given. During an interview on 4/24/23 at 4:31 PM, Staff L, CNA queried how often residents are showered and she stated daily on their scheduled shower days at least a majority of the time they received their showers on their scheduled shower days. She stated except for days they are short staffed like today. Staff L queried if the residents received showers today and she stated no. 4. The MDS dated [DATE], listed diagnosis for Resident #4 of congestive heart failure (CHF), type two diabetes, chronic obstructive pulmonary disease (COPD), sleep apnea and morbid obesity. The MDS listed the resident dependent on staff for toileting, and picking up dropped objects from the floor, and the resident needed substantial assistance rolling side to side while lying in bed, and listed the resident's BIMS score as 12 out of 15, indicating moderate impairment of cognition. On 4/11/23 at 10:00 AM, the resident observed sitting in bed, with greasy hair and Depend brief on showing at waist. Overall disheveled look. Resident speech difficult to understand however able to answer yes and no questions by shaking head. When asked if a shower had been taken recently the resident shook her head no. A 10/31/22 Care Plan entry directed only female staff to provide personal care and stated the resident required extensive assistance in the shower and to provide a sponge bath when a shower could not be tolerated. Review of the Electronic Health Care Record showed the resident last received a shower on 3/22/23 and documented the activity did not occur on 3/29/23. Dates of 4/1/23 and 4/12/23 documented the activity was not applicable. The electronic reports lacked documentation of further showers/bath assistance given during the time period. 6. The MDS, dated [DATE], listed diagnoses for Resident #56 which included heart failure, diabetes, and morbid obesity. The MDS documented the resident did not receive a bath during the review period and listed the resident's BIMS score as 14 out of 15, indicating intact cognition. During an interview on 4/12/23 at 9:44 a.m., the Resident #56 stated she missed baths but that was because she took them independently and forgot to go in and complete them. The resident's hair appeared greasy and unkempt. A 7/2/22 Care Plan entry directed staff to provide a sponge bath when a full bath or shower could not be tolerated. Care Plan entries, dated 11/3/22, stated the resident required assistance with ADL's due to impaired mobility and right hemiplegia(one-sided weakness). The March 2023 Documentation Survey Report documented the resident received a shower on 3/2/23 and 3/30/23 and documented the resident refused on 3/13/23 and the activity did not occur on 4/23/23. The April 2023 Documentation Survey Report documented the resident received a shower on 4/6/23 and 4/13/23. The 4/10/23 entry stated the resident was not available. The reports lacked documentation of further showers/bath assistance given during the time prior of 3/1/23-4/17/23. 7. The MDS, dated [DATE], listed diagnoses for Resident #61 which included malnutrition, morbid obesity, and weakness. The MDS documented the resident required extensive assistance of 2 staff for personal hygiene and bathing and listed the resident's cognition as moderately impaired. During an observation on 4/13/23 at 8:07 a.m., Resident #61 laid in bed. All of his nails were very long, extending past the fingers approximately 3 millimeters(mm). The resident was unshaven, had a long beard and his hair was unkempt. Observations on 4/17/23 at 12:29 p.m. and 4/18/23 at 7:38 a.m. revealed the resident's nails were the same length, he was unshaven, and his hair was unkempt. Care Plan entries, dated 4/6/23, stated the resident had a self-care performance deficit related to impaired mobility and stated the resident required extensive assistance of 1 staff for personal hygiene. 8. The 3/9/23 MDS listed diagnoses for Resident #63 which included diabetes, burns, and unspecified fall. The MDS identified the resident required extensive assistance of 1 staff for personal hygiene and completely depended on 1 staff for bathing. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The MDS documented the resident admitted to the facility on [DATE]. In an interview on 4/17/23 at 1:15 p.m., Resident #63 stated she only received 2 showers since admission to the facility. The March 2023 Documentation Survey Report stated the resident had partial baths on 3/4, 3/6, 3/8, 3/11/23, and 3/14, and had a shower on 3/21/23. The April 2023 Documentation Survey Report for stated the resident had a partial bath on 4/1/23 and 4/11/23. The record lacked documentation of further showers during the period of 3/3/23-4/17/23. A Care Plan entry, dated 3/13/23, stated the resident had a self-care performance deficit related to impaired mobility and stated the resident required total assistance of 1 staff for bathing and showering. 