**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy, Electronic Health Record (EHR) review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs for 1 of 13 residents (Resident #6) reviewed. The facility reported a census of 72 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) of 00 indicating severe cognitive impairment. MDS also indicated diagnosis of dysphagia, oropharyngeal phase. Review of EHR titled, Physician Orders for Resident #6 documented a regular diet of pureed texture. Review of EHR titled, Care Plan for Resident #6 documented a diet of puree consistency with thin liquids. Review of document titled, University Park FW 2024-2025, Week 3 Tuesday at noon documented a puree menu of 1 serving (8 oz) puree chili, 1 serving (1 each) puree cinnamon roll, 1 serving puree tossed salad, puree brownie/cinnamon buttercream frosting and 8 oz beverage. Review of untitled document dated Tuesday May 6, 2025 for Resident #6 documented diet of pureed - No Added Salt with menu items 1 serving puree chili, 1 serving puree cinnamon roll, 1 serving puree tossed salad/dressing, 1 serving puree brownie/cinnamon buttercream frosting and 8oz beverage. On 5/6/25 at 12:35 PM Staff A, Dietary Aide acknowledged her intention was to serve Resident #6 who was on a puree diet one 4oz scoop of chili for lunch. On 5/6/25 at 12:45 am Staff B, Dietary Manager acknowledged the puree measured to 4 cups and Staff A should serve all residents with a puree diet two 4oz scoops for the appropriate serving size. Staff B stated he did not tell her that she needed to use 2 scoops prior to lunch service. Staff B acknowledged it was his error that led to the incorrect serving size. During a continuous observation of lunch service on 5/6/25 Staff A completed hand hygiene, served all regular diets, Resident #6 was served two 4oz scoops of chili. Staff A stated at that time that was all Resident #6 received for lunch. Staff B stated no Resident #6 also needed to get the puree vegetables and dessert. Staff A then gave Resident #6 puree vegetables and dessert. Observation at that time of pureed cinnamon roll sitting on the table and remained unserved. Staff A acknowledged she was done with lunch service at that time. On 5/6/25 at 12:56 PM Staff B acknowledged Staff A stated she was done serving and had not served the cinnamon roll, cinnamon cream cheese frosted brownie or the vegetable. Staff B acknowledged he had to tell Staff A to serve the pureed dessert and pureed vegetable and that the pureed cinnamon roll was never served during any of the service. Review of undated policy titled, Portion Control documented food will be served according to standard portion sizes to ensure adequate serving of food and to provide portions that are equal in size for those residents that do not require specialized dietary modifications. Residents on diets that require portion variations will have the required information either stated on their tray card or it can be found on the diet spreadsheet under the diet they were on. On 5/7/25 at 4:00 PM the Administrator stated the facility's expectation was the meal would have been served according to the menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Electronic Heath Record (EHR) review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a surgical wound, a pressure wound and a resident with a wound vacuum, that were on Enhanced Barrier Precautions (EBP) for 3 of 3 reviewed (Resident #3, #4, and #7). The facility reported a census of 72 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. MDS also indicated Resident #3 had an unstageable pressure ulcer. Review of Resident #3's EHR dated 5/5/25 titled, Weekly Pressure Wound Assessment documented an unstageable pressure wound present on the left heel that measured 3/6 cm length x 1.1 cm width x 0.1 depth. Review of Resident #3's EHR titled, Care Plan documented Resident #3 required EBP related to the presence of a chronic wound - pressure ulcer. Observation on 5/6/25 at 8:32 AM of dressing change for Resident #3 by Staff C, Licensed Practical Nurse (LPN) completed hand hygiene, did not apply gown, removed boot from left foot, removed gloves, completed hand hygiene, applied gloves, opened dressing packages, removed gloves, completed hand hygiene, applied gloves, removed sock from left foot, applied barrier under foot, removed gloves, completed hand hygiene, applied gloves, removed dressing, removed gloves, completed hand hygiene, applied gloves, area cleansed with wound wash, area allowed to dry, betadine applied to area, 4 x 4 gauze dressing applied to area, gauze wrap applied to left heel, gloves removed, hand hygiene completed, gloves applied, sock applied, Prevalon boot applied, gloves removed, hand hygiene completed, left room cleansed bedside table, and hand hygiene completed. 2. The MDS dated [DATE] documented Resident #4 had a BIMS of 15 indicating no cognitive impairment. MDS also indicated Resident #4 had a stage 3 pressure ulcer and surgical wounds. Review of Resident #4's HER titled, Care Plan documented Resident #4 required BP related to the presence of wounds (pressure ulcer). The HER titled, Care Plan also documented Resident #4 had surgical incisions to both lower extremities. 3. The MDS dated [DATE] documented Resident #7 had a BIMS of 15 indicating no cognitive impairment. MDS also indicated Resident #7 had a surgical wound. Review or Resident #7's HER titled Care Plan documented Resident #7 Required BP related to the presence of a chronic wound - surgical wound. Observation on 5/5/25 at 9:45 AM of Staff D, Certified Nurse Assistant (CNA)/Certified Medication Assistant (CMA) and Staff E, CNA in room [ROOM NUMBER] transfer Resident #4. Both staff completed hand hygiene, applied gloves, did not apply gowns, placed full body transfer sling under Resident #4 in bed, Staff D asked Resident #4 to cross her arms, full body sling supported by Staff E, Staff E placed Wheelchair under Resident #4, Resident #4 lowered into the wheelchair, lift cloth removed by Staff E. Both staff removed gloves, Staff D completed hand hygiene, Staff E threw her gloves away, did not complete hand hygiene, left Resident #4's room, walked down the hall to the next resident's room with full body mechanical lift. Staff E entered Resident #7's room. Staff E applied gloves, applied lift cloth to lift, Staff D supported left cloth with resident for transfer from wheelchair to bed, Staff E utilized lift controls. EBP equipment noted outside Resident #7's room. Resident #7 laid down in bed and lift cloth removed. Staff D placed Resident #7's wound vacuum on the foot of Resident #7's bed. Staff D removed Resident #7's brief, Staff E assisted the resident in turning to the left, brief was replaced, Resident #7 was currently having a bowel movement. Both staff removed gloves and completed hand hygiene On 5/6/25 at 2:41 PM the Director of Nursing (DON) stated Resident #3 had a 3 drawer outside of his room on 5/1/25 with a sign reflecting the need to wear EBP outside the room. The DON acknowledged Resident #3 had a care plan for EBP in place. The DON stated the staff should have worn gowns and gloves in Resident #4's room. The DON acknowledged that the staff should have completed hand hygiene after care with Resident #4, completed hand hygiene when entered Resident #7's room and then applied gowns in Resident #7's room. The DON acknowledged Resident #7 also had a care plan in place for EBP to be worn in the room with personal care. Review of policy dated 3/25/24 titled, Enhanced Barrier Precautions documented Enhanced Barrier Precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs). EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied before performing high-contact resident care activities. Personal protective equipment (PPE) was changed before caring for another resident. Examples of high-contact resident care activities requiring the use of a gown and gloves include dressing, transferring, providing hygiene, changing briefs, and wound care. Review of policy revised 8/19 titled, Handwashing/Hand Hygiene documented hand hygiene should be utilized during the following situations: before and after direct contact with residents, before handling clean or soiled dressings, after contact with a resident's intact skin, and before and after entering isolation precaution settings On 5/7/25 at 4:00 PM the Administrator stated the facility's expectation was gowns would have been worn in rooms where residents had enhanced barrier precautions in place. The Administrator stated the facility's expectation was that hand hygiene would have been completed before resident care, when moving from contaminated areas of the body to non-contaminated areas and after resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interviews, staff interviews and policy review, the facility failed to assure residents were treated with respect and dignity for 2 of 3 residents reviewed (Resident #84 and #54). The facility reported a census of 76 residents. Findings include: 1. According to the Minimum Data Set (MDS) for Resident #84, dated 1/21/25, Resident #84 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognition. The resident was dependent on staff for toileting assistance and required substantial assistance for lower body dressing and chair to bed/chair transfer. The resident's diagnoses included a stroke. The Care Plan included Resident #84 had the potential for diversional activity due to cognitive impairment and/or physical assistance needed and the resident needed assistance to and from activities. Interventions included invite and encourage resident to attend activities and offer assistance for locomotion as indicated. The Care Plan further included the resident had a self-care deficit as evidenced by requiring assistance with Activities of Daily Living (ADLs), impaired balance during transitions requiring assistance and /or walking, incontinence. The resident required a one person staff assist with dressing/undressing and toileting and a two person staff assist with transfers with a sit to stand lift. During an observation 1/27/25 at 2:22 PM, Resident #84 was sitting upright in his reclining chair with his pants partway down his legs with a brief on. The brief was completely visible, initially it appeared the resident was sitting in his chair in his underpants. The door to his bedroom was open, his roommate was in the room, the curtain was open and the roommate was awake, the roommate could visually see the resident sitting in his chair with his pants down and the brief exposed. The resident could be observed sitting in his brief from the open doorway. The resident was observed sitting in his brief until 2:50 PM, when a staff placed blanket over his lower body. During an interview 1/27/25 at 2:25 PM, Resident #84 stated staff was just in his room, they needed to get another person for assistance and said they would return. The resident stated he was wanting to get into his wheelchair and go down to the activity that started at 2:00 PM. During an interview 1/27/25 at 2:45 PM, Resident #84 stated he turned his call light on because no one came back to help him into his wheelchair. The resident stated he has been sitting in his chair with his pants partway down waiting for assistance to get into his wheelchair since 2:00 PM. He wanted to transfer to his wheelchair to go down to the activity on the lower level. During an interview 1/27/25 at 2:50 PM, Resident #84 stated he wanted to go downstairs for the activity, which was national cupcake day and get a cupcake, he has now missed this activity. During an observation 1/27/25 at 2:56 PM, staff brought Resident #84 a cupcake wrapped in a paper towel. The resident was still sitting upright in his reclining chair with a blanket over him, his pants were still not pulled up and he was still not transferred to his wheelchair. During an interview 1/29/25 at 2:45 PM, Staff D, Registered Nurse (RN), stated she was working on Monday, the 27th, on the 4th floor. She recalled being asked to go into Resident #84's room to assist him to pull up his pants, this was later in the afternoon, sometime around 3:00 PM or after. She stated the resident was sitting upright in his reclining chair with his pants down, he said he had been waiting for staff to help him with his pants and transfer him to his wheelchair. She helped him with his pants and then had to get another staff to assist with the transfer. Staff D stated another staff asked her to help the resident because he had been sitting for at least an hour in his chair waiting to have his pants pulled up and transferred to his wheelchair. She stated for dignity she would not leave a resident sitting in his chair with his pants down. During an interview 1/29/25 at 3:00 PM, Staff E, Assistant Director of Nursing (ADON) on the 4th Floor, stated an expectation staff cover a resident and not leave a resident in their chair with their pants pulled down and the door open to their room. ADON stated an expectation staff assist the resident immediately, and not leave them in an exposed condition. The ADON stated an expectation the resident be covered for dignity purposes. The ADON stated an expectation staff assist residents to activities and accommodate resident's choices to attend activities. Review of the facility policy Quality of Life-Dignity, revision date of August 2009, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 2. The Quarterly MDS dated [DATE] revealed Resident #54 with a BIMS of 15, indicating intact cognition. Diagnoses included anxiety, diabetes, and depression with severely impaired vision. The MDS stated Resident #54 requires set-up assistance at meals with maximal assistance with transfers and self-cares. The Care Plan revealed Resident #54 had a self-care deficit, was at risk for falls and had visual impairment/blindness. Interventions include set-up assistance at meals, environment free of spills and personal items within reach. Resident #54 utilized a wheelchair that staff propels. During breakfast observation on 1/28/25, the dining room was full with approximately 15 residents and 4 staff members (3 staff assisting residents to eat and 1 staff checking-in with residents throughout the meal). At 8:40 AM, Resident #54 accidentally dropped a bowl of oatmeal on the floor next to them creating a trail of oatmeal approximately 18-inches long. Staff did not immediately acknowledge or respond. At 8:48, an unknown therapy staff member picked-up the bowl, left the dining room and returned with towels to clean up. There was no interaction with the resident during this time. At 8:52 AM an unknown staff member cleaned-up the area further. The staff member did not interact with Resident #54, such as alerting to the spill/clean-up or offering another bowl of oatmeal. At 8:58 AM, when asked, Resident #54 indicated they were done with breakfast and staff began to clear off the table. At 9:08 AM staff escorted the resident back to their room. During an interview on 1/28/25 at 1:10 PM, Resident #54 indicated they were aware the oatmeal bowl fell to the floor. Resident #54 believes the bowl may have been moved accidentally and was not in its usual position. Resident #54 stated they would have liked another bowl of oatmeal if asked in a timely manner. However when staff asked if they were finished with the meal (18 minutes later), Resident #54 just wanted to return to their room. During an interview with Staff C, Assistant Director of Nursing, suspected staff overcompensated with the lack of interaction with Resident #54 as not to draw attention. Staff C would expect staff to address any food spills in a timely manner. The policy Quality of Life-Dignity, revised August 2009, stated staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before performed.

