**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to incorporate recommendations from the PASRR (Pre-admission Screening and Resident Review) Level II Determination into the Care Plan for 2 of 3 residents reviewed (Residents #10 and Resident #52). The facility reported a census of 57 residents.Findings include:1.The Minimum Data Set (MDS) dated [DATE] identified Resident #10 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 14 out of 15, and had the following diagnoses: Seizure Disorder/Epilepsy, Depression, Bipolar Disorder and Schizophrenia. Daily observations of Resident #10 on July 21, 22, 23, 24 revealed he was well groomed, wearing clean clothing and shoes and did not display any behaviors that would require staff interventions.Review of an assessment of PASRR compliance report dated 4/16/25 revealed Resident #10 had a Level II Outcome dated 3/10/25. The Clinical Reviewer Assessment section revealed the facility was noncompliant with disability specific specialized services, rehabilitative services, and community placement supports. The report noted the facility lacked multiple required components of Resident #10's Care Plan. 2. The MDS dated [DATE] identified Resident #52 as cognitively intact with a BIMS of 15 and had the following diagnoses: Diabetes Mellitus, Anxiety Disorder, Depression and Post Traumatic Stress Disorder.Multiple observations of Resident #52 daily on July 21, 22, 23, 24 and 28 revealed she was tearful and upset over the events that have occurred recently, ie: Care Plan changed to require staff to provide cares in pairs and being sent out to the Emergency Department for an evaluation.Review of an assessment of PASRR compliance report dated 3/19/25 revealed Resident #52 had a Level II Outcome dated 12/19/24. The Clinical Reviewer Assessment section revealed the facility was noncompliant with disability specific specialized services, rehabilitative services, and community placement supports. The report noted the facility lacked multiple required components of Resident #52's Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility policy review the facility failed to update the Care Plan after a new mental health diagnosis for 1 of 4 residents reviewed (Resident#2). The facility reported a census of 57 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE], list of diagnoses for Resident #2 included Post Traumatic Stress Disorder (PTSD) and anxiety.Review of the Medical Diagnosis list in the electronic health record for Resident#2 revealed a diagnosis of PTSD, date 5/11/2023. Review of the Pre-admission Screening & Resident Review (PASRR) dated 7/11/24, revealed a diagnoses of PTSD.The Care Plan for Resident #2, revised date of 6/20/25, failed to reflect the updated PASRR, and address the diagnosis of PTSD. Review of the Trauma Informed Intake assessment dated [DATE], directed review or update the Trauma Care Plan. During an interview on 07/30/25 at 9:33 AM, the MDS Coordinator reported Resident#2 did not know her PTSD triggers, as a result the facility lacked the information to put in the Care Plan. She reported the facility did not have a policy that directed what to put on the Care Plan. The MDS Coordinator reported she followed the Resident Assessment Instrument (RAI).During an interview on 07/30/2025 at10:49 AM, the Director of Nursing (DON) reported she expected a diagnosis of PTSD to be addressed on the Care Plan.The facility provided a policy titled Goals and Objectives, Care Plans dated 4/09. The policy directed goals and objectives are reviewed and/or revised:a. When there has been a significant change in the resident's condition;b. When the desired outcome has not been achieved;c. When the resident has been readmitted to the facility from a hospital/ rehabilitation stay; andd. At least quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and facility policy review the facility failed to respond to call lights in a timely manner for 2 out of 10 residents reviewed (Resident # 2 and Resident #51). The facility reported a census of 57 residents.Finding include:1. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a list of diagnosis for Resident #2 which included heart failure, and anxiety disorder. The Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicated cognition intact. The MDS identified Resident #2 dependent for transfers to bed and chair, and dependent with toileting hygiene. Review of the Care Plan, dated 9/8/22, identified Resident #2 dependent and required the assist of 1 staff with toileting and the assist of 2 staff for transferring in and out of bed. The Care Plan further identified the resident needed the substantial assist of 1 staff for personal hygiene, and bed mobility.During an interview on 7/21/25 at 2:48 PM, Resident #2 stated staff can take up to 30 minutes to get her call light before and after meals. She said between 11 AM to 2 PM is when it happens the most, and on the weekends. She stated the staff failed to explain to her why staff took so long to get her call lights.2. Review of the MDS assessment dated [DATE], revealed a list of diagnoses for Resident #51 which included heart failure, cancer, and high blood pressure. The BIMS score of 13 out of 15 indicated intact cognition. The MDS identified Resident #51 as dependent on staff with toileting transfers and toileting hygiene. Review of the Care Plan, dated 4/25/25, identified Resident #51 as non-ambulatory, dependent on the assist of 2 staff for toileting and transfers. The Care Plan directed the assist of 1 staff for personal hygiene. During an interview on 07/30/2025 at 9:22 AM, Staff L, Certified Nurse Assistant (CNA) stated staff need to get to the call lights in 15 minutes. She revealed at times residents reported call lights took longer than 15 minutes. She stated never on her hall. During an interview on 7/22/25 at 8:42 AM, Resident #51 stated it can take 40 minutes to an hour for staff to come get his light and help him after lunch. He stated he's been incontinent due to waiting so long for help. Resident #51 explained he felt frustrated and upset after the incontinence because of the waiting. He stated the staff told him they were busy helping others, and doing the best they could. During an interview on 07/30/2025 at 10:49 AM, the Director of Nursing reported she expected the call lights answered in 15 minutes. During an interview on 07/30/2025 at 11:13 AM, the Administrator confirmed she knew residents complained of long call light times. She reported she's filled out grievances for long call light times and she does audits. Review of a Resident Council Meeting note dated 5/22/25, revealed a concern of the CNAs took a while to answer the call lights. Review of the facility policy titled Answering the Call Light dated 3/2021, identified the purpose of this procedure is to ensure timely responses to the resident's requests and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, the facility failed to ensure ongoing care planning to address a resident's behavioral health needs, including timely implementation of a Crisis Intervention/Safety Plan per Preadmission Screening and Resident Review (PASRR) recommendation for 1 of 1 resident reviewed for behavioral healthcare (Resident #52). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #52 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15, and had the following diagnoses: diabetes mellitus, anxiety disorder, depression, and post traumatic stress disorder. The MDS also identified Resident #52 had little interest or pleasure in doing things several days over the past two weeks, and did not respond when asked if feeling depressed or hopeless. Per the MDS, the resident sometimes felt lonely and isolated from those around her. The Care Plan initiated 1/6/23 and revised on 3/13/24 revealed the following for Resident #52: I have a history of using attention seeking behaviors. I have a history of suicidal ideations, with no active plan. The care plan interventions included the following: a. I have been noted to have issues staying on topic when discussing things I don't want to discuss (Initiated 3/14/23, revised 3/13/24). b. I refuse care on occasion, so cares in pairs is recommended (Initiated 3/3/23, revised 5/2/23). c. I will not have any items in my room that I could harm myself with while on suicidal precautions. Suicidal precautions will remain until cleared by a physician (Initiated 1/6/23, revised 3/13/24).d. I write myself notes to remind myself of self-affirmations (Initiated 1/6/23). e. My counselor from [Behavioral Health Services Provider] (counselor)/[Name Redacted] (Psychiatrist) will continue to attempt to talk to me, despite me refusing at times. (Initiated 1/6/23, revised 3/14/23).Additional Care Plan interventions included the following: f. I refuse to talk to [Behavioral Health Services Provider] counselor. I am going to get an appointment with [Name Redacted] (Initiated 1/6/23, revised 12/9/24).g.I wear a rubber band on my wrist and will snap it. This helps me manage my mental health more independently. (Initiated 12/6/24).The Encounter Note for psychiatric follow up dated 12/5/24 at 12:00 AM, revealed the resident was seen for an acute visit due to an increase in agitation and self-harm. The note further revealed, It has been noted that she has been punching herself in the chest, scratching her arms and slapping her face. She also has some suicidal ideation with no specific plan at this time.