9. The MDS assessment tool, dated 1/3/23, listed diagnoses for Resident #70 which included heart failure, paraplegia, and anxiety disorder. The MDS stated the resident required supervision assistance of 2 staff for personal hygiene, limited assistance of 2 staff for transfers, extensive assistance of 1 staff for dressing, extensive assistance of 2 staff for toilet use, and depended completely on 2 staff for bathing. The MDS listed the resident's BIMS score as 14 out of 15, indicating intact cognition. The 4/7/23 entry MDS stated the resident admitted from an acute hospital on 4/7/23. In an interview on 4/12/23 at 10:11 a.m., Resident #70 stated she returned from the hospital Friday night(4/7/23) and stated she had not received a shower since. She stated she felt like she stinks. The April 2023 Documentation Survey Report lacked documentation the resident received a shower or bath from 4/7/23-4/12/23. A Care Plan entry, dated 4/20/22, stated the resident required extensive assistance of 1 staff for bathing/showering. Based on observations, clinical record review, staff and resident interviews and facility policy review the facility failed to keep 1 out of 1 residents hands clean for 5 out of 5 days observed (Resident #35), failed to trim the finger nails of 1 out of 2 residents reviewed (Resident # 61), failed to provide bathing 9 out of 9 out of residents reviewed (Resident #2, #4, #10, #35, #56, #61, #63, and #70), and failed to provide incontinence cares for 1 out of 7 residents reviewed (Resident # 46). The facility reported a census of 69. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #35 dated 1/18/23, listed diagnoses of dementia and cancer. The MDS identified the Brief Interview of Mental Status (BIMS) score of of 00 (indicating sever cognitive impairments), and showed Resident #35 required extensive assist of 1 staff for personal hygiene and bathing. The Care Plan dated 10/28/19, identified Resident #35's activities of daily living (ADL) self-care performance deficit related to Dementia. The Care Plan reflected Resident #35 able to assist with showers. The Care Plan intervention included, avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short and keep skin clean and dry. Use lotion on dry skin. The Task List Report dated 2/20/23, directed ADL - Bathing/Shower Task Scheduled as needed (PRN): 6 AM-2 PM, 2 PM-10 PM, 10 PM-6 AM. Tuesday/Friday Shift: 6-2 shift. The Bath Record dated 4/18/23, showed Resident #35 received 3 baths in 30 days. The record reflected baths given to Resident #35 on 3/21/23, 3/28/23 and 4/11/23. The Hospice Communication log at the Nurses Station included notes from the nurses and lacked documentation of bathing. The Hospice Care Plan dated 3/16/23, failed to reflect bathing provided for Resident #35. On 4/18/23 at 2:17 PM, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) reported they expected staff wash residents faces and hands after meals and when they go bed. The DON continued to state baths are completed two times a week. On 4/18/23 at 2:23 PM, the DON stated Resident #35 is on Hospice care. The DON reported Hospice completed the bath 2 times a week. The DON stated Hospice staff took her into the shower if she could tolerate it. During the following observations of Resident #35, noted dirty fingernails on both hands: a. On 4/11/23 at 12:50 PM, Resident #35 sat in her wheel chair (w/c) at the dining room. The resident's right and left hands under her fingernails noted a dark substance. b. On 4/12/23 at 12:26 PM, Resident #35 finger nails on her left hand continued with a dark colored substance under the nails. c. On 4/12/23 at 12:15 PM, under all five finger nails on Resident #35's right hand contained dark substance. d. On 4/13/23 at 8:42 AM, Resident #35's fingernails to her right hand remained with dark colored substance under the nail. e. On 4/17/23 12:54 PM, Resident #35's right hand under her finger nails held dark black colored substance as she sat at the dining room table. f. On 4/18/23 at 12:34 PM, Resident #35's sat at the dining room table and her right hand under her fingernails held a dark colored substance. On 4/17/23 at 1:17 PM Staff L, Certified Nurse Aid (CNA) removed Resident #35 from the dining room and took her to her room. Staff L transferred Resident #35 to her bed, positioned her and left the room. Staff L failed to wash Resident #35's hands. The facility provided a policy titled Resident Showers dated 3/2022, identified it is the facility practice to assist resident with bathing to maintain hygiene, stimulate circulation and help prevent skin issues as per current standard of practice. The facility provided a policy titled Incontinence dated 3/2022, directed at point #4, Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. The facility provided a policy titled Nail Care dated 3/2023, identified The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. The policy directed at point # 3: routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. The policy included at point #4: Routine nail care, to include trimming and filing, will be provided on a regular basis. Nail care will be provided between scheduled occasions as the need arises. The facility failed to provide a policy directing staff when and how to provide Incontinence Care. 5. The MDS dated [DATE] identified Resident #46 as cognitively intact with a BIMS score of 13 out of 15 and with the following diagnoses: Multiple Sclerosis, Coronary Artery Disease and Respiratory Failure. It also identified the resident required extensive staff assistance with all ADL's except for eating and totally dependent on staff for showers/baths. In an interview on 4/12/23 at 10:50 AM, the resident's family member reported she would visit the resident once or twice a week. They are supposed to reposition her every 2 hours. She reported she would be at the facility for 5 hours and not see anyone come in to reposition her. Observations of the resident revealed the following on 4/12/23: a. At 1:30 PM remains lying on her back in bed, both resident and her mother verified it had been 2.5 hours and no one had been in to reposition the resident. b. At 2:45 PM remains lying on her back in bed, she and her mother both reported no staff member has been in to reposition the resident for the past 3.75 hours. Observations of the resident revealed the following on 4/13/23: a. At 7:13 AM asleep in bed with door to room