Based on observation, staff interviews and policy review, the facility failed to maintain resident living areas in good repair and provide a homelike environment. The facility reported a census of 76 residents. Findings include: During an observation 1/27/25 at 12:00 PM, Resident #27 and #34's shared bathroom had wall damage on the floor board, a hole in the wall and the border coming off by the floor, with a large gap and hole in the wall. During an observation 1/27/25 at 12:58 PM, Resident #19 and #81's shared bathroom had a hole in the bathroom door in the middle, on the outside of the door. The bottom of the bathroom door was observed to be falling apart, with jagged edging and splintered wood. There was a hole along the floor board in the bathroom, by the sink. During an observation 1/29/25 at 12:30 PM, with the Administrator present, Resident #27 and #34's bathroom was observed, as well as Resident #19 and 81's bathroom. The Administrator advised she was not aware of the condition of the bathroom with damage to the walls in the bathrooms in more than one area and damage to the bathroom door. The Administrator stated the facility uses a tracking system called TELS to report, track and monitor repairs and maintenance issues. Staff are to use the TELS system to report repairs and maintenance issues. The Administrator pulls the report from TELS to see how timely repairs are fixed. The Administrator stated the damage to the floor and wall in the bathrooms is not homelike and stated an expectation this be repaired. The Administrator acknowledged the damage to the bottom of the door could be a safety concern with the wood being jagged and splintered. The Administrator is unaware if this damage was reported in TELS. During an interview 1/29/25 at 1:58 PM, the Administrator stated the damage to the bathrooms and doors were not reported in TELS and maintenance was not notified of the damage. The Administrator stated an expectation this damage be reported and be repaired. Review of the facility policy Quality of Life-Homelike Environment, with a revision date of May 2017, documented residents are provided with a safe, clean, comfortable and homelike environment.

Based on record review, staff interviews, and policy review, the facility failed to ensure residents were free from misappropriation of resident property for 1 of 1 resident's reviewed (Resident #35). The facility reported a census of 76 residents. Findings include: According to the Quarterly Minimum Data Set (MDS) for Resident #35, dated 1/22/25, a Brief Interview for Mental Status (BIMS) was not conducted as the resident is rarely/never understood. The resident had diagnoses to include Debility, Cardiorespiratory Conditions, heart failure, renal insufficiency and Non-Alzheimer's Dementia. The Care Plan for Resident #35, with a revision date of 8/7/24, included the resident had the potential for diversional activity due to cognitive impairment and/or physical assistance needed. Interventions included to encourage ongoing family involvement and provide for social interaction opportunities. The Care Plan further included Resident #35 was the recipient of an allegation of abuse: theft of cellphone, with a revision date of 11/7/24. Interventions included encourage visits with Social Services/designee to promote healing/recovery, notification to local Law Enforcement as required, replacement of items evaluated by facility, staff to provide for separation from perpetrator of the allegation. Staff member suspended and terminated. The facility has ordered a cellphone holder to be worn around neck if desired. During an interview 1/28/25 at 9:53 AM, Resident #35's daughter, who is the responsible party and emergency contact for the resident, stated the facility offered to replace the phone that was stolen. She advised they did not have a passcode on the phone that was stolen because it was easier for Resident #35 to use it without the passcode. The daughter stated the family did not want to have criminal charges pressed against the staff who stole his phone. The daughter stated they realized the phone was missing around the end of October when she tried to Facetime her father and he did not answer. She thought the phone was dead or just misplaced, but they could not locate the phone in his room or at the facility. About a week later the family decided to activate an old phone they had and used the same phone number as the phone that was missing/stolen. The daughter noticed some text messages coming through that she did not recognize. She gave the messages to the Administrator. She stated the facility handled the phone incident really well, she believed the facility conducted a thorough investigation and let the staff member go who was believed to have taken the phone. During an interview 1/28/25 at 1:00 PM, the Administrator stated the facility made a referral to the Des Moines Police Department (DMPD), who said the family had to be the one to press charges. The family did not want to press charges. The facility offered to replace the missing cell phone, the family said they would replace the phone and did not want the facility to do this. The Administrator stated they realized the phone was missing when the family tried to Facetime the resident, this was around the first part of November, the family thought the phone was dead so they called the facility and the facility staff looked for the phone and could not find it. The family then activated another phone they had with the resident's phone number and when they did this, they noticed text messages on the phone. The facility thought it was Staff F, Certified Nursing Aide (CNA), who was using the resident's phone. Staff F did not admit to this and she did not show up for the 2nd interview they had scheduled with her. Staff F was terminated on 11/5/24. Review of the facility internal investigation report with regard to Resident #35's cell phone revealed on the night of Friday 10/25/2024, the daughter of Resident #35 messaged Staff E, Assistant Director of Nursing (ADON) to let her know that the resident's phone was dead and they were not able to facetime him like they wanted too. Staff E and other facility staff were not able to find the phone at this time. The daughter was notified and shared that she figured he lost it like he had in the past and it will come back like it has before. Staff continued to look for the phone. The daughter shared that the family decided to replace the phone because they believed that he had misplaced the phone, and it was in the facility somewhere. On Friday night 11/1/2024 the family of Resident #35 decided to activate an old phone that they had sitting at home. At this point they had turned on the new phone they saw messages from Friday the 1st that they did not know who they were from. The family then let the facility know that they believed the phone had been taken out of the facility by someone else. The facility worked with the family and received the cell phone from the family on Saturday night to be able to see if the facility knew any of the numbers that were messaged or called on the phone. A message that was received to the resident's new phone at 6:06 pm on Friday night was from Staff F stating that she was clocking out. This message was the only message sent to the phone from a staff member. The facility did call other numbers to see who they were and a lot of them were males that the facility did not have any correlation with. The facility then conducted interviews from all the staff that worked between 10/25/2024 to 11/1/2024. On 11/4/2024 when interviewing staff members the facility received the following responses, I have never seen the phone. I saw the phone a while ago but can not remember the last time. I saw the phone about 2 weeks ago sitting on the resident's mini fridge plugged in. The facility asked staff if they remember the color of the iPhone and the ones that have seen it stated that it was red. The color was verified by the family. The staff that typically work with the resident and on the fourth floor stated that they saw it approximately 2 weeks ago and on the mini fridge. The facility has been in contact with the family and let them know they believe they know who has taken the phone. The family still has stated that they will not be pressing charges but knows that it is their right to do so. The facility has also encouraged the family to change the resident's phone number so he does not receive messages from anyone who might have the old number. During a review of the text messages that came through to Resident #35's phone when the number was reactivated on 11/1/24, at 6:20 PM a text message was received on the resident's phone sent from a number stating I'm at Wayne's house. At 6:09 PM a text message was received that a Cricket update was completed. At 6:06 PM a text was received on the resident's phone number, this was a different number from the one received at 6:20 PM, it stated Clocking out. During an interview 1/29/25 at 11:12 AM, the Administrator stated the phone number that sent the message I'm at Wayne's house was a number the facility did not know or recognize. The Administrator called that number and a male answered and did not say their name, she did not recognize the voice. The Administrator called the number that sent the message to Resident #35's cell phone number on 11/1/24 at 6:06 PM that said Clocking out and a female answered, said hello. The Administrator said who she was and asked to whom she was speaking with, the female did not say, and hung up. The Administrator said she recognized the voice and thought it was Staff F, who had worked at the facility for a year. The Administrator texted that number from her personal phone on the 1st of November, saying hey is this Staff F, it's the Administrator from UP? Staff F replied back to the Administrator on the 4th of November, saying yes, this is her, what's going on? The Administrator texted Staff F back on this number that sent a text to the resident's number, asking Staff F to come into UP, they have a situation that they need her help with. Staff F replied back saying okay, I can come in a sec, let me throw some sweats on, is it bad? This was on Monday, the 4th of November. Staff F came in for an interview with the Administrator on the 4th of November. Staff F admitted the phone number that sent a text message to Resident #35's cell phone number on the 1st of November saying clocking out was her number, she said she used a texting app phone number and it generated the number that she had used to send text messages. The Administrator asked Staff F who she was texting to Resident #35's number that she was clocking out. Staff F then said she didn't text that number, she said she didn't know who it was. The Administrator watched video footage when Staff F clocked out that day and she got in her own car and left, did not see her on her phone or get into anyone's car. Staff F worked on the 1st of November, from 6:00 AM to 6:00 PM. The Administrator stated they looked through other staff phone's and did not see Resident #35's number come up anywhere on their phones. The Administrator thought Staff F took Resident #35's phone and gave it to someone she knows, because she texted that number. Staff F was asked to come back in for a second interview on the 4th of November, Staff F initially said she would come in, then she did not show up for the interview or show up for work on her next scheduled shift. Staff F was terminated on 11/5/24 due to a violation of company policy regarding not working with the facility on an investigation and a no call no show for a scheduled shift on November 5th, 2024. Resident #35 had a different roommate at the time, the roommate had a low BIMS and was not interviewable. Telephone contact was attempted with Staff F on 1/29/25 at 11:26 AM, a voice message was left and a text message was sent requesting a return call. During an interview 1/30/25 at 11:00 AM, the Administrator stated an expectation residents are free from abuse and do not have their property stolen or misappropriated. Review of the facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting, updated 7/8/24, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family and staff interview, and policy review, the facility failed to ensure call light was within reach for 1 of 19 residents reviewed (Resident #68). The facility reported a census of 76. Findings include: The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #68 with a Brief Interview for Mental Status score of 13 indicating intact cognition. Diagnoses included anemia, heart failure, hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body), hip fracture with presence of an artificial hip joint, and osteoporosis. The MDS stated Resident #68 used either a walker or wheelchair and requires moderate assistance with transfers. The Admission/readmission Narrative Bundle, Section C-Falls, dated 12/19/24, assessed Resident #68 at risk for falls with a score of 14. The Care Plan revised on 1/15/25 revealed Resident #68 has self-care deficits. Interventions included staff assistance of one for transfers and walker mobility. The Care Plan also stated Resident #68 is a fall risk. Interventions included call light within reach, removal of wheelchair pedal while in the wheelchair to avoid self-transfers, and completion of Morse Fall Assessment quarterly and as needed. During a family interview on 1/27/25 at 2:00 PM, family reported seeing the call light out of reach for Resident #68 to use. This occurred when the resident was sitting in the recliner. During an observation on 1/29/25 at 1:30 PM, Resident #68 was in their room and seen sleeping in a recliner. The call light observed laying across the bed-side table which was over 3-feet away from the resident and out of their reach. During a return visit at 2:10 PM, Resident #68 remained asleep in the recliner with the call light on the bed-side table over 3-feet away. During an interview on 1/30/25 at 10:00 AM, Staff C, Assistant Director of Nursing, reported an expectation that staff should ensure call lights are within resident's reach. The policy titled Answering the Call Light, revised March 2021, stated when a resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.