[Resident #52] also states that she has called the suicide hotline over 5 times and they have not been able to help her. She is not currently seeing a therapist. Does report being severely depressed and anxious. [Resident #52] also tells me that she has a butter knife that was kept off of her room tray and is having ideations of continuous self-harm. Order given to the facility to facility to send to ED (Emergency Department) for further evaluation and treatment due to the acuity of the situation and residents inability to remain safe or make safe decisions at this time.The Encounter Note further revealed Resident #52 had disorganized thought process, poor insight, suicidal ideation with means, and current self harming behaviors. Recommendations to address depression included, in part, regularly observing the patient's behavior and emotional state to detect any changes or signs of improvement, and to implement safety protocols to prevent self-harm or harm to others, especially if the patient was at risk of suicide. The Behavior Note dated 12/5/24 3:30 PM revealed, in part, Resident #52 has called the suicide hotline 5 times this week. She has held a knife back from her tray and has been punching and slapping herself. The psych provider gave an order to be evaluated and treated at the hospital. A Nurses Note dated 12/5/24 at 6:15 PM indicated Resident #52 returned from the hospital, and was currently one on one (one on one supervision).The Progress Note dated 12/6/24 at 12:00 AM note by Psychiatric Nurse Practitioner reported resident seen in person for acute suicidal ideation, behaviors, and actions. The Progress Note further revealed, today, staff reports that the patient is continuing her self-harm behaviors and suicidal threats. Behaviors include punching herself in the chest, scratching skin to excoriation and bleeding, and slapping herself. Additionally staff reported finding additional knives and forks in her room (removed by staff) that the patient had previous stated she would use for self-harm. Upon in-person interview today by this Provider, patient is found to be despairing and tearful. She verbalizes that I am bad and need to be punished. Patient is seen to be continuously scratching her arms, causing open wounds. When asked if she is aware of scratching herself, she shakes her head as if to indicate no and does not respond verbally. When asked questions, her verbal response is delayed, halting, and agitated. When she provides no responses. Her mood is despondent, frustrated, and downcast; her affect is consistent with mood. [Resident #52] continues to state that she does not want to live. She (Resident #52) also newly endorses intermittent auditory and visual hallucinations. In the judgement of this Provider, patient at this point continues to pose an imminent threat to self and potentially to staff and other residents.The Progress Note dated 12/6/24 at 12:00 AM further revealed a recommendation by the provider for resident's transfer to the ED, noted resident refused transport to the ED, and emergency medical services (EMS) were unable to transport the resident due to lack of consent. The resident remained on one-to-one staffing, and was seen by the Nurse Practitioner (NP) with cognitive behavioral therapy provided. Per the Progress Note, Resident #52 provided with a homework exercise in which she (Resident #52) verbally replaced negative self-statements with positive ones when they occurred, was provided lotion to apply to arms instead of scratching, with staff education completed on the plan.The Focused Evaluation Note dated 12/7/24 at 9:38 AM revealed, in part, Resident does have flat affect majority of the time. Does have a monotone voice, lacks eye contact and has little facial expressions.Resident states she is doing better and currently has no desire to self harm or to end life. Resident states she did have a plan for suicide, would not tell nurse what that entailed. The Social Services Note dated 12/10/24 at 9:16 AM revealed notification made that the resident was taken off one to one the night before.Review of a clinical reviewer assessment of Resident #52's PASRR revealed the following Level II Outcome Date: 12/19/24. The review identified noncompliance as the review outcome. The Rationale section revealed the facility was noncompliant in development of a Crisis Intervention/Safety Plan, developed by the facility in conjunction with the individual and behavioral health providers.Review of Resident #52's Care Plan revealed the resident did not have a PASRR care plan focus area until 12/24/24. One of the goals of the PASRR focus area included the following: Development by the nursing facility in conjunction with the