open. Continuous oxygen maintained at 3.5 liters per minute per nasal cannula per concentrator. b. At 7:20 AM assessment unchanged. No staff in hall c. At 7:40 AM remains asleep in bed lying on back, bells used to call staff on tray table out of the resident's reach. Remainder of assessment unchanged. d. At 7:43 AM, Staff F, CMA outside resident's room with a medication cart. e. At 7:46 AM Staff F entered the resident's room and administered medications to the resident and left the room. No other cares provided. f. At 7:57 AM assessment unchanged. g. At 8:03 AM assessment unchanged. h. At 8:09 AM Staff C entered resident's room, and placed her breakfast tray on the tray table. i. At 8:12 AM resident asleep again, tray remains on tray table, untouched. Remainder of assessment unchanged. j. At 8:22 AM Staff C passing breakfast trays in this hall k. At 8:23 AM the Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Social Worker in room across the hall, no staff provided cares or repositioned resident for 43 minutes now. Resident remains asleep, remainder of assessment unchanged. l. At 8:29 AM, the ADON entered room and assisted the resident with breakfast. m. At 8:45 AM, the ADON left the resident's room. The resident reported the ADON did not provide cares, that it had been several hours since anyone had washed her private parts. n. At 8:49 AM, Staff F, entered room to administer medications. No cares provided o. At 8:56 AM, Staff C walked by the resident's room and removed linens from linen closet and walked down the other way. No peri cares provided for 1 hr and 16 minutes. p. At 9:07 AM assessment unchanged, no staff in hallway q. At 9:13 AM, housekeeping staff entered the room to move belongings to another room. r. At 9:25 AM, Staff C walked into the resident's room and refilled resident's water pitcher with ice water. She did not provide peri cares before leaving the room. s. At 9:29 AM, Staff C walked by the resident's room with a cart of water pitchers and cooler with ice. No peri cares provided to this resident. t. At 9:31 AM resident ringing her bells to call staff, currently no staff in the hallway. North Dining Room Alarm sounding overhead and bells could not be heard above alarm sounding. The resident did not have peri cares for 2 hours and 18 minutes. u. At 9:32 AM Staff C entered room to provide peri cares. Observations of the resident on 4/17/23 revealed the following: a. At 8:20 AM resident lying in bed with the call light wrapped around frame of her bed behind her head, stated I've been calling out for over an hour now, I can't find my call light, I need my brief changed Surveyor turned on the call light for the resident. Staff BB, RN stood out in the hallway by a medication cart, did not check on resident. b. At 8:25 AM the call light remains on, audible, Staff BB moved the medication cart down the hall and walked into another resident's room. Staff L, CNA walked into another resident's room at the end of the hall. Call light on for 5 minutes. c. At 8:27 AM, Staff BB walked by this resident's room as her call light remained lit and did not check on her. d. At 8:28 AM, Staff L walked into the resident's room and turned off the call light and left the room and brought two bags of linens down the hall. e. At 8:30 AM, the surveyor asked the resident if the Staff L addressed her needs, she reported I asked her to change my brief and she left my room without doing it f. At 8:37 AM, the resident's cell phone rang, resident called out can someone help me get my phone No staff provided assistance g. At 8:54 AM, Staff BB entered the room to check on resident, did not provide peri cares. The resident has been waiting 24 minutes to have someone provide peri care. h. At 10:00 AM, the resident's call light remained on. She reported no one ever came to change her incontinent brief. Then Staff BB the entered room to ask what she needed, she said I need my brief changed Then he said let me get someone to help you and left room. The resident reported yesterday she turned on her call light from 8:30 AM to get her brief changed and no one changed her brief until 2:30 AM that night. I'll turn on my call light, they keep coming in to turn it off and don't help me and I have to keep turning my call light on again i. At 10:08 AM Staff L entered the room to provide cares as requested 1 hour and 48 minutes later. On 10/29/22, the Care Plan identified the resident with the problem of bowel and bladder incontinence and directed staff to clean peri-area with each incontinence episode. The facility policy titled: Incontinence dated as last reviewed March 2023 had documentation of the following: 1. The facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. 2. For residents with urinary incontinence, the facility will ensure that residents are not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. 3. Residents that enter the facility with an indwelling catheter, or receives one while in the facility, will be assessed for removal of the catheter as soon as possible, unless the resident's clinical condition demonstrates that catheterization was necessary. 