Based on observation, resident and staff interviews, record review and policy review, the facility failed to have sufficient nursing staffing to respond to resident's needs in a timely manner after a call light was activated. The facility reported a census of 76 residents. Finding include: 1. According to the Minimum Data Set (MDS) for Resident #50, dated 11/15/24, Resident #50 scored 14 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The resident was dependent on staff for toileting hygiene and required substantial assistance for lower body dressing. The resident's diagnoses included muscle weakness and other orthopedic conditions. During an observation 1/27/25 at 2:00 PM, upon entering the hallway, Resident #50's call light was activated above the door to the bedroom. During an observation 1/27/25 at 2:10 PM, Resident #50 was sitting on the toilet in the bathroom located in his bedroom, the call light above his door was on and activated. Resident #50 stated he pushed his call light at least 20 minutes prior and was waiting for staff to assist with toilet hygiene. Observed staff enter the resident's room at 2:10 PM and inquire what the resident needed and said they would return. Observed staff re-enter at 2:15 PM to assist the resident. During an interview 1/27/25 at 2:39 PM, Resident #50 stated he sat on the toilet for 45 minutes, he said he has his phone with him in his shirt pocket and said he pushed his light at 1:45 PM today. Resident #50 pulled his cell phone out of his shirt pocket, indicating he had this with him and it was on and working. Resident #50 stated he has sat on the toilet before for 25-30 minutes waiting for staff to help him wipe, he said he does not need assistance with transferring, he just needs assistance with wiping. He said his legs get sore from sitting on the toilet for so long. The resident stated this has happened a few times. He said they answer quickly when he pushes it while in his bed. The resident stated today when he sat for so long on the toilet he called down to the front desk to ask for someone to come up and help him. He said he has waited for 30-45 minutes for someone to come into the bathroom to assist him more than once. 2. According to the MDS for Resident #84, dated 1/21/25, Resident #84 scored 15 on the BIMS, indicating intact cognition. The resident was dependent on staff for toileting assistance and required substantial assistance for lower body dressing and chair to bed/chair transfer. The resident's diagnoses included a stroke. During an observation 1/27/25, beginning at 2:22 PM, Resident #84 was sitting sitting upright in his reclining chair with his pants partway down his legs with a brief on and visible from the open doorway to his bedroom. Resident #84 was observed sitting in this position until 2:50 PM when a staff placed a blanket over the resident's legs. The resident's call light was observed to be activated at 2:45 PM. Observation from 2:22 PM to 2:49 PM revealed no staff member entering the resident's room to assist the resident. During an interview 1/27/25 at 2:25 pm, Resident #84 stated staff was just in his room and little while ago, they needed to get another person for assistance. The resident stated he was wanting to get into his wheelchair and was a two person assist for transfers. During an interview 1/27/25 at 2:45 PM, Resident #84 stated no one came back to help him into his wheelchair so he put his call light back on, he said he has been sitting in his chair with his pants partway down waiting for assistance to get into his wheelchair since 2:00 PM. During an observation 1/27/25 at 2:56 PM, Resident #84 was still sitting upright in his reclining chair with a blanket over him, his pants were still not pulled up and he was still not transferred to his wheelchair. During an interview 1/29/25 at 2:45 PM, Staff D, Registered Nurse (RN), stated she was working on Monday, the 27th, on the 4th floor. She recalled being asked to go into Resident #84's room to assist him to pull up his pants, this was later in the afternoon, sometime around 3:00 PM or after. Staff D stated the resident was sitting upright in his reclining chair with his pants down, he said he had been waiting for staff to help him with his pants and transfer him to his wheelchair. She helped him with his pants and then had to get another staff to assist with the transfer. Staff D stated another staff asked her to help the resident because he had been sitting for at least an hour in his chair waiting to have his pants pulled up and transferred to his wheelchair. Staff D stated they normally answer call lights quickly, within 15 minutes. She said if staff need another staff to assist, they come back quickly, within a few minutes, she said they should not leave a resident for longer than 15 minutes waiting for assistance. During an interview 1/29/25 at 3:00 PM, Staff E, Assistant Director of Nursing (ADON), stated an expectation call lights are answered within 15 minutes, or sooner. If a staff responds to a call light and needs another staff to assist, they should return within a few minutes, no longer than 15 minutes. If it will take longer than just a few minutes, staff need to let the resident know and return within 15 minutes. Review of the facility Resident Council meeting minutes, dated 1/27/25, documented under Nursing, day shift slow to answer call lights. Review of the facility policy Answering the Call Light, revised March of 2021, documented the purpose of this procedure is to ensure timely responses to the resident's requests and needs.

Based on personnel document review, staff interviews, and facility policy review the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 17 residents. Findings include: On 1/27/25 a request for documentation from the facility revealed the Dietary Director did not have the required certification. On 1/29/25 at 12:30 PM the Dietary Director confirmed he had been in the position for 3 weeks and had not completed the certification requirement yet. The Dietary Director stated he had previously held a Serve Safe Certification, but it had expired. The staff stated he was currently enrolled in the necessary coursework to complete the certification. On 1/29/25 at 1:20 PM the Administrator acknowledged the Dietary Manager was a new employee and had not completed his certification, but was currently taking the necessary coursework. The facility did not have a policy related to having a certified dietary manager. The Food and Drug Administration Food Code 2022 revealed the person in charge of the kitchen must be a certified food protection manager who has shown proficiency in required information through passing a test that is part of an accredited program.

Based on documentation review, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility failed to document temperatures of food in the kitchen prior to distribution. The facility reported a census of 76 residents. Findings include: Reviewed the kitchen meal temperature logs for 3 months. 4 meal temperatures out of 90 meals were not recorded in November. 8 meal temperatures out of 93 meals were not recorded in December. 25 meal temperatures out of 78 meals were not recorded in January On 1/29/25 at 12:30 PM the Dietary Director expected that all temperatures would be completed in the kitchen prior to distributing the food to the dining rooms, and completed in the dining rooms prior to serving. The Dietary Director stated he further expected that all temperatures were to be logged on the appropriate log forms whether the kitchen or dining rooms. The Dietary Director acknowledged with incomplete documentation it was unknown if the temperatures were taken prior to food distribution or serving, and the food had reached the required temperatures. On 1/29/25 at 1:20 PM the Administrator expected all food temperature logs be kept current to document temperatures taken in the kitchen and in the dining rooms. The Administrator concurred documentation is required to prove the food temperatures were taken prior to food distribution or serving. The facility policy, Food Preparation and Service, revised October 2017 revealed specific temperatures/times required for specific foods to be reached to inactivate pathogenic microorganisms. The document further revealed dietary staff would adhere to proper practices to prevent the spread of foodborne illness. The Food and Drug Administration Food Code 2022 revealed the person in charge of the kitchen should be provide daily oversight of the employees ' routine monitoring of the cooking temperatures.

Based on observations, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility placed cooking utensils on countertops, and delivered drinks uncovered. The facility reported a census of 76 residents. Findings include: Observation on 1/27/25 at 9:45 AM revealed the ice machine had a light pink substance throughout. Continuous observation on 1/28/25 at 9:53 revealed Staff A placed a scraper on a countertop without a barrier during the preparation of pureed meat. During the preparation of mashed potatoes Staff A placed the whisk on the countertop without a barrier. Continuous observation on 1/28/25 at 12:07 PM revealed room tray service initiated. A room service tray left the dining room with 3 drinks uncovered. During preparation of the second tray, Staff B, Certified Nursing Assistant (CNA), stated forgot to put lids on the drinks. Observed a tray with uncovered drinks leave the dining room and enter the hallway when the Registered Dietitian stopped the delivery, and directed the staff to return to the dining room to cover the drinks. During an interview 1/27/25 at 2:56 PM, Resident #84 stated he eats in his room. He said he wondered if the State was here today because his drinks had a cover over them for lunch and normally they do not, he said his drinks are served to him without a cover normally. On 1/29/25 at 12:30 PM the Dietary Director stated he was not aware of the ice machine needing to be monitored and cleaned as he was new to the position. The staff stated cooking utensils could be set on the countertops if the countertops were wiped off. The Dietary Manager stated he was not aware of when the last time the counters were wiped off prior to setting the utensils on them. The staff stated all liquids on room trays were to be covered prior to delivery. On 1/29/25 at 1:20 PM the Administrator stated she expected the ice machine to be kept in a clean manner and maintenance should be responsible for this. The Administrator stated she would be fine with utensils on counters if the counters had been wiped down, but could not guarantee when the counters had been wiped or if things had been set on them prior to staff setting utensils on them. The Administrator stated that cups should have lids on them prior to carrying them down the hall from the dining rooms on the floors. The facility policy, Ice Machines and Ice Storage Chests, revised January 2012 revealed the facility would have procedures for cleaning and disinfecting the ice machine adhering to the manufacturer's instructions. It further revealed the ice machine will be used and maintained to assure a safe and sanitary supply of ice. The facility policy, Food Preparation and Service, revised October 2017 revealed food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview and facility policy review the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice by providing oxygen (O2) without a physician's order and not changing oxygen tubing for 1 of 1 resident (Resident #73) reviewed. The facility reported a census of 79 residents. Findings include: A Minimum Data Set, dated [DATE] for Resident #73, included diagnoses of chronic obstructive pulmonary disease and received O2 therapy. A Brief Interview for Mental Status score of 12 indicated mild cognitive impairment. On 3/18/24 at 3:06 PM, observed the resident sitting in a wheelchair with O2 on at 2.5 Liters (L) per nasal cannula (NC) and O2 tubing with no date marked on it. On 3/19/24 at 1:48 PM, observed the resident sitting in a wheelchair with O2 on at 2.5 L per NC and tubing remained without a date. Resident's Order Summary Report with active orders as of 3/19/24 lacked a physician's order for O2. The facility policy, Respiratory Therapy revised 11/2011 instructed to change the oxygen cannula and tubing every 7 days. Interview on 3/20/24 at 11:56 AM, Staff E, Assistant Director of Nursing confirmed the resident did not have a physician's order for O2 and expectation is to have an order and change the O2 tubing weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review the facility failed to notify the Long Term Care Ombudsman of discharge/transfer of residents as required for 5 of 5 residents reviewed who were discharged or transferred from the facility (Residents #5, #14, #23 #42, and #59). The facility reported a census of 79 residents. Findings include: 1. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #5 had an unplanned discharge to the hospital and reentered the facility on 10/16/23. The facility's Census List revealed Resident #5 hospitalized [DATE]-[DATE]. Review of the Notice of Transfer Form to the Long Term Care (LTC) Ombudsman lacked documentation of Resident #5's discharge to the hospital on [DATE] as required by federal regulation. 2. Review of the MDS assessment dated [DATE] and 1/3/24 revealed Resident #23 had unplanned discharges to the hospital and reentered the facility on 10/12/23 and 1/5/24. The facility's Census List revealed Resident #23 hospitalized [DATE]-[DATE] and 1/3/24-1/5/24. Review of the Notice of Transfer Form to the Long Term Care (LTC) Ombudsman lacked documentation of Resident #23's discharge to the hospital on [DATE] and 1/5/24 as required by federal regulation. 3. The MDS for Resident #14 dated 1/9/24, included diagnoses of a seizure disorder and diabetes. A Brief Interview for Mental Status score of 14, indicated mild cognitive impairment. The facility Census List revealed Resident #14 admitted to the hospital 12/9/23 and returned to the facility 12/13/23. Review of the facility's Notice of Transfer Form to Long Care Term Ombudsman form for 12/2023 lacked documentation of Resident #14's transfer to the hospital. 4. The MDS assessment dated [DATE] revealed Resident #42 had an unplanned discharge to the hospital and reentered the facility on 1/16/24. The Census List on the facility's computer software program used for electronic medical record documentation revealed Resident #42 hospitalized [DATE] to 1/16/24, and 2/8/24. Review of the E-interact transfer form revealed Resident #42 transferred to the hospital on 1/10/24, 2/1/24, and 2/8/24. Review of the Notice of Transfer Form to the LTC Ombudsman lacked documentation of Resident #42's discharge to the hospital on 1/10/24, 2/1/24, and 2/8/24 as required by federal regulation. 