individual and behavioral health providers of a Crisis Intervention/Safety Plan to identify triggers and symptoms, best methods for management of challenges, and action steps to be taken by all parties in order to reduce risk of hospitalization. Interventions to address this goal were not present on the resident's Care Plan until revision (date initiated 12/24/24, revised on 4/30/25). The Social Services Note dated 3/14/25 at 12:43 PM revealed the resident was given some positive adult coloring pages for the weekend, were going to utilize a notebook for communication between [resident and staff] to build trust, and Crisis Plan worksheet had been provided to the resident the day prior, and Crisis Plan scanned into [Electronic Health Record].The PHQ 2 to 9 Evaluation Note (depression screening tool) dated 5/1/25 at 3:46 PM revealed the resident had little interest or pleasure in doing things, with a frequency of 2 to 6 days, as well as feeling down, depressed, or hopeless for 2 to 6 days.On 7/21/25 at 11:47 AM Resident #52 sat in her wheelchair in her room, reported conflict with staff, and explained things had been getting a lot worse this week because of the way she was treated. The resident explained she had Post Traumatic Stress Disorder (PTSD) due to depression and anxiety, and began to cry. Resident #52 reported the Social Worker had come in and asked how long she had refused her medications as she had not heard anything about it.On 7/23/25 at 11:38 AM, Staff C, NP queried if Resident #52 had ever reported to them that resident felt suicidal, and queried as to what expected staff to do when resident voiced that. Staff C responded they did not take care of that part of it when the resident was taken to the emergency room (ER) in December, and could not remember what happened that led to the resident feeling suicidal in December. Staff C explained they did not know the exact protocol, check room for harmful objects, and someone check on her every 15 minutes. Per Staff C, this was not the first time the resident had suicidal ideations, and explained the first time she met the resident, the resident voiced that she could kill herself using the cord to the call light. Staff C explained there was another NP that specialized in psychiatric services that no longer treated the resident, and now another NP treated the resident's psychiatric needs. Per Staff C, the resident had been refusing her medications, and there had been a point two weeks ago that she stopped taking all of her medications except for Tylenol (pain medication) and Hydrocodone (narcotic pain medication). On 7/23/25 at 3:45 PM, Staff D, Licensed Practical Nurse (LPN) queried if ever heard Resident #52 talk about committing suicide, and responded no. When queried as to the last time the resident called the suicide hotline, Staff D responded was not aware that she had called. When queried if police or ambulance had ever come to check on the resident or were called to the facility, Staff D responded they did not think so, not to check on her. Staff D further explained, in part, they did not know anything about the incident the resident was sent to hospital for in December.On 7/23/25 at 4:17 PM, Staff F, Certified Nurse Aide (CNA) reported that Resident #52 had not said she wanted to kill herself, but over the past month, kept saying, I don't want to be here. Staff F denied knowledge the resident called the suicide hotline, and was unsure if the police or ambulance had ever come to check on the resident/were called to the facility. When queried as to what should happen if the resident had suicidal behavior, Staff F responded there should be one on ones with resident, was not sure how often to document resident's behavior, and would report to the nurse, who would notify the Director of Nursing (DON). On 7/24/25 at 9:19 AM, the Social Services Coordinator (SSD) reported, in part, the resident had not talked about wanting to kill herself recently, and she believed the last time the resident was sent out to the emergency room was the end of last year due to being a threat to herself. Per the SSD, the resident had scratches on one of her arm, from wrist to about five inches. When queried as to what interventions were in place to address the resident's suicidal ideations, the SDD reported the resident had a crisis plan that she wrote up herself, that was included in the resident's care plan. When queried who was responsible for monitoring the resident's behavior, the SSD responded the nurses were responsible every shift, and for Resident #52, that would be any changes, any behaviors, refusing medications, refusing to sign out, resident crying, and remarks to staff. The SSD also explained they knew