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Reviewed the Resident Council Meeting Minutes documented the following concerns: a. The January Resident Council Meeting Minutes revealed call lights were not answered timely. Residents present reported it took more than 30 minutes for a response. CNA's were on cell phones and used ear buds. The DON was at the meeting and made aware of the concern. b. The February Resident Council Meeting Minutes revealed call lights were not being answered. CNA's continued to wear ear buds and on cell phones during care. The DON present at the meeting and agreed to address the concern. c. The March Resident Council Meeting Minutes revealed call lights still not being answered and staff wore earbuds and used phones. A Grievance Paper was filled out and was given to the DON. The facility failed to provide any written information during the survey regarding the Call Light Grievance Form submitted by Resident Council in [DATE]. Resident Council Members met on [DATE] at 1:00 PM to discuss concerns within the facility. Residents #13, #17, #24, #26 and #55 were present. Call lights continued as a concern of the Council Members and the group agreed that call light wait times were at least a half hour on average. The group reported that the worst time was between shifts when no one answered lights. The group reported that residents waited in soiled pants or linens for two hours because the call light was not answered. The group was concerned that staff shut off call lights and did not provide care. During an interview on [DATE] at 10:55 AM, the Director of Nursing (DON) was asked what response was implemented based on the Resident Council's Grievance about call lights. The Assistant Director of Nursing (ADON) educated 5 staff members on call lights through a in service training. The DON stated it depended on the day how long it took to get lights answered. One problem identified was that not everyone was answering the call lights. Staff indicated it was not their patient and would not answer the light. The DON stated she would provide training on that to correct it. There was a new no tolerance for cell phone and ear bud use implemented by the facility. Review of policy titled Resident Council Meetings revised [DATE] stated the facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. 7. The MDS dated [DATE] revealed Resident #10 scored 10 out of 15 on the BIMS, which indicated moderate cognitive impairment. During an interview on [DATE] at 10:15 AM, the Resident #10 stated it took from 30 minutes to an hour to answer call lights and he used the clock on his TV to determine the time. He stated no certain time of the day worse than other times. 8. The MDS dated [DATE] revealed Resident #24 scored 15 out of 15 on the BIMS exam, which indicated cognitively intact. During an interview on [DATE] at 11:09 AM, Resident #24 stated the Nurse Aides used their cell phones when they performed cares. During an interview on [DATE] at 11:21 AM, Resident #24 stated it took up to 2 hours to answer call lights and he used his clock and watch to gauge the time. He stated it occurred mostly on 3rd shift. During an interview on [DATE] at 4:31 PM, Staff L, CNA queried how often residents are showered and she stated daily on their scheduled shower days at least a majority of the time they received their showers on their scheduled shower days. She stated except for days they are short staffed like today. Staff L queried if the residents received showers today and she stated no. 5. The [DATE] MDS listed diagnoses for Resident #63 which included diabetes, burns, and unspecified fall. The MDS documented the resident required extensive assistance of 1 staff for personal hygiene and completely depended on 1 staff for bathing. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. During an interview on [DATE] at 7:41 a.m., Resident #63 stated sometimes it took staff more than an hour to respond to call lights and she stated this occurred last weekend. 6. The MDS dated [DATE], listed diagnoses for Resident #70 which included heart failure, paraplegia, and anxiety disorder. The MDS documented the resident required supervision assistance of 2 staff for personal hygiene, limited assistance of 2 staff for transfers, extensive assistance of 1 staff for dressing, extensive assistance of 2 staff for toilet use, and depended completely on 2 staff for bathing. The MDS listed the resident's BIMS score as 14 out of 15, indicating intact cognition. During an interview on [DATE] at 10:11 a.m., Resident #70 stated staff were supposed to turn her at night every 2 hours but they did not. She stated last night Staff JJ, Licensed Practical Nurse (LPN) came in and told her they did not have time to turn her. She stated Staff JJ was the only nurse with 1 aide for Halls A and B. During a phone interview on [DATE] at 8:29 a.m., Staff JJ stated staffing was absolutely horrible and she could not express how bad it was. She stated she sometimes worked the back hall with only 1 Certified Nursing Assistant(CNA) when there was supposed to be 2. She stated they did not have time to turn residents every 2 hours. During a phone interview on [DATE] at 9:10 a.m., Staff KK, CNA stated they did not have enough staff to take care of everyone and it affected the residents a lot. She stated they did not have time to turn people or answer call lights in a timely manner. Based on clinical record review, observations, staff and resident interviews, and facility policy review the facility failed to answer call lights in a timely manner for 8 of 26 residents reviewed (Residents #10, #18, #24, #46, #48 and #122) and for 5 of 5 residents who participated in the Group Interview (Residents #13, #17, #24, #26, and #55). The facility reported a census of 69 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #18 as cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15 and with the following diagnoses: Deep Vein Thrombosis, Diabetes Mellitus, and a wound infection. The MDS identified the resident required extensive staff assistance with repositioning in bed, locomotion on and off the unit, dressing, toileting and personally hygiene and it also identified her