5. The MDS assessment dated [DATE] revealed Resident #59 had an unplanned discharge to the hospital and reentered the facility on 2/2/24. The Census List on the facility's computer software program used for electronic medical record documentation revealed Resident #59 hospitalized [DATE] - 2/2/24. Review of the Notice of Transfer Form to the Long Term Care (LTC) Ombudsman lacked documentation of Resident #59's discharge to the hospital on 1/27/24 as required by federal regulation. In an interview 3/20/24 at 3:15 PM, Staff E, ADON, stated the Administrator reported the resident discharges to the LTC Ombudsman. In an interview 3/21/24 at 8:45 AM, the Administrator reported the facility did not have policy for reporting to the LTC Ombudsman. The Administrator reported she sent a report to the LTC Ombudsman when residents discharged or transferred from the facility. In an interview 3/21/24 at 9:30 AM, the Administrator reported she pulled a report from the electronic software program but the report did not include some of the residents who discharged from the facility. She found another report that pulled all of the resident's discharged and/or transferred to the hospital. She planned to use this report now and in the future to provide a report to the LTC Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to provide a sanitary environment to help prevent the spread of communicable disease and infections. The facility failed to perform hand hygiene, don gloves, change gloves and use a barrier under a graduate during catheter drainage for 3 of 3 residents reviewed (Resident #51, #11 and #61). The facility reported a census of 79 residents. 1.The Minimum Data Set (MDS) assessment for Resident #51 dated 1/3/2024, included diagnoses of non-Alzheimer's dementia and obstructive uropathy (condition that blocks the flow of urine). The MDS documented the resident had an indwelling catheter (tube to drain urine from the bladder). The MDS documented a Brief Interview for Mental Status (BIMS) score of 8 completed, indicating moderate cognitive impairment for decision-making. During an observation on 3/19/24 at 2:50 PM, Staff D, Certified Nurse Aide (CNA) entered Resident #51's room, did not perform hand hygiene and applied gloves. Staff D drained the catheter bag into a graduate and placed the graduate directly on the floor, not placing a barrier under the graduate. Facility policy, Emptying a Urinary Drainage Bag revised 10/2010 instructed to place a paper towel on the floor beneath the drainage bag and position the measuring container under the drainage bag. Interview on 3/20/24 at 11:53 AM, Staff E, Assistant Director of Nursing (ADON) stated expectation is to complete hand hygiene before completing care and place a barrier between the graduate and floor. 2. On 3/18/24 at 12:43 PM, observed Staff C, Environmental Services, wear gloves and push a cleaning cart onto the elevator. Staff C used her gloved hand and pushed the buttons on the wall inside the elevator. Staff C continued to wear the gloves as she rode the elevator to the next floor and then proceeded to push the cleaning cart off the elevator. 3. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had diagnoses of multiple sclerosis, cerebrovascular accident, and hemiplegia (paralysis on one side of the body). The MDS indicated the resident had incontinence, and had total dependence on staff for toileting, dressing, and personal hygiene. The Care Plan revised 1/26/24 revealed the resident had incontinence and at risk for skin impairment, urinary tract infections, and skin irritation in the peri-area. The Care Plan also indicated the resident required assistance with activities of daily living (ADL's). Staff directives included check and change the resident's brief and provide peri-care with every incontinence episode and as necessary. On 3/19/24 at 1:13 PM, observed Staff A, certified nursing assistant (CNA) and Staff B, CNA, don a pair of gloves. Staff A removed the resident's brief, then took disposable wipes and cleansed Resident #11's groin and perinea. Staff B assisted the resident to roll onto her left side. Staff A removed the brief from the resident's backside which had a large amount of stool present. Staff A took disposable wipes and cleansed between the buttocks front to back, then removed the soiled brief. Staff A changed gloves, then took additional wipes and cleansed the buttocks area again. Staff A then tucked a clean brief under the resident, rolled the resident onto her back, pulled the brief up, and attached the tabs on the brief. In an interview 3/21/24 at 11:50 AM, Staff E, Assistant Director of Nursing (ADON) reported she expected staff changed gloves in-between going from dirty to clean tasks. 4. The MDS assessment dated [DATE] revealed Resident #61 had diagnoses of dementia and mild intellectual disability. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severely impaired cognition. The MDS revealed the resident had total dependence on staff for toileting. The Care Plan revised on 9/10/22 revealed the resident had incontinence and required assistance with ADL's. The Care Plan directed staff to provide peri-care with every incontinent episode. On 3/19/24 at 1:44 PM, observed Staff A, CNA, and Staff B, CNA, use a mechanical lift and transfer Resident #61 from a wheelchair to the bed. Staff A and Staff B wore gloves during the transfer. Staff A and Staff B removed the sling under the resident, then removed the resident's pants and soiled brief. Staff A took disposable wipes and cleansed the resident's groin and penis. Staff B rolled the resident onto his left side. Staff A opened the back of the brief, which contained a moderate amount of stool. Staff A took disposable wipes and cleansed between the resident's buttocks, and then removed the soiled brief under the resident. Staff A placed a clean brief under the resident, rolled the resident onto his back, and attached the brief tabs. Staff A wore the same gloves during cares. The facility's Handwashing/Hand Hygiene policy (version 2.2) revealed an alcohol-based hand rub or soap and water used before moved from a contaminated body site to a clean body site during resident care, and after gloves removed. The facility's Personal Protective Equipment -Using Gloves policy revised 9/2010 lacked direction as to when gloves needed changed. The facility's Perinea Care policy revised 2/2018 revealed the following procedural steps: a. Wash hands. b. Put on gloves. c. Wash perinea area, wiping from front to back. d. Turn resident on side. e. Wash the rectal area. f. Remove gloves. g. Wash hands. In an interview 3/21/24 at 11:50 AM, Staff E, ADON, reported she expected staff changed gloves in-between going from dirty to clean tasks.

Based on clinical record review, staff interviews, and information from the Davis's Drug Guide, the facility failed to consistently report weight loss to the physician for 1 of 1 residents (Resident #4) reviewed who was prescribed a dosage of a weight based medication. The facility reported a census of 80 residents. Findings include: The Minimum Data Set (MDS) for Resident #4, dated 5/4/22 documented diagnoses that included heat failure, hypertension (high blood pressure), ischemic cardiomyopathy (damaged heart muscle) and coronary artery disease. The Care Plan revealed a focus area of anticoagulant medication dated 2/24/22. The Care Plan directed staff to perform daily skin inspection and to monitor and report signs of anticoagulant complications. The Care Plan failed to reveal to monitor resident weight related to the weight based ordered dosage. The Medication Administration Record (MAR) for August of 2022 for Resident #4 documented the resident received 10 mg of Prasugrel, (an anti-platelet medication) with an order start date of 2/24/22. The Weight Summary section of the Electronic Health Record (EHR) of Resident #4 documented a weight of 134.6 pounds (61.18 kg) on 2/24/22. The Davis's Drug Guide documented the dosage of Prasugrel for adults who weigh equal to or greater than 60 kg (132 pounds) is 10 mg once daily and 5 mg once daily for adults who weigh under 60 kg. The Weight Summary documented the resident had a weight loss over the next several months. Her weight was monitored frequently and documented in progress notes as being discussed in weight and skin meetings and having no dietitian recommendations. The Nurse Practitioner was notified of the resident's weight changes multiple times through 5/26/22 per the progress notes. The Weight Change Note dated 6/2/22 by the Registered Dietitian documented the resident to have a stable weight of 124.7 pounds (56.68 kg) and recommended discontinuing daily weights. The note stated the resident was on diuretic medication and weight loss was expected. The Weight Summary documented the resident weighed 129.6 pounds (58.9 kg) on 5/6/22 and remained under 60 kg continuously from that point forward. On 8/1/22 the resident was down to 111.0 lbs (50.45 kg) and the EHR flagged this as an 11.1% weight loss since 7/1/22. No progress notes documented notification to the Nurse Practioner or Medical Director of the weight loss past 5/26/22. In an email from the Director of Pharmacy operations dated 11/17/23, the pharmacy stated there was no order change for the Prasugrel. The resident was on 10 mg of the medication from 2/24/22 until 8/4/22. The email stated the medication has a boxed warning for bleeding risk and one of the risk factors is a body weight of <60kg. He stated he found no documentation from the facility notifying of a weight change. In an email dated 11/21/23, the Administrator stated the facility does not have a policy regarding dosing weight based medications. She stated the facility would follow physician orders and pharmacy recommendations which are completed monthly with a full chart review. In a second email from the Director of Pharmacy dated 11/21/23, the Director stated the system does not contain updated real time information on the weight of the residents. He stated the only time the pharmacy would be aware of a weight change is if they received notice from the facility. On 11/21/23 at 8:35 am, the Registered Dietitian (RD) stated that when the resident was receiving hospice care, they stopped closely monitoring her weights. She stated the facility still weighed her but she was no longer discussed in weight meetings. She stated the normal protocol for notifying the medical provider of a weight change is for she, the RD to notify the staff nurses and they would then notify the nurse practitioner. She stated she did a dietary review on 8/2/22 noting the significant weight loss of the reticent. However, the resident passed away prior to a weight meeting to discuss the weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, resident and staff interviews, and staff competency checklist, the facility failed to ensure a mechanical (Hoyer) lift in a safe and functional condition to safely transfer a resident for 1 of 4 residents observed during a transfer (Resident #10). The facility staff also failed to ensure a proper sized sling used for transfer of a resident in a mechanical lift for 1 of 4 residents observed for transfers (Resident #13). The facility reported a census of 80 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had diagnoses of dementia, sepsis, and schizophrenia. The resident had a Brief Interview for Mental Status (BIMS) of 0 out of 15, indicating severely impaired cognition. The MDS documented the resident had total dependence for transfers. The Care Plan revised 7/18/23 revealed the resident had a self-care deficit and required assistance with ADLs (activities of daily living). The staff directives included use of a Hoyer and two staff for transfers. During observation on 11/14/23 at 2:10 PM, Staff A, certified nursing assistant (CNA), and Staff B, CNA, connected a sling to an EZ way mechanical lift. Staff A raised Resident #10 up in the mechanical lift and transferred the resident from a broda chair into the bed. The resident had dark faded bruises to her right calf and shin. During the transfer, the mechanical lift was slow in raising and lowering the resident from one surface to another. Staff A stated she didn't know if the battery would last. The mechanical lift had exposed wires and what appeared to be electrical tape loosely wrapped around some of the wiring that extended toward the battery pack. During a confidential resident interview on 11/15/23 at 9:00 AM, a resident reported two staff used a Hoyer whenever they transferred her, but staff practically flipped her out of the Hoyer when they transferred her. The resident reported one of the Hoyer machines was antiquated and the facility needed to get a new one. She had hit her head on the Hoyer three times due to the unpredictable mechanics of the Hoyer. The resident reported she told staff about the Hoyer and filled out a grievance about it. She recommended they get rid of it but staff continued to use the Hoyer. The resident reported the Hoyer was not related to the CNA's who used it, but rather the functionality of the machine. During an interview 11/20/23 at 9:45 AM, Staff F, CNA, reported the facility's mechanical lifts was always broken or had something electrical wrong. The staff always had to switch out the Hoyer because they didn't work. Staff F reported the equipment had a lot of battery issues, and the battery charger didn't charge the batteries. Staff F reported one time she had to use the emergency button on the Hoyer because they got the resident up in the sling, in the air, and then the machine didn't work. She got the resident over the bed and raised the bed up, then had to use the Hoyer's emergency button to lower the resident into her bed but it wasn't that far of a drop. Staff F stated she took a CNA course in 2017 to learn how to operate a Hoyer mechanical lift but had no other training on how to use this equipment. During an interview 11/20/23 at 10:40 AM, Staff H, Registered Nurse (RN) and Unit Manager, reported she let maintenance staff know whenever equipment, such as a mechanical lift, was broken. Staff H reported a lock out tag out was placed on broken equipment if they didn't want the staff to use it. During an interview 11/20/23 at 11:00 AM, Staff G, CNA reported she let the nurse or management know whenever equipment was not working. Staff G stated she looked at the resident's care plan to know how a resident transferred, and if a device such as a Hoyer or EZ stand used. Staff G reported she had not had a Hoyer lift malfunction. Staff G reported when the battery is low, the machine is slow, and that meant the battery needed charged. During an interview 11/20/23 at 12:15 PM, the Social Worker reported no concerns or grievances