the resident had called the crisis/suicide hotline because someone from the corporate office sent them the voice mail from the hotline nimber that she called. Per the SSD, the message was played, which requested follow up on a call regarding Resident #52. When the call was returned, the response provided was person was not there at that time, and the SSD explained the all was made last week. Per the SSD, they were not aware that any follow up was done on that phone call, and were not sure who was responsible for the follow-up. The SSD queried if the resident's therapist was made aware that the resident called the crisis hotline, and responded no. The SSD acknowledged calling the hotline was in the resident's plan of care. On 7/24/25 at 12:35 PM, the facility's Administrator queried if the resident had called the suicide hotline, and how she had found out the resident did. The Administrator acknowledged they were aware she called the crisis hotline, and got a message from central intake department, and listened to the message from the crisis hotline just recently (past week). Per the Administrator, the message was that had a patient who called, and requested a call back to get surrounding details. The Administrator explained they returned the call, and the person who answered could not give any information. The Administrator explained it was a patient at their facility, and needed more information. Additional information was not provided. The Administrator requested a call back, and had not heard back. The Administrator explained went to Resident #52's room, asked if she called the crisis line, the resident said she did, and said she just needed to talk to somebody. The resident said had already talked to someone and was fine. On 7/29/25 at 1:07 PM, Staff G, LPN reported the MDS Coordinator was responsible for adding PASRR recommendations to the Care Plan.In an interview on 7/30/25 at 9:35 AM, the DON reported when reports from [PASRR] arrived to the facility, they were sent to the Business Office Manager and the SSD, and they were responsible to follow up on areas identified as non-compliant.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to prime an insulin pen prior to 2 of 2 observations for insulin administration (Resident #25). The facility reported a census of 57 residents. Findings include: Review of the Minimum Data Set assessment, dated 7/10/25 revealed a list of diagnoses for Resident #25 which included diabetes mellitus, renal insufficiency, and osteomyelitis (infection of bone) to the right ankle and foot. The Brief Interview for Mental Status score of 13 out of 15 indicated intact cognition. The MDS identified Resident #25 had orders for insulin (a hypoglycemic medication used to lower blood sugars) to be administered at least daily.A review of the July 2025 Medication Administration Record revealed the following orders:a. NovoLOG Solution 100 UNIT/ML (unit per milliliter) (Insulin Aspart) Inject 2 units subcutaneously three times a day .Start date: 7/18/25. b. Tresiba FlexTouch Subcutaneously Solution Pen-Injector 200 UNIT/ML (Insulin Degludec) Inject 10 units subcutaneously one time a day .Start date: 7/19/25.During an observation on 7/22/25 at 7:26 AM, Staff G, Licensed Practical Nurse removed 2 insulin pens from the medication cart. Staff G placed a new needle on the Novolog pen (dated as opened 7/8/25) and dialed to 2 units; and on the Tresiba pen (dated as opened 7/21/25) and dialed to 10 units. Staff G did not prime needles prior to administering both insulins.During an interview on 7/23/25 at 2:00 PM, the Director of Nursing reported she would expect the nurse to prime the needle after putting on the insulin pen with 2 units and waste the 2 units.During an interview on 7/29/25 at 1:07 PM, Staff G, LPN reported when administering insulin from a pen, she should prime the pen with 2 units. She thought she primed the needles when she administered the insulins to Resident #25 during the observation on 7/22/25 at 7:26 AM. A review of the facility policy titled: Insulin Administration, last revised September 2014, Insulin Delivery section directed, in part: The forms of insulin delivery include: 3. Pens - containing insulin cartridges deliver insulin subcutaneously through a needle.The Steps in the Procedure section (Insulin Injections via Syringe) did not provide direction on the use of Pen to deliver insulin.