to be totally dependent on staff for transfers out of bed. Observations on [DATE] revealed the following: a. At 8:30 AM, the resident's call light turned on. b. At 8:38 AM, Staff BB, RN showed a visitor in to the resident's room, but did not ask if either resident needed help and walked out of the room. c. At 8:42 AM, the call light has been on 12 minutes now. Staff DD, Certified Medication Aide (CMA) stood at the end of the hall with a medication cart and did not check on resident. d. At 8:49 AM, the call light was still on, Staff BB, Registered Nurse (RN) walked past the room with the medication cart without stopping to check on the resident, while the call light is audible. Staff DD remained at the end of hall and failed to checked on the resident. e. At 8:50 AM, the Housekeeping Supervisor walked by the resident's room and said I'll tell the girls and did not check to see what the resident needed. The call light has been on x 20 minutes now. f. At 8:53 AM, Staff BB walked by the room without checking on resident, the call light remained on. g. At 8:54 AM, Staff L, CNA entered the room and turned off the call light which had been on for 25 minutes On [DATE], the Care Plan identified the resident with the problem of being dependent on staff for meeting physical and social needs, however, no interventions addressed the need to answer call lights in a timely manner. 2. The MDS dated [DATE] identified Resident #46 as cognitively intact with a BIMS score of 13 out of 15 and with the following diagnoses: Multiple Sclerosis, Coronary Artery Disease and Respiratory Failure. The MDS also identified the resident required extensive staff assistance with all activities of daily living (ADL's) except for eating and totally dependent on staff for showers/baths. It did not identify the resident had continuous oxygen. In an interview on [DATE] at 10:50 AM, the resident's family member reported she would come to the facility once or twice a week. When the resident did have a call light she would turn it on and the longest they had to wait was 30 minutes for someone to come in and help. This happened every time she would turn the call light on for her. Observations of the resident on [DATE] revealed the following: a. At 8:20 AM resident lying in bed with the call light wrapped around frame of her bed behind her head, stated I've been calling out for over an hour now, I can't find my call light. Surveyor turned on the call light for the resident. Staff BB, RN stood out in the hallway by a medication cart, did not check on resident. b. At 8:25 AM the call light remains on, audible, Staff BB moved the medication cart down the hall and walked into another resident's room. Staff L, Certified Nursing Assistant (CNA) walked into another resident's room at the end of the hall. Call light on for 5 minutes. c. At 8:27 AM, Staff BB walked by this resident's room as her call light remained lit and did not check on her. d. At 8:28 AM, Staff L walked into the resident's room and turned off the call light and left the room and brought two bags of linens down the hall. d. At 8:30 AM, the surveyor asked the resident if the Staff L addressed her needs, she reported I asked her to change my brief and she left my room without doing it e. At 8:37 AM, the resident's cell phone rang, resident called out can someone help me get my phone No staff provided assistance f. At 8:54 AM, Staff BB entered the room to check on resident, did not provide peri cares. The resident has been waiting 24 minutes to have someone provide peri care. g. At 10:00 AM, the resident's call light remained on. She reported no one ever came to change her incontinent brief. Then Staff BB the entered room to ask what she needed, she said I need my brief changed Then he said let me get someone to help you and left room. The resident reported yesterday she turned on her call light from 8:30 AM to get her brief changed and no one changed her brief until 2:30 AM that night. I'll turn on my call light, they keep coming in to turn it off and don't help me and I have to keep turning my call light on again g. At 10:08 AM Staff L entered the room to provide cares as requested 1 hour and 48 minutes later. On [DATE], the Care Plan identified the resident with the problem of being at risk for falls and directed staff to place the call light within reach and encourage her to use it 3. The Minimum Data Set, dated [DATE] identified Resident #48 as cognitively intact with a BIMS score of 15 out of 15 and with the following diagnoses: Cancer, Atrial Fibrillation (an abnormal heart rhythm) and chronic obstructive pulmonary disease (COPD). The MDS also identified the resident required extensive staff assistance with all ADL's except with eating (she had been independent) and with walking where she had been totally dependent on staff for assistance. Interviews with the resident revealed the following: a. On [DATE] at 11:02 AM, the resident reported she had to wait as long as an hour to get call light, has been incontinent waiting for help as she is unable to stand on her own. This happens 3 times a week on 2nd shift. The resident had a clock on wall easily visible from her bed and a cell phone. b. On [DATE] at 9:36 AM, the resident reported last night on evenings, the staff would answer the call light timely, but turn off the light and never come back, then she had to turn her call light on again. Twice she lost control of her bladder because she had to wait so long for them to come back, especially after she takes her medication for diuresis. On [DATE] the Care Plan identified the resident with the problem of bowel incontinence and directed staff to check on the