reported about a Hoyer mechanical lift equipment. During an interview 11/20/23 at 1:05 PM, Staff E, Maintenance, reported he had worked at the facility for 7 months. Staff E reported he checked the TELS computer program daily to see what needed done. Staff and residents tracked him down or called and told him when something needed repaired or checked. Staff E reported he worked on some equipment such as mechanical lifts and wheelchairs, but called the company for some of this equipment depending upon warranty or contracts. Staff E reported he kept track of equipment and repairs in the computer. Staff E reported no current preventative maintenance on mechanical lift equipment, he worked on the equipment whenever staff or a resident reported an issue. The only repairs he had done on the mechanical lifts recently included cleaning out the wheels to make it easier to move the machine and fixing a battery. Staff E stated staff are supposed to charge batteries on mechanical lifts at night. During an interview 11/16/23 at 12:30 PM, Staff I, Licensed Practical Nurse (LPN), reported she let maintenance know if equipment not working. Staff I recalled over 8 months ago, one of the CNA's had to use the emergency button on a Hoyer when a resident was in it. The CNA no longer worked at the facility. During an interview 11/21/23 at 11:20 AM, Staff P, Unit Manager, reported she expected staff to let maintenance or their manager know if wires exposed or equipment not working properly. Staff P stated the batteries checked by manufacturer 4/2023 and a battery was replaced. The problem lies with staff not charging the batteries fully. The facility's grievance log dated 5/1/23 to 11/14/23 revealed no information pertaining to mechanical lift or equipment concerns. The EZ Way service manual revealed the EZ Way Smart Stand required a minimum of servicing to keep it in good working order. It is important the maintenance staff completed certain basic checks periodically to ensure on-going safety of the device. The manufacturer suggested components checked (such as all bolts tightened, pins engaged, safety tabs not missing or torn, wheels and brakes checked, check for damaged, loose, or missing parts, and a load test performed). Any detected deficiency must be rectified before equipment put back into service. The Invacare Reliant patient lift user manual revealed regular maintenance of patient lifts by qualified personnel is necessary to assure proper operation of the equipment. A facility's policy for Quality of Life-Homelike Environment revised 5/2017 revealed facility staff and management shall maximize the characteristics of the facility including a safe and comfortable environment. 2. The admission MDS assessment dated [DATE] revealed Resident #13 had diagnoses of Parkinson's disease, seizure disorder, and intellectual disability. The MDS documented a BIMS of 9 out of 15, indicating moderately impaired cognition. The resident had dependence on staff for transfers. The Care Plan revised 11/9/23 revealed the resident had a diagnoses of Parkinson's disease and had involuntary muscle movements. The resident had a risk for falls related to neuromuscular impairment. The care plan directed staff to provide a safe environment and use a Hoyer and two staff for assistance with transfers. The care plan lacked information pertaining to the sling size to use. During observation on 11/15/23 at 1:15 PM, Staff C, CNA, and Staff D, CNA, pulled a small blue sling under Resident #13 while the resident sat in a wheelchair, and connected the sling straps to a Hoyer mechanical lift. Staff C took a remote and began to raise the resident up. Resident #13 had jerking motions in her arms and legs. Staff C told Staff D she didn't think this was going to work because the sling didn't look like it was under the resident far enough. Staff D told Staff C it's ok, she hung the straps so the straps closest to the resident were longer than the straps connected closer to the lift/ resident legs. Staff D explained to Staff C when they lifted the resident up in the sling, the resident would be in more of a reclining position rather than a sitting position and she won't slide out. Staff C stated the sling was up too high, because it was not under the resident's legs. Staff D stated the reason was because the sling was small. Staff D took the lift remote and raised the resident in the sling. Resident #13 yelled they're hurting me. Staff D reassured the resident. Resident #13 continued to holler. Staff D offered to get someone else to help the resident, but the resident said no. Staff D and Staff C transferred the resident into bed and removed the sling from under the resident. During an interview 11/20/23 at 9:45 AM, Staff F, CNA, reported she determined what sling size to use based on a resident's weight and width. Staff F reported the care plan showed how many staff to transfer a resident but did not include what size sling to use on a resident. Staff F stated she took a CNA course in 2017 to learn how to operate a Hoyer mechanical lift but had no other training on how to use this equipment. During an interview 11/20/23 at 11:00 AM, Staff G, CNA, reported she looked at the resident's care plan to know how a resident transferred, and if a device such as a Hoyer used. Staff G reported she looked at the color of the sling to determine the size of the sling. Staff G thought the resident's care plan included the size of the sling used. During an interview 11/21/23 at 10:50 AM, Staff O, Occupational Therapy, reported therapy made recommendations on how a resident transferred if they were on therapy's caseload. Therapy filled out a communication sheet with recommendations for transfers. Therapy doesn't make recommendation on the sling size to use or provide training to staff on use of equipment such as a Hoyer. During an interview 11/21/23 at 11:20 AM, Staff P, Unit Manager, reported they used the mechanical lift user guide for recommendations on what size sling to use for residents who transferred with a mechanical lift. The sling size was determined by the resident's height and weight. Staff P reported staff told in a verbal report what size sling to use on a resident. Resident council meeting notes dated 10/9/23 revealed residents requested to keep wider Hoyer slings on the 3rd and 4th floors, not just on the 3rd floor. A Hoyer Lift Competency Checklist revealed the following procedural steps: a. Check the resident's care plan for transfer instructions b. Ensure resident provided correct sling size and proper weight for device per manufacturer specifications. c. Ensure resident feels safe, comfortable, and secure with transfer. d. Position sling under the resident in a seated position. e. Tip resident forward and position sling handles facing outside and away from the resident. f. Position leg straps inside the arms of the wheelchair. The horseshoe seam reinforcing the sling should touch the seat of the chair, conforming to the resident's tailbone area. g. Pull the leg straps of the sling toward you and position them between the chair and the resident's legs. Pull the leg straps across under the resident's thighs. h. Attach the sling to the lift. Attach right and left shoulder strap to the nearest sling support hook. Attach sling support hooks away from the resident. i. Push the up button to raise the resident up. j. Transport resident to desired location, and carefully lower the resident into desired location. k. Lower the lift beam enough to allow unhooking and removal of sling straps. The Invacare Reliant patient lift user manual revealed slings are specifically designed to be used in conjunction with Invacare patient lifts. Slings designed by other manufacturer's are not to be utilized as a component of Invacare patient lift system. When the sling is connected with color-coded straps to the patient lift, the shortest of the straps MUST be at the back for support of the patient. Make sure there is sufficient head support when lifting a patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS for Resident #6, dated 10/19/23 revealed the resident was totally dependent for toileting hygiene. The MDS documented the resident was always incontinent of urine and frequently incontinent of bowel. The Care Plan dated 10/18/23 documented Resident #6 has the potential for infection related to a history of UTI. During a continuous observation on 11/20/23 beginning at 1:32 pm, Staff L and Staff M, CNA's, stated they were going to transfer Resident #6 to her bed and change her incontinence brief. The resident was in her wheelchair with a Hoyer lift sling in place behind her. Both CNAs performed hand hygiene and placed clean gloves on their hands. Staff M reached down with his gloved hands and removed the pedals off of the wheelchair. Staff L guided the Hoyer lift into place in front of the resident's wheelchair. The two employees discussed the proper safe checks of hooking the Hoyer sling to the machine and verified resident safety. Staff L then pulled the curtain separating Resident #6's side of the room from the roommates side of the room. Staff M used the remote control of the Hoyer lift to raise the resident in the air. Staff M wheeled the machine over to the bed and laid the resident safely onto the bed. Staff M entered the restroom and performed hand hygiene and placed new gloves on his hands. Staff L moved the bed from against the wall and stood between the bed and the wall, keeping the same gloves on. Staff M brought a package of wet wipes from the restroom and handed them to Staff L. Staff L assisted Resident #6 to turn to her left side, facing the wall. Both staff members assisted to tuck the Hoyer pad under the resident, turn her, and remove the Hoyer pad from the bed. Staff M assisted to lower Resident #6 pants. Staff M opened the resident's brief. After touching the resident's wheelchair, the Hoyer lift, the privacy curtain and moving the bed, Staff L, wearing the same gloves, then began to hand wipes to Staff M who used those wipes for cleaning the resident's groin area due to incontinence. Both staff turned the resident side to side to thoroughly cleanse the resident. Staff M then removed the soiled brief and placed it in the trash can. Staff M removed his gloves and went to the restroom to wash his hands and placed new gloves on. Staff L remained in the same gloves since the beginning of observation. Staff L tucked a new clean brief under the resident. Both staff assisted to attach the tabs to the brief, and positioned the resident for comfort. After placing a blanket over the resident, Staff L then removed her gloves. She pushed the bed back against the wall and placed a body pillow on the bed and lowered the bed. Based on clinical record review, observations, staff interview, and facility peri-care competency checklist, the facility failed to provide incontinence care to minimize the risk and occurrence of urinary tract infections for two of four residents observed for incontinence care (Resident #10 and Resident #6). The facility reported a census of 80 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had diagnoses of sepsis, UTI (urinary tract infection) in the past 30 days, and dementia. The resident had a Brief Interview for Mental Status (BIMS) of 0 out of 15, indicating severely impaired cognition. The MDS documented the resident had dependence for toileting hygiene, dressing, and transfers. The Care Plan revised 7/18/23 revealed the resident had a self-care deficit and required assistance with activities of daily living (ADLs). The resident also had a potential for infection related to a history of UTI, and had incontinence. The care plan staff directives included two staff for toileting. The Order Summary revealed an order for macrobid (an antibiotic) one capsule by mouth two times a day for 10 days for diagnoses of UTI started 11/5/23 until 11/14/2023. During observation on 11/14/23 at 2:10 PM, Staff A, certified nursing assistant (CNA), donned a pair of gloves, removed the tabs on Resident #10's brief, then took a disposable wipe and cleansed between the labia. Staff A turned the same wipe over and cleansed between the labia again. Staff B, CNA, assisted the resident to roll onto her left side. Staff A removed the soiled (wet) brief under the resident, took a disposable wipe, and cleansed between the buttocks front to back. Staff A turned the same wipe over and cleansed between the buttocks again. Staff A placed a clean brief under the resident, rolled the resident onto her back, attached the tabs on the brief, then removed her gloves. During an interview 11/21/23 at 11:20 AM, Staff P, Unit Manager, reported she expected staff use one wipe per swipe and cleansed all areas whenever they provided incontinence cares. Staff P stated she expected staff to change gloves whenever they went from a dirty to a clean area, and whenever gloves visibly soiled. An undated Peri-care Competency Checklist revealed the following procedural steps: a. Gather equipment b. Wash hands and don gloves c. Remove soiled products d. Remove gloves, wash hands, and don gloves. e. Wipe the perineal area with a disposable washcloth, wiping front to back. Place washcloth in a bag. f. Remove gloves, wash hands, and don gloves. g. Wipe the inner thighs and all areas soiled except the buttocks and anal area. Use a new washcloth/wipe. Change gloves if soiled with feces, wash hands, and reapply gloves. h. Wash buttocks and anal area using a new cloth. i. Remove gloves, wash hands, and reapply gloves. j. Apply incontinent product and adjust clothing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident council meeting, and facility policy review, the facility failed to ensure staff responded and answered residents' call lights within 15 minutes and met residents needs in a timely manner for one of two nursing units observed. The facility reported a census of 80 residents. Findings include: Observations on 11/15/23 on the 4th floor revealed: a. At 7:10 AM, 3 call lights on (which included room [ROOM NUMBER]). Staff I, Licensed Practical Nurse (LPN) stood by a medication cart in the hallway. b. At 7:12 AM, Staff J, certified nursing assistant (CNA) entered room [ROOM NUMBER], told the resident she had to help another aide get someone up and then she would be back to help her. Staff J shut the resident's call light off, then left the room and entered room [ROOM NUMBER]. c. At 7:22 AM, Staff J and Staff K, CNA, came out of room [ROOM NUMBER], wheeled a hoyer to the storage room, then went into another resident's room. d. At 7:36 AM, the resident in room [ROOM NUMBER] turned her call light on again. e. At 7:38 AM, Staff K walked down the hall, peeked into room [ROOM NUMBER], then entered room [ROOM NUMBER] and shut the door. f. At 7:39 AM, Staff J entered