resident every 2 hours and assist with toileting as needed. On [DATE], the Care Plan identified the resident with the problem of being at risk for falls and directed staff to place the call light in reach and encourage the resident to use it. 4. The MDS dated [DATE] identified Resident #122 as moderately cognitively impaired with a BIMS score of 10 out of 15 and with the following diagnoses: necrotizing fasciitis, heart failure and renal insufficiency (kidney failure). The MDS identified he required extensive staff assistance with repositioning, moving between surface, walking, dressing, toileting and totally dependent on staff for showers/baths. The MDS documented the resident as frequently incontinent of bowel and identified the resident with an indwelling urinary catheter. It also identified the resident admitted with a Stage IV pressure ulcer. In an interview on [DATE] at 11:16 AM, the resident's family member reported the resident would have to wait to get his call light answered for one to two hours on a daily basis and the longest he waited to get a soiled incontinent brief changed was 5 hours. On [DATE] the Care Plan identified the resident required assistance to be repositioned at least every 2 hours, more often as needed or requested. It had documentation of the following intervention: Toilet Use: The resident requires (Specify assistance) by (X) staff for toileting. Date Initiated: [DATE] The Care Plan failed to specify the type of assistance the resident required for toileting. In an interview on [DATE] at 9:06 AM, Staff OO, CNA/CMA reported that staff should answer call lights right away and within 13 minutes. She also reported Residents #18 and #46 had complained to her about their call lights not being answered in a timely manner. In an interview on [DATE] at 10:24 AM, Staff PP, CNA reported staff are expected to answer call lights within 15 minutes and that Resident #46 had complained to her about her call lights not being answered in a timely manner. She also reported Resident #122 had been incontinent of stool and he complained to her that his call light not being answered timely on 3rd shift. In an interview on [DATE] at 9:43 AM, Staff D, Licensed Practical Nurse (LPN) reported staff are expected to answer call lights within 12 to 13 minutes. She also reported Residents #24, #46 and #70 complained to her about their call lights not being answered in a timely manner. In an interview on [DATE] at 9:53 AM, Staff K, RN reported staff are expected to answer call lights within 12 to 15 minutes. She also reported residents who complained to her about their call lights not getting answered in a timely manner were Residents #7, #24, #70 and #48 who also reported when certain staff are not there, their call light does not get answered. They all complained about their call lights on a weekly basis. In an interview on [DATE] at 3:17 PM, the Director of Nursing (DON) reported she expected staff to answer call lights within 15 minutes, that no residents have complained to her about their call lights. She also reported she was not sure if this had been an issue reviewed by the Quality Assurance Committee, but felt it should have been. She also reported staff have been educated on answering call lights. A review of the facility policy titled: Call Lights: Accessibility and Timely Response with the last review date of [DATE] had documentation of the following: 1. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.) 2. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 3. Process for responding to call lights: a. Turn off the signal light in the resident's room. b. Identify yourself and call the resident by name. c. Listen to the resident's request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel. d. Inform the appropriate personnel of the resident's need. e. Do not promise something you cannot deliver. f. If assistance is needed with a procedure, summon help by using the call light. Stay with the resident until help arrives.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure 2 out of 2 Treatment Carts and 1 out of 2 Medication Carts were locked and secured when staff not present. The facility reported a census of 69. Findings Include: During an observation on 4/12/23 at 2:48 PM, a Medication Cart left unlocked in the dining hall when staff delivered medication to resident in the dining hall. Observed a resident pass in a wheelchair by the unlocked cart. During an observation on 4/13/23 at 7:51 AM, Staff BB, Registered Nurse (RN) walked down Hall B with the Treatment Cart unlocked and stated he needed to get a computer and walked away from the Treatment Cart and left it unlocked. During an observation on 4/13/23 at 7:53 AM, Staff BB returned to the cart and looked for blood glucose paperwork and stated he grabbed the wrong paper and walked away from the unlocked cart and walked into the dining room and retrieved the papers and returned to the cart. Staff BB prepared the insulin for the resident and went into the resident's room and left the insulin vial and insulin pen on top of the treatment cart and left the cart unlocked in the hallway. Staff CC, Licensed Practical Nurse (LPN) observed in the hallway with her back turned to the Treatment Cart and residents in the hallway in their wheelchairs. During an observation on 4/13/23 at 8:09 AM, Staff BB prepped insulin for another resident and left the insulin vial and insulin pen on top of the Treatment Cart and left the cart unlocked when he went into the resident's room to ask the resident if he wanted his fast acting insulin. The cart observed sitting in the hallway 2 doors down from the resident's room. During