room [ROOM NUMBER]. Staff J told the resident she had to get an EZ stand and left the resident's room. Resident council meeting notes revealed the following: a. On 8/8/23, calls (lights) not answered fast, CNA's on the phone. b. On 9/12/23, call lights not answered in a timely manner. c. On 10/9/23, revealed CNA's made residents wait a long time before call (lights) answered. During an interview 11/21/23 at 11:20 AM, Staff P, Unit Manager, reported she expected call lights answered timely within 15 minutes. During an interview 11/21/23 at 12:30 PM, the Administrator reported she expected resident call lights answered as soon as possible, or at least within 15 minutes. A facility policy for Answering the Call Light revised March 2021 revealed a timely response to call lights needed to ensure resident's requests and needs are met. Staff should indicate the approximate time it will take to respond when answering the call light and provide assistance needed. If another staff member required, notify the resident. Ask the nurse supervisor for assistance if unable to fulfill the resident's request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interview, and policy review, the facility failed to ensure a safe, clean, and homelike environment for 2 of 2 nursing units. The facility reported a census of 80 residents. Finding include: Observations on 11/14/23 starting at 1:50 PM revealed the following: a. Missing paint from door frames on rooms 305, 306, 307, 308, 309, 312, 417, 419, 420, 422, 426, 427. b. A panel covering the lower part of the door on rooms [ROOM NUMBERS] was lifted up from the surface of the door, and had a sharp edge. c. The wall in room [ROOM NUMBER] was marred and had scuffed up paint. On 11/14/23 at 2:00 PM, the exit door on the 4th floor had a motorized wheelchair parked in front of it. The motorized wheelchair was plugged into an electrical outlet near the exit door. On 11/15/23 at 1:30 PM, the wall by the resident's bed and the recliner in room [ROOM NUMBER] had missing paint and dry wall showing. The ceiling tiles by the window were discolored and had shades of brown-colored water stains. On 11/16/23 at 12:20 PM, room [ROOM NUMBER] had several holes in the wall near the TV. The wall had a golf ball sized hole with a broken cable plate and cable cords attached, and five round holes (approximately 1 centimeter). The wall by the bed had missing paint and drywall showing. The bathroom floor by the toilet had a black soiled area. At the time, the resident reported the holes in the wall had been there since he moved into the room. The resident reported he had seen mice in his room but it had been awhile ago. Observed he still had 3 mousetraps set up in his room. On 11/16/23 at 12:25 PM, room [ROOM NUMBER] had a large dried puddle of a black liquid debrided under the sink in the bathroom. During an interview 11/21/23 at 11:20 AM, Staff P, Unit Manager, reported the facility recently went through a color selection to upgrade walls and paint certain areas. During an interview 11/21/23 at 12:30 PM, the Administrator reported paint color chosen and they were working on painting areas in the facility, starting on the fourth floor. A facility's policy for Quality of Life-Homelike Environment revised 5/2017 revealed facility staff and management shall maximize the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a safe, clean, comfortable and homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with staff and residents and record review, the facility failed to provide a homelike environment for 3 of 21 residents reviewed (Resident #42, #74 and #52). Two rooms were found to have chipped plaster and holes in the walls. One room had a dirty stained floor in the bathroom. The facility reported a census of 90 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required set up assistance only with help of one staff for transfers, locomotion, toilet use and hygiene. In an observation on 2/1/23 at 10:52 AM, Staff A, housekeeper, pointed out a large hole in the bathroom wall of room [ROOM NUMBER] and a hole on the inside of the bathroom door. Staff A said that the holes had been there for some time. The Housekeeping Supervisor said that she had not been aware of either one of these concerns. She said that she would put in a request to maintenance. On 2/01/23 at 12:08 PM, Resident #42, in room [ROOM NUMBER] said that the hole in the wall happened when his roommate lost his balance and fell a couple of weeks prior. The hole in the door had been there since he was admitted and maintenance had been up to look at it but hadn't yet followed up with repairs. According to the admission tab in the electronic chart, Resident #42 was admitted to the facility in July of 2022. 2) An MDS for Resident #74 dated 11/24/22, showed that he had a BIMS score of 8 (moderate cognitive deficit). The resident required extensive assistance with the help of one staff for bed mobility, transfers, dressing and toilet use. In an observation on 1/30/23 at 12:52 PM Resident #74 was out in the hallway in his wheel chair. An observation of his bathroom found that around the toilet, in the corners, and against the tub the floor was very dirty with dark stains. On 2/01/23 at 10:52 AM Staff A, housekeeper, said they only used Clorox to clean the floors and that was not adequate to clean the stains out of the floors. 3) The MDS dated [DATE] for Resident #52 showed that he had a BIMS score of 9 (moderate cognitive deficits). He required limited assistance with the help of one for transfers and toilet use, and set up only with help of one for eating. During an observation 1/30/23 at 1:08 PM, Resident #52 was laying in bed with the right side of the bed against the wall. It appeared like there could be food spills all along the wall. The wall had large areas of chipped paint and plaster and the resident's bed was up against the wall. On 2/1/23 at 10:50 AM Staff A said that she had notified maintenance about the chips and stains on the walls but she hadn't seen any follow up repairs. On 2/01/23 at 3:15 PM Staff I, maintenance staff, said that he had recently started his position with the facility and had been trying to get things organized, especially with communication. He said that he was aware of the holes in the bathroom of 401 and many areas of chipped plaster and paint. He said that he was trying to prioritize the needs. According to the Maintenance Services Policy dated Dec. 2009 maintenance department is responsible to maintain the building, grounds, and equipment in a safe and operable manner. Functions include maintaining the building in good repair and keeping free from hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family member interview, staff interviews, and facility policy review, the facility failed to make prompt efforts to resolve grievances for 1 of 1 residents reviewed for grievances (Resident #73). Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #73 identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. A resident care conference note dated 8/3/22 at 10:57 am, authored by the Admissions Coordinator/former Social Services Director, documented a Social Services Summary which stated the resident and his son voiced they are still concerned about missing money and a missing wallet. The note further documented the Administrator was aware of the missing wallet and the grievance form had been completed and given to the Administrator. During an interview 1/30/23 at 11:31 am, Resident #73 stated he had a wallet with $200 that went to the laundry and he never got it back. He stated he believed this happened 7 to 8 months earlier. He further stated he had reported this to staff members and expressed concern about having lost his drivers license which was also in the wallet. On 2/1/23 at 12:38 pm, the Administrator stated she had no knowledge of the missing wallet or cash but she would speak with Resident #73. She further stated no grievance had been filed about this matter. During an interview 2/01/23 at 2:48 pm, a family member of Resident #73 stated a report was filed with the facility in regards to the missing wallet. The family member failed to recall an exact date but stated it had been greater than 6 months prior. He further recalled the facility representative who they were in contact with was the current Admissions Coordinator/former Social Services Director. He stated he did not feel anyone even looked for the lost items and the grievance was never resolved. He voiced on the day in question, he and the resident had left the facility together for an outing and the resident had the wallet in his pants pocket. When the resident returned to the facility his pants were taken to the laundry that evening and the wallet was still in the pants pocket. The family member stated in addition to the cash, which he believed to be $210, the wallet also had the resident's driver license and social security card in it. On 2/1/23 at 3:00 pm the Administrator stated she would look for a grievance file related to this incident. On 2/1/23 at 3:04 pm, the Admissions Coordinator/former Social Services Director stated she had completed a grievance regarding the missing wallet and cash. She stated that to her knowledge, the wallet was never found. She stated multiple staff members including the Administrator did look for the wallet. She stated she filled out the grievance form and all notes regarding the investigation were given to the Administrator along with the grievance form. On 2/1/23 at 4:15 pm the Administrator stated she had not had a chance to look for the grievance at that time. She was provided with the date of the care conference note indicating an approximate time frame of the grievance and stated she would look through the grievance log. During an interview 2/01/23 at 4:20 pm, Staff G, Certified Medication Aide, stated she did recall the missing wallet. She stated that she had assisted in searching the resident's room. She further voiced the search included pulling out dresser drawers, looking under and behind furniture and in drawers with other items but the wallet was not found. She stated the missing wallet was definitely reported to management and they were aware of it. A document dated 1/11/22 titled [NAME] Street Services Grievance/Concern Reporting, Investigation and Resolving directs: • All grievances should be handled in a timely fashion, with typical resolution to be sought within 5-7 business days. • Grievances will be maintained for a period of no less than 3 years from the issuance of the resolution. A document dated 3/3/22 titled [NAME] Street Services Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy directs: • All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and employee interview, the facility failed to accurately develop and implement a baseline care plan within 48 hours of a resident's admission which provided the minimum information necessary to care for the resident for 1 of 1 resident reviewed for new admission (Resident #335). The facility reported a census of 90 residents. Findings include: The entry Minimum Data Set (MDS) dated [DATE] reflected Resident #335 admitted to the facility on [DATE]. Review of the baseline care plan for Resident #335, dated 1/27/2023, lacked documentation of the resident being on antibiotics, an anticoagulant or opioid pain medication. It further stated the resident needed no set up or staff assistance for personal hygiene assistance, toileting assistance or transfers and stated he used no assistive device such as a wheelchair or a walker. Review of the order summary for Resident #335 revealed the resident had orders for Apixaban (an anticoagulant), Atovaquone and Cephalexin (both are antibiotics) and Norco (an opioid pain medication), all ordered on the admission date of 1/27/23. On 1/30/23 at 12:44 pm, Resident #335 stated that 2 staff members have been assisting him to transfer from the bed to the wheelchair and he has not been walking. He stated he had come close to falling from the wheelchair during one transfer but the staff was able to stop the fall. On 2/1/23 at 10:29 am, Staff N, Occupational Therapy Assistant stated she was getting the resident ready for therapy but was awaiting a second staff member to assist. She further stated the resident needed two staff members for transfer assistance due to the resident's inability to safely sit upright unassisted. She stated he had displayed a tendency to lean back and not sit upright. The resident then stated that had been an issue for quite some time and he had experienced falls due to this when at home prior to admission. During an observation on 2/1/23 at 10:43 am, two staff members (Staff M, Director of Rehab and Staff N, Occupational Therapy Assistant) completed a transfer from the bed to the wheelchair for Resident #335. Staff N stated she felt a two person staff assist was necessary due to the resident having difficulty maintaining an unassisted sitting position on the side of the bed. The resident stated he had that problem at home prior to admission as well and it resulted in falls at home on more than one occasion. He stated he would sit on the side of the bed and slip to the floor and had to call 911 for assistance to get back up. During an interview 2/1/23 at 1:11 PM, Staff G, Certified Medication Aide (CMA) stated when new residents are admitted , the admissions coordinator fills out a new admit form which states the resident's name, primary diagnosis, if the resident is skilled or long term care and other information. She stated if the transfer status of the resident is known at the time, that is included on the form. She stated otherwise the staff needs to wait for therapy to evaluate a new resident in order to know how to transfer or provide care for the resident. She stated she has no means of accessing the baseline care plan through the electronic health record as a CMA. She can ask a nurse to look it up for her. She stated the normal routine is to learn about a new resident through the admit form or verbally in report or by asking a nurse. On 2/1/23 at 1:44 pm, Staff C, Certified Nurse Aide (CNA) stated she can see the full resident care plan but cannot see the baseline care plan. She stated she would have to ask a nurse to see it. On 2/1/23 at 2:15 pm, Staff J, 4th Floor Assistant Director of Nursing (ADON) stated until the comprehensive care plan is completed, the CNAs have no way of seeing the baseline care plan. She stated they completed shift to shift report and if they have questions they get the information from their nurse or the admission information form. A facility document dated December, 2016, titled Care Plans - Baseline directs: • A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. • The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.

Based on observation, clinical record review, resident and family interviews, and staff interviews, the facility failed to invite &/or allow the resident &/or the resident's representative to participate in the care conference meeting for 2 of 2 residents reviewed (Resident #24 & #39). The facility reported a census of 90 residents. Findings include: 1.The Minimum Data Set (MDS) assessment for Resident #24, dated 1/9/23, identified a BIMS score of 15, which indicated no cognitive impairment. The MDS documented diagnosis that included: renal insufficiency, diabetes, and cerebrovascular accident (CVA). The Care Plan for Resident #24 revised date of 9/21/22, identified the resident & the responsible party chose for the resident to remain at the facility long term. The care plan interventions included: a. Invite the resident, the resident's responsible party, and any resident supports to care conference/discharge planning as indicated. b. The resident and the responsible party preferred to only discuss the topic of returning to the community on the comprehensive assessments. On 1/30/23 at 2:49 PM, during initial tour of the facility, Resident #24 stated she had never had a care conference with the facility staff. Resident #24 stated she/her family had not been to the facility for a care conference. Resident #24's clinical record lacked documentation of a care conference with the resident &/or the resident's representative. On 2/1/23 at 8:42 AM, the MDS Coordinator stated there were times she would be involved in the resident's care conference meetings; however, not always. The MDS Coordinator stated the Admissions Coordinator, the former Social Services (SS), would send out the invitations to the resident's and the responsible party for the care conference. The MDS Coordinator stated the care conference meeting would be documented as an IDT (interdisciplinary team) meeting in the resident's electronic health record (EHR) under the progress notes. The MDS Coordinator stated the facility staff that attended the care conference had to sign-in for recorded attendance. On 2/1/23 at 10:47 AM, the Admissions Coordinator (AC) stated she had previously been in the Social Services position and returned to the Admissions Coordinator position in December 2022. The AC stated she had not received training for the SS position and did not know what the expectations were. The AC stated she had completed care conferences with the residents for a period of time when she was in the SS position, and the care conference meetings would be documented in the resident's EHR. The AC stated care conference meetings were being done in person &/or over the phone. The AC stated the facility did not have a social services position on staff. The AC stated she knew the nursing staff along with Staff J & Staff K were readily available to deal with the resident and family concerns when the facility did not have SS. The AC stated the conversations may not be documented and would not be considered a formal care conference, however, stated the care conferences were being taken care of. The AC stated the facility did not have official care conference due to not all of the facility departments being present. The AC stated she would send invitations out for care conference to the MDS nurse, activities, dietary, wound care, Staff J (4th floor Assistant Director of Nursing) or Staff K (3rd floor Assistant Director of Nursing), therapy, the Administrator, and the Business Office Manager. The AC stated Resident #24's family were difficulty to get a hold of and she had been unable to contact the family. The AC stated she had not documented when she attempted to contact Resident #24's family. The AC stated Resident #24 had request her family be invited to care conference. The AC stated Resident #24 did not have documentation related to a care conference with the resident &/or the family due to being unable to reach the family. The AC stated she had met with Resident #24 to review grievances, however, not an official care conference. The AC confirmed Resident #24 would not have documentation in her EHR related to a care conference or that invitations had been sent out. The AC stated care conference were to be held quarterly when the MDS was due and impromptu as needed. 2. The MDS assessment for Resident #39 dated 12/6/22, listed admission date of 7/28/22. The MDS identified a BIMS score of 6, which indicated severe cognitive impairment. The MDS documented diagnosis that included: congestive heart failure, diabetes, and schizophrenia. The Care Plan for Resident #39 with revised date of 1/4/23, identified the resident & the responsible party chose for the resident to remain at the facility long term. The care plan interventions included: a. Invite the resident, the resident's responsible party, and any resident supports to care conference/discharge planning as indicated. b. The resident and the responsible part preferred to only discuss the topic of returning to the community on the comprehensive assessments. During an interview 1/31/23 at 7:38 AM, Resident #39's responsible party stated when the resident was first admitted to the facility there had been a care conference meeting that had been attended, however, there had not been once since that time. Resident #39's responsible party stated they visited with the facility staff every month when they paid the resident's bill. Resident #39's responsible party stated they visited with SS occasionally, however, had not had a care conference since the resident's admission to the facility. Resident #39's clinical record lacked documentation of a care conference with the resident &/or the resident's representative. On 2/1/23 at 10:49 AM, the AC stated Resident #39 had a care conference with the resident and the responsible party when a concern was identified related to alternate placement for Resident #39. The AC stated the meeting was held with the brother, however, was not a scheduled care conference. The AC stated she did not document the meeting because it was not an official care conference. The AC stated her meeting with Resident #39's responsible party was related to finding the resident alternate placement. The AC confirmed Resident #39 would not have documentation in the EHR related to a care conference or that invitations had been sent out. The AC stated care conferences were to be held quarterly when the MDS was due and impromptu as needed. On 2/1/23 at 2:42 PM, the Administrator stated care conferences were to be completed within 72 hours for new admissions to the facility and then yearly, possibly quarterly. The Administrator stated the facility did not have a SS position and knew the facility was lacking care conference meetings with the residents &/or the residents responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to meet resident needs of personal hygiene and grooming for 1 of 21 residents reviewed (Resident #185). The facility reported a census of 90 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #185 had a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive deficits). The resident required extensive assistance with the help of 1 for transfers, dressing, and toilet use. The care plan dated 1/30/23 showed that Resident #185 was at risk for falls related impaired balance and poor safety awareness. He had diagnoses that include congestive heart failure, type 2 diabetes, lack of coordination, difficulty walking and muscle weakness. On 1/30/23 at 11:54 AM Resident #185 observed in bed on his back. His finger nails were approximately one quarter of an inch long and stained with dirt under the nails. The resident said that he had been asking for weeks to get his nails clipped. According to the bath documentation, the resident had a shower on 1/31/23. The documentation did not indicate that his nails had been cleaned or trimmed. On 2/01/23 at 7:14 AM, Resident #185 observed in bed sleeping and his nails were still long and dirty. On 2/01/23 at 9:56 AM, Staff B, Licensed Practical Nurse (LPN) said that she had offered to file his nails but she thought that the policy was for staff not to clip nails when the resident had a diagnosis of diabetes. On 2/02/23 at 10:28 AM Staff K, Assistant Director of Nursing (ADON) said that the nurses were able to trim the nails of diabetic residents. She said that she would expect them to provide that care as needed and the nail care should be addressed on shower days. A facility policy titled Fingernails/Toenails, Care, dated 2/2018, stated that nail care included daily cleaning and regular trimming.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to only use bed rails after trying other alternatives and explaining the risks and benefits to the resident for 1 of 1 residents reviewed for bed rails (Resident #335). Findings include: The entry Minimum Data Set (MDS) dated [DATE] showed Resident #335 admitted to the facility on [DATE]. The baseline care plan for the resident dated 1/27/2023 directs the resident needed no set up assistance or physical assistance from staff for bed mobility. The side rail assessment dated [DATE] at 3:01 pm, completed by Staff J, 4th floor Assistant Director of Nursing (ADON) revealed documentation that Resident #335 had no side rails on his bed. In an observation on 1/30/23 at 12:44 pm, the resident was noted to have bilateral side rails on his bed. The resident stated the bed rails were in place on the bed when he admitted to the facility. He further stated nobody had asked him if he wanted the side rails and he had not signed a consent for them. In an observation on 2/1/23 at 9:45 am, Resident #335 was seen lying in bed watching television. Both side rails were seen in the raised position. In an observation on 2/1/23 at 10:43 am, Staff M, Director of Rehab and Staff N, Occupational Therapy Assistant assisted the resident to transfer from the bed to the wheelchair. Staff M was observed lowering the side rail on the outside of the bed in order for the resident to sit on the side of the bed for transfer. On 2/1/23 at 2:15 pm, Staff J, 4th floor ADON stated if a resident wants side rails, therapy will assess the resident's need for side rails and they will obtain a physician's order before putting the side rails on the bed. She stated when the side rail assessment is completed on admission, she always documents no side rails. She stated she had no knowledge of any doctor's order or assessment completed for side rails for Resident #335. On 2/2/23 at 10:29 am, Staff M, Director of Rehab stated no side rail assessment or recommendation for use of side rails had been completed for Resident #335. A document dated December, 2007 titled Bed Safety directs: • If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. • The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. • After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed). • Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment for Resident #8, dated 1/9/23, identified a BIMS score of 15, which indicted no cognitive impairment. The MDS listed diagnoses of: quadriplegia and seizure disorder. The MDS identified the use of oxygen (O2) in the last 14 days. The Care plan for Resident #8 with a revised date of 10/16/22, identified the resident with altered respiratory status with the continuous use of oxygen. The care plan interventions included oxygen via nasal cannula (NC) as ordered. On 1/30/23 at 12:48 PM, during initial tour, Resident #8 observed lying in bed with eyes closed. O2 on at 2L/NC. A plastic bag hanging on the oxygen concentrator dated 11/30/22. On 1/31/23 at 8:21 AM, Resident #8 observed lying in bed with O2 on at 2L/NC, with the plastic bag hanging on the oxygen concentrator dated 11/30/22. On 2/1/23 at 2:53 PM, Resident #8 observed lying in bed with O2 on at 2L/NC, the plastic bag hanging on the oxygen concentrator dated 11/30/22 and the oxygen tubing had no date in place. Resident #8 stated the facility used to have a nurse that went around & changed the oxygen tubing weekly, however, that nurse took a different position and no longer changes the oxygen tubing. Resident #8 stated she was not aware of the last time the tubing had been changed, but it had been quite a while. Resident #8 stated it had been over a month since her oxygen tubing was last changed. The facility policy titled Departmental (Respiratory Therapy) Prevention of Infection revised November 2011, stated the purpose of this procedure was to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among the residents and the staff. Infection Control Considerations Related to Oxygen Administration: a. Change the oxygen cannula & tubing every 7 days or as needed b. Keep the oxygen cannula & tubing used as needed in a plastic bag when not in use. On 2/1/23 at 2:47 PM, Staff J the 4th floor Assistant Director of Nursing stated she would expect the oxygen tubing to be changed out weekly. Staff J stated a nurse went around every Sunday to change out the oxygen tubing. Staff J stated the oxygen tubing changes were not in the resident's charting. Staff J stated she would expect the tubing to have tape with a date of when changed. Based on observations, interviews with staff, and policy review the facility failed to implement and follow appropriate infection control practices for 2 of 18 residents reviewed (Resident #184 & Resident #8). The facility reported a census of 90 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE] Resident #184 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). According to a nursing note dated 1/26/23 at 5:24 PM the resident was admitted with a diagnosis of Covid-19 virus and was placed in isolation precautions. Observations of the resident's room revealed the following: a. On 1/31/23 at 7:22 AM Staff E, Certified Nursing Assistant (CNA) put on a gown, N95 mask and gloves. She failed to don eye protection. b. On 1/31/23 at 7:36 AM, Staff B, Licensed Practical Nurse (LPN) came out of resident's room and was not wearing eye protection. c. On 1/31/23 at 8:51 AM Staff F, CNA went into the resident's room without a gown or eye protection. Staff F did not use hand sanitizer after exiting the room. d. On 1/31/23 09:17 AM Staff L, CNA came out of the residents room and was not wearing eye protection. She did not know where the eye protection was kept and said that it was her first time in the room and second day on the job. On 2/02/23 at 10:30 AM, the facility administrator stated that staff are expected to use the appropriate PPE when entering a resident's room that is Covid-19 positive. That PPE is; N95 mask, face shield or goggles, gown, and gloves. A policy titled; Personal Protective Equipment, updated on 10/24/22 stated that while providing care of residents that are suspected or confirmed positive of Covid-19 a gown, gloves, eye protection and N95 masks are required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with staff and residents, and policy review the facility failed to adequately provide pest control throughout the building as evidenced by mice in the resident's rooms. The facility reported a census of 90 residents. Findings include: On 2/01/23 at 11:12 AM Staff A, housekeeper, stated that she had seen mouse droppings in several of the residents rooms especially around the corners of the rooms where there are small holes in the walls. She also said that she had recently seen a mouse caught in a trap in a resident's room. On 2/01/23 at 12:13 PM, Staff D Licensed Practical Nurse (LPN) stated that she had seen several mice. One was in room [ROOM NUMBER] and one in room [ROOM NUMBER] both had been caught in a trap and the sightings had been recent. On 2/01/23 at 3:21 PM, Staff J Assistant Director of Nursing (ADON) stated that they usually had trouble with mice in the winter but the last sighting she knew of had been a few months prior. She said that she hadn't seen any herself and she hadn't seen any droppings. On 2/01/23 at 3:25 PM the facility administrator said that she has been aware of some mice but they had Ecolab Pest Services coming to the building on a regular basis. She said that she hadn't heard about any recent concerns. The previous maintenance manager had been aware of a mouse problem so the staff were making sure there wasn't any food left out and that the meal trays were picked up in a timely fashion. According to the Minimum Data Set (MDS) dated [DATE], Resident #50 had a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive deficit). On 2/01/23 03:28 PM Resident #50 said that he had seen a mouse or two in his room. He saw them running across the floor within the last couple of weeks. He did not remember if he had told anyone about it. On 2/01/23 at 3:15 PM Staff I, Maintenance Assistant stated that he had been very new on the job and was trying to work on lines of communication. He said that he was aware of a mouse problem and knew of at least one hole in the corner of a resident's room that was a point of entry. He said that the pest control service had recommended that they put steel wool in the hole and patch it up but he hadn't gotten that done yet. He said that when he replaced some ceiling tile, he did find mouse tracks and carcasses up in the ceilings but he had no way of knowing how long they had been up there. According to the MDS dated [DATE], Resident #5 had a BIMS score of 15 (intact cognitive ability). On 2/2/23 at 7:15 AM the resident stated that she had just seen a mouse running across the room that morning. She pointed to the corner of the room where there was a sticky trap pad. The pad was very dirty. There was a [NAME] Krispy Bar wrapper on the floor next to her dresser. According to the MDS dated [DATE] Resident #13 had a BIMS score of 15 (intact cognitive ability). On 02/02/23 at 7:17 AM Resident #13 was in her wheel chair and dressed for the day. She had boxes and containers stacked in the corner of the room, along with some empty pop and water bottles on the floor next to her dresser. The resident said that she had just seen a mouse that morning running across the room and it went under her roommates' bed. She said her roommate liked to eat in the room and many times there would be food on the floor. On 2/02/23 at 10:21 AM the service provider for pest control said that he came to the facility on a monthly basis and focused on the main areas of; the kitchen, dining room, showers, utility room, and laundry room. He said that he did not go into resident's rooms unless the staff told him there was a specific problem. He said that the communication with maintenance and staff was the key to getting the best pest control services. The service provider said that the last time he had any communication regarding a problem with mice was in March of 2022. Back then, he caught mice on the 2nd, 3rd, and 4th floors and in the ceiling tile. He said that he recommended back in March that any holes be fixed and blocked to prevent rodent entry. On 2/02/23 at 10:25 AM the Administrator and the Assistant Director of Nursing said that they would follow up on recent mouse sightings and communicate with maintenance. A facility policy titled: Pest Control, dated May of 2008 stated that the facility will maintain an ongoing pest control program to ensure that the building was kept free of insects and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, investigative file review, resident and staff interviews, policy review the facility failed to ensure 1 of 3 resident had a comprehensive care plan (Resident #1) to include his living history, he was a smoker and had a wander guard on. The facility reported a census of 90 residents. Findings include: The admission Minimum Data Set (MDS) assessment tool with a reference date of 9/23/22, documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 11. A BIMS score 11 suggested mild cognitive impairment. The assessment documented he did not exhibit wandering behavior during the 7 day review period and did not utilize a wander or elopement alarm. The MDS documented he was independent for transfers, ambulation and utilized set up help for eating, toilet use and personal hygiene. The MDS listed the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation, malnutrition, Schizophrenia, respirator failure, and coronary artery disease. The Social Services MDS Documentation tool dated 9/19/22 documented Resident #1 was at a homeless shelter prior to his admission. The Social Service Psychosocial History admission Assessment also dated 9/19/22 documented he had lived in a homeless shelter for an unknown length of time. The admission History and Physical (H&P) with a result date of 9/9/22 documented Resident #1 was a current smoker; smoked every day, used tobacco within the last 30 days, smoked five or more cigarettes per day and smoked for 45 years. The H&P also documented he was homeless. The September 2022 Treatment Administration Record (TAR) contained the following order: check placement and function of wander guard every shift with a start date of 9/30/22 and end date of 11/1/22. The Care Plan with a revision date of 10/4/22 failed to document Resident #1 had lived in a homeless shelter prior to his admission, had been a smoker, and wore a wander guard since being admitted to the facility. A progress note dated 10/29/22 at 7:30 PM documented staff found in Resident #1's top dresser drawer the tampered with wander guard and a butter knife. On 11/1/22 at 4:00 PM the Administrator acknowledged that Resident #1 was a previous smoker and they had placed a wander guard so he would not go outside to smoke. She added residents are not allowed to smoke on facility grounds. A follow-up interview on 11/3/22 at 10:12 AM the Administrator indicated they had placed the wander guard on Resident #1 on 9/30/22. On 11/2/22 at 9:07 AM C [NAME] Licensed Practical Nurse (LPN) indicated Resident #1 had a wander guard and had heard he had cut it off a few times On 11/2/22 at 10:11 AM Staff A Certified Nursing Assistant (CNA) indicated she had asked the nurse if Resident #1 had a wander guard on and they told her he took it off. She was unsure if he had one before he eloped. On 11/2/22 at 10:26 AM Staff B stated she did not remember if Resident #1 had a wander guard on but knew he was supposed to wear one. On 11/2/22 at 12:52 PM the Interim Director of Nursing (DON)/4th Floor Unit Manager indicated they did put a wander guard on Resident #1 as a cautionary thing because he was asking about smoking when he came to the facility. Staff were nervous about him going out to smoke of grounds, since residents were not permitted to smoke on the property. A follow-up interview on 11/8/22 at 12:10 PM she was informed that Resident #1's care plan did not include the use of a wander guard, his history of being a smoker and being homeless. She stated it all should have been on the care plan. The Comprehensive Assessments and the Care Delivery Process Policy revised December 2016 indicated comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.