an interview on 4/13/23 at 8:13 AM, Staff BB queried if the Treatment Carts expected to be locked and he stated yes, the carts are supposed to be locked. Staff BB stated he guessed he had left it unlocked. He stated they had a lack of keys. Staff BB asked if medications were supposed to be secured in the carts and he stated yes, and he walked back to the cart to check. Staff BB informed he had left the insulin vials and pens on top of the cart when he administered the medications and Staff BB did not respond. During an observation on 4/13/23 at 8:16 AM in Hall B, Staff BB drew up insulin and went into a resident's room and left the insulin vial on top of the cart and left the cart unlocked. During an interview on 4/13/23 at 8:25 AM, Staff CC, LPN queried if medication carts are supposed to be locked and she stated yes, unless you are pulling or popping pills. Staff CC asked if the facility was short on keys and she stated she didn't know, she just started, maybe so. During an observation on 4/13/23 at 9:52 AM in Hall A, Treatment Cart #1 left unlocked between rooms A5 and A7. Observed Staff DD, Certified Medication Aide (CMA), down the hall two doors looking at the computer on her Medication Cart. The following observations made with the unlocked Treatment Cart: a. At 9:55 AM, staff walked by the cart and didn't lock the cart. A resident in an electric wheelchair circled around the cart. b. At 10:04 AM, staff walked by the cart and asked Staff DD where to locate Staff BB and looked at the treatment cart and walked away. c. At 10:16 AM, resident wheeled by the unlocked treatment cart. d. At 10:17 AM, Staff DD wheeled her Medication Cart past the treatment cart and didn't lock it. e. At 10:21 AM, resident wheeled by the treatment cart in their wheelchair. f. At 10:22 AM, surveyor opened the cart and observed insulin and syringes found in the drawers. g. At 10:46 AM, Staff BB, approached the Treatment Cart and moved it next to the Medication Cart by room A 3 and opened the drawers and pulled up medication into a syringe. h. At 10:48 AM, Staff BB went into a resident's room with syringe and left the cart unlocked and the 3rd drawer slightly opened on the cart. During an observation on 4/13/23 10:50 AM, found a set of keys left on the Treatment Cart in B Hall. During an observation on 4/13/23 10:51 AM. Staff DD, CMA picked up the keys off the cart. During an interview on 4/13/23 at 10:52 AM, Staff DD queried who the keys belonged to that she picked up and she stated she believed the keys belonged to one of the nurses and not supposed to be left on the cart so she snatched them up. Staff DD asked what the keys unlocked and she stated she didn't know, but thought the Treatment Carts and something else. During an interview on 4/13/23 at 2:11 PM, Staff BB queried if he had keys in his pocket and he stated yeah. Staff BB informed a pair of keys found on the Treatment Cart and he pulled out the keys from his pocket and stated his keys went to the utility room. Staff BB asked if the keys unlocked the Medication or Treatment Carts and he stated no, he didn't even know what most of the keys on the chain went to. He stated he was the A and B Hall Nurse and when he needed to do treatments he went to someone else to get the keys for the carts because they were short on keys. Staff BB queried why they were short on keys and he stated the Medication and Treatment keys are on the same key chain and if he needed something he would need to go to the Nurse or the Medication Aide for their keys. During an observation on 4/18/23 at 2:51 PM, the Medication Cart left unlocked in the dining hall. Staff EE, Activity Director with her back to the cart sat at a table with 9 residents and another staff member. Three other residents observed at tables in the dining area. During an observation on 4/18/23 at 2:53 PM, Resident #70 wheeled by the Medication Cart and spoke to a staff member right next to the cart. During an observation on 4/18/23 at 2:55 PM, Staff EE walked out of the dining area, another staff member walked into the dining area and sat behind the Nurse's Station with a computer monitor and counter between the staff member and unlocked Medication Cart. During an observation on 4/18/23 at 2:56 PM, the Director of Nursing (DON) walked by the cart and then turned around and stood in front of the cart and locked the Medication Cart. During an interview on 4/24/23 at 4:01 PM, the DON queried about the expectations of medication and treatment carts being locked and she stated they should be locked at all times. The DON asked about the expectations of key control and she stated the Medication Aides had their own set of keys and the nurses had their own keys. The DON queried if the facility was short on keys and she stated she knew that one set of keys for A Hall had the Medication Cart and Treatment Cart keys and at one time the Assistant Director of Nursing (ADON) requested more keys for the carts. The DON stated she had the master keys for the carts. The undated document named Cognitively impaired and independently mobile provided by the Administrator revealed 26 residents cognitively impaired and independently mobile. The Facility Policy titled Medication Storage dated March 2022 revealed the following: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel accessed to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, food temperature checks, staff and resident interviews, the facility failed to provide food at a safe and appetizing temperature from the steamtable located within the North Dining Room kitchenette and failed to ensure food items held at a safe temperature after plated for serving on Hallway R. The facility had reported a census of 69. Findings Include: On 4/12/23 at 11:35 AM, the Noon meal food items temperatures checked by Staff S, Dietary [NAME] for the steam table in the South Main kitchen. The Hallway R and Hallway L Noon meals were individually plated for each resident and then each individual tray placed on an open transport wheeled cart rack. Dietary Staff responsible for transporting the plated tray rack to each hallway and labeled as Hallway R and Hallway L. After all resident Hallway R and Hallway L (South) individual trays plated, Dietary Staff individually plate Hallway A and Hallway B trays (North). On 4/12/23 at 12:06 PM, Staff X, Dietary Manager completed a temperature check, utilizing a digital ThermoWorks brand thermometer to check an individual plated tray located in the Hallway R with the following results: a. At 11:35 AM, Regular squash had temperature checked at 188 degrees and then at 12:06 P.M. had cooled to 131 degrees. b. At 11:35 AM, Regular peas and carrots had temperature checked at 168 degrees and then at 12:06 P.M. had cooled to 129 degrees. c. At 11:35 AM, roast beef had temperature checked at 197 degrees and then at 12:06 P.M. had cooled to 152 degrees. d. At 12:06 PM, the Fruit Cocktail had been temperature checked and had been warm at 58 degrees. On 4/12/23 at 12:06 PM, during an interview with Staff X the discussion of warm fruit cocktail had led to Staff X stating the fruit had never been refrigerated and a new can had been opened and dispersed into individual containers for serving. On 4/12/23 after all Hallway individual trays plated in the Main kitchen, the Dietary Staff observed to place stainless-steel containers of prepared meal items from the Main kitchen steam table onto a plastic 3-tier cart and then transported the cart to the North Dining Hall kitchenette. The stainless-steel containers then placed within the North Dining Hall kitchenette steam table. On 4/12/23 at 12:31 PM, Staff S completed a temperature check of all food items prior to serving North Dining Hall residents individual plated Noon meals. Staff S utilized a digital ThermoWorks brand thermometer to check all food items located in the North Dining Hall kitchenette steamtable prior to serving. the temperature registered below safe parameters and had cooled as follows: a. At 11:35 AM, the pureed butternut squash temperature checked at 160 degrees and then at 12:31 PM, the temperature had cooled to 131 degrees. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #63 shown the Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating intact cognition. During an interview on 4/12/23 at 7:41 a.m., Resident #63 stated the food was always cold. 3. The MDS assessment dated [DATE] for Resident #48 shown the BIMS score was 15 out of 15 indicating intact cognition. Interviews with Resident #48 in regards to food temperatures revealed the following: a. On 4/11/23 at 11:02 AM, the resident reported the food is not always warm b. On 4/12/23 at 9:36 AM, the resident reported the food in the meals she received yesterday were not warm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and facility policy review, the facility failed to maintain an effective pest control program to assure the environment remained free of pests and rodents. The facility reported a census of 69. Findings Include: 1. On 4/11/23 at 11:25 AM, observation of the North Dining Hall kitchenette shown small winged insects flown out from beneath the stainless-steel sink. 2. On 4/13/23 at 8:18 AM, a green fly swatter had been observed lying on the Nurse's Station counter that had brown spots on it. 3. On 4/20/23 at 11:00 AM, an observation of the North Dining Hall kitchenette shown a black plastic garbage can lid on the floor and the trash can observed overflowing with garbage and small winged insects flying around the garbage can. A toaster placed on a tray sitting on the counter with small winged insects flying around the toaster. During an interview on 4/12/23 at 3:30 PM, Staff R stated on 4/11/23 at 8:10 PM, observed a mouse run in front of his foot in the main kitchen. During an interview the facility Registered Dietician (RD) on 4/16/23 at 1:00 P.M., she reported facility staff reported within the last month that rodents were in the building. During an interview on 4/26/23 at 12:25 PM, Staff NN, Licensed Practical Nurse (LPN) stated staff spoke of the facility had mice. When asked if mice seen in the last month, Staff NN stated yes. When asked if mice seen in a particular area of the facility, Staff NN stated no, but during the nightshift mice seen throughout the hallways and in resident rooms in the last month. The facility provided an Extermination Invoice dated 4/21/23 at 9:58 AM, for services provided on that date. Documented evidence of small flies/gnats found in the kitchenette and treated. Also Interior rodent service performed by checking and reset all traps, and checked and reset temporary snap traps in patient and office areas. The facility policy titled Pest Control had been reviewed by the facility March 2023. The Policy documented the facility responsible to maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis, and also issues that may arise in between scheduled visits with the outside pest service were to be treat as indicated. The facility failed to provide an Extermination Company agreement when asked. 4. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #70 shown the Brief Interview for Mental Status (BIMS) score was 14 out of 15 indicating intact cognition. During an interview on 4/11/23 at 2:05 p.m., Resident #70 stated she observed mouse feces in rooms.