Based on observations, record review, investigative file reviews, facility video footage review, resident and staff interviews the facility failed to provide the appropriate supervision for 2 of 4 residents (Resident #1 and Resident #2) reviewed for adequate nursing supervision. The facility reported a census of 90 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment tool with a reference date of 9/23/22, documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 11. A BIMS score 11 suggested mild cognitive impairment. The assessment documented he did not exhibit wandering behavior during the 7 day review period and did not utilize a wander or elopement alarm. The MDS documented he was independent for transfers, ambulation and utilized set up help for eating, toilet use and personal hygiene. The MDS listed the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation, malnutrition, Schizophrenia, respirator failure, and coronary artery disease. The Care Plan with a revision date of 10/4/22 documented Resident #1 was independent for bed mobility, ambulation, toileting, transfers, dressing and undressing. Observations on 11/1/22 at 1:35 PM at the front entrance of the facility revealed a red stop sign on the door that stated stop, press button before opening door. At the bottom of the stop sign was a white arrow pointing to the right to a silver box with a red button. Individuals prepped the button and were able to walk out of the building, once exiting a second door. There were no alarms or key pads on the elevators. The Progress Noted dated 10/29/22 at 10:14 AM Staff C Licensed Practical Nurse (LPN) went in to Resident #1's room to give him his morning medications between 9:00 AM and 10:00 AM, observed him not in his room. A head count was conducted and the resident was not in the facility. All perimeters were checked, no door alarms sounding. At 12:07 PM Resident #1 was not visualized in the facility. On 11/1/22 at 12:30 PM Resident #1 stated he went for a walk outside of the facility. When asked if he left the building through the main entrance he stated yes. On 11/1/22 at 2:10 PM Staff D Certified Nursing Assistant (CNA)/Scheduler stated she usually sat at the desk at the front entrance. She indicated she sits there Monday through Friday from about 8:00 AM until 6:00 PM, depending on her down and what needs done. When asked who sits at the desk during the weekends, she stated no one. She added the front door is monitored through cameras on the 3rd and 4th floors of the building. She added the 3rd floor has a speaker where visitors can speak to staff before being allowed in the building. The monitors on those two floors are located next to the elevators. In order to leave the facility, one must push the red button first. If that button is not pushed, an alarm would sound. Review of the camera footage on 11/1/22 at 4:00 PM with the Administrator revealed on 10/29/22 at 9:13 AM Resident #1 sat in a chair by the front entrance of the facility, looking out the window. At 9:14 AM Resident #1 pushed the red button to the left of the main entrance door and walked out the first door, clapped his hands and then exited out the second door before being outside of the facility. On 11/2/22 at 9:07 AM Staff C Licensed Practical Nurse (LPN) stated the front entrance door is not observed by someone at the front desk on the weekend. If someone wants in the facility, they are to ring the door bell that goes to a speaker on the 3rd floor. There is an intercom system up there, staff ask why they are at the facility. The staff will push a button and the door unlocks. If someone wanted to leave the facility, they know they need to push the button to exit. If they do not push the button an alarm will sound. On 11/1/22 at 4:00 PM the Administrator stated they started to have someone sitting at the front desk to assist with COVID-19 screening then just had the scheduler remain at the front desk. Staff D is there during the week from about 8:00 AM to 6:00 PM. On the weekends if visitors want to enter the facility they have to push the speaker button to talk with staff on the 4th floor. Staff will determine what they need then let them in. To leave the building they need to push the red button next to the door. There are video monitors located on the 3rd and 4th floors next to the elevators, so that staff can view who is at the door at all times. If the visitors do not press that push to exit and alarm will sound. On 11/2/22 at 2:25 PM the Interim Director of Nursing (DON)/4th Floor Unit Manager was asked what if a resident was cognitively intact, no a risk for elopement, develops a urinary tract infection and became confused, goes to the front entrance without letting staff know, reads the sign and walks out. How would staff know they were gone? She stated they would know if they went in to administer medications or provide cares and the resident was not in their room. She added staff can look at the camera monitors on the 3rd and 4th floors by the elevators to see if anyone is at the door. When made aware that it is pretty easy to get out of the facility if someone knows how to read and follow instructions, she stated she did not think this was set up to be a nursing home. If someone were to set off the alarm at the front door on the weekends, someone from the 2nd, 3rd, or 4th floor would have to come down to physically reset the alarm and by then who knows where the resident(s) may be. When brought to her attention that anyone that can see that stop sign and figure out how to get out of her, she stated she did not think of that until now. She added she's not sure if there needs to be a code on the door or what. 2. The admission Minimum Data Set (MDS) assessment tool with a reference date of 10/18/22 documented Resident #2 BIMS score of 14. A BIMS score of 14 suggested no cognitive impairment. The BIMS indicated she required extensive assistance of two staff for transfers, required assistance of two staff for toilet use and assistance of one staff for personal hygiene. The MDS listed the following diagnoses: COPD, heart failure, anxiety, schizophrenia, and post traumatic syndrome disease. The Care Plan with a date initiated of 10/19/22 encouraged staff to assist Resident #2 with Activities of Daily Living (ADL's) and provide with comfort measures as indicated. The Progress Note on 10/30/22 at 11:19 AM documented a Certified Nursing Assistant (CNA) went in to Resident #2's room at 3:00 AM for bedlinen, brief check and noted all were dry. Her oxygen cannula was properly in her nares and she appeared to be resting comfortably. Review of the video footage on the hall that Resident #2 resided on 11/1/22 at 4:11 PM with the Administrator revealed Staff F Registered Nurse (RN) went in do the resident's room on 10/30/22 at 12:47 AM and walked right back out. Staff did not enter Resident #2's room until 5:32 AM when Staff E walked in to her room. The video footage revealed Resident #2 was not checked on from 12:47 AM until 5:32 AM. The Administrator verified staff did not go in to Resident #2's room from 12:47 AM until 5:32 AM. On 11/3/22 at 10:41 AM Staff E CNA stated she last saw Resident #2 at 3:00 AM because she went in her room to check on her. When asked how often residents are checked on during the overnight shift, she stated on their rounds every 2 hours. When asked where Resident #2's bed was in the room, she stated by the window across the room, with the head of her bed facing the window away from the entrance door. On 11/3/22 at 12:06 PM Staff G CNA stated residents are to be checked on every 2 hours or when answering their call lights. Most of the independent residents share a room with residents that they would check on frequently, so they would check on the independent residents as well. On 11/8/22 at 12:14 PM the Interim Director or Nursing (DON)/4th Floor Unit Manager indicated staff are to do rounds on every single resident that are on the assigned staff halls, every 2 hours. She had heard that the video footage indicated the resident had not been checked on at 3:00 AM like the CNA reported.

Based on record review, facility investigative file review, video footage review, staff interviews and facility policy review the facility failed maintain a complete and accurate record for 1 of 1 residents (Resident #2) reviewed. The facility reported a census of 90 residents. Findings include: The admission Minimum Data Set (MDS) assessment tool with a reference date of 10/18/22 documented Resident #2 BIMS score of 14. A BIMS score of 14 suggested no cognitive impairment. The BIMS indicated she required extensive assistance of two staff for transfers, required assistance of two staff for toilet use and assistance of one staff for personal hygiene. The MDS listed the following diagnoses: COPD, heart failure, anxiety, schizophrenia, and post traumatic syndrome disease. The Care Plan with a date initiated of 10/19/22 encouraged staff to assist Resident #2 with Activities of Daily Living (ADL's) and provide with comfort measures as indicated. The Progress Note on 10/30/22 at 11:19 AM documented a Certified Nursing Assistant (CNA) went in to Resident #2's room at 3:00 AM for bedlinen, brief check and noted all were dry. Her oxygen cannula was properly in her nares and she appeared to be resting comfortably. Review of the video footage on the hall that Resident #2 resided on 11/1/22 at 4:11 PM with the Administrator revealed Staff F Registered Nurse (RN) went in do the resident's room on 10/30/22 at 12:47 AM and walked right back out. Staff did not enter Resident #2's room until 5:32 AM when Staff E walked in to her room. The video footage revealed Resident #2 was not checked on from 12:47 AM until 5:32 AM. The Administrator verified staff did not go in to Resident #2's room from 12:47 AM until 5:32 AM. On 11/3/22 at 10:41 AM Staff E CNA stated she last saw Resident #2 at 3:00 AM because she went in her room to check on her. Staff E was made aware of the video footage documenting staff did not go in Resident #2's room at 3:00 AM; no one went in her room from 12:47 AM-5:32 AM. Staff E stated that is weird that the video did not have her or Staff F going in Resident #2's room during that timeframe. All Staff E would say is hmmm, are you sure you did not see me go in her room at 3:00 AM. She was informed the Administrator reviewed the footage as well and verified no staff member in to the resident's room during that time. When asked how often residents are checked on during the overnight shift, she stated on their rounds every 2 hours. When asked where Resident #2's bed was in the room, she stated by the window across the room, with the head of her bed facing the window away from the entrance door. On 11/3/22 at 12:06 PM Staff G CNA stated residents are to be checked on every 2 hours or when answering their call lights. Most of the independent residents share a room with residents that they would check on frequently, so they would check on the independent residents as well. On 11/8/22 at 12:14 PM the Interim Director or Nursing (DON)/4th Floor Unit Manager indicated staff are to do rounds on every single resident that are on the assigned staff halls, every 2 hours. She had heard that the video footage indicated the resident had not been checked on at 3:00 AM like the CNA reported. The facility's policy titled Charting and Documentation revised in July 2017 indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.