Based on observation, review of kitchen staff training records, and staff interviews the facility failed to prepare pureed foods under safe and sanitary conditions during 1 of 2 kitchen observations. The facility reported a census of 57 residents.Findings include:During an observation on 7/22/2025 at 8:23 AM, Staff A, [NAME] started the puree process for lunch. She stated she would make 4 servings of puree for 2 residents and wanted a pudding consistency. Staff A placed 12 ounces of turkey and turkey gravy in the machine, added additional gravy from a pan, and blended. She used a measuring cup to determine scoop size and transferred the pureed turkey into a holding pan and set it on another counter. She used a dry cloth to wipe the prep surface and the side of the puree machine. There was not a sanitizer bucket or spray on the counter or near the puree machine. Staff A did not wash her hands.At 8:30 AM, Staff A poured the peas from a holding pan into the puree canister. She wiped the counter again with the dry rag, smearing turkey from the rag back onto the counter where she wiped away a few mashed peas. When the peas were pureed, Staff A measured them and poured them into a clean holding pan and set them on the counter next to the turkey. She wiped the puree machine and food prep surface with the same dry cloth she used before. She did not sanitize the counter or wash her hands. She then wiped her right hand on the side of her shirt, picked up the rag, and wiped at the counter one more time.At 8:38 AM, Staff A reported she was done with puree because the bananas needed for lunch did not come on the truck. Staff B, Certified Dietary Manager (CDM), stated he was going to get them since she was done. When asked why she did not puree the bread on the menu, Staff A stated she was not thinking on that and forgot. She stated she should have done it with the meat. She was not able to describe what her process should be next and asked the Regional Dietary Manager (RDM) if she could add the bread to the meat. The RDM stated she could and would have to remeasure the total for a correct scoop size. Staff A said forget it. When asked what she would do if the Regional Dietary Manager and surveyor were not present, Staff A stated she would skip it (pureeing the bread). The RDM told her to puree the bread. Staff A did not wash her hands, and put gloves on to pick up the bread. She took off the gloves and did not wash her hands. She wiped the prep surface with the same dry rag used earlier to clean up spilled gravy she added to the bread, which smeared mashed peas and turkey back on to the surface. The surface was not sanitized. Staff A did not tap down the bread and gravy mixture in the measuring cup and indicated they needed a size 12 scoop. The RDM corrected Staff A and told her that the scoop should be a 16 scoop to make sure the residents had the right amount. At the end of the observation turkey, gravy, and peas were noted on the prep surface and the puree machine. The pureed food remained in the holding containers on the counter.During an interview on 7/22/25 at 8:49 AM, the CDM and RDM acknowledged Staff A did not sanitize the prep surface between foods or wash her hands properly during the puree process. The RDM indicated all staff were trained on these topics when they started. The CDM stated she should have washed her hands between food items and after removing her gloves. He reported that staff needed education, it was better to be safe than sorry, and he would start from the beginning. He stated Staff A needed to review filling and using the sanitizer bucket, keeping it near to her, sanitizing between foods prepped, how to store foods, tapping down the puree for accurate measurement, and proper use of the puree chart. A document titled Course Completion History printed 7/21/25 documented Staff A completed the following Kitchen related training:a. An Overview of Safe Eating and Drinking on 1/21/25;b. Customer Service in Dining Rooms on 1/23/25;c. Dry Storage on 1/23/25; d. Food Safety Fundamentals on 1/27/25; e. Handling Food Safely Part 1 on 1/27/25f. Handling Food Safely Part 2 on 1/27/25; g. Setting up the Steam Table on 1/27/25; h. Using a 3 Compartment Sink on 1/27/25; i. Using the Dishwasher on 1/27/25. During an interview on 7/23/25 at 9:29 AM, the CDM stated he started staff re-education. A document titled Five Minute Meeting for Employees dated 7/22/25 documented topics that included the puree process, washing hands, added bread, measuring cups, sanitizing, and temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview and facility document review the facility failed to use enhanced barrier precaution (EBP) and keep resident catheter tubing off the floor for 1 out of 2 residents reviewed (Resident #2). The Facility reported a census of 57 residents.Finding include:Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a list of diagnosis for Resident #2 which included neurogenic bladder (loss of control due to nerve damage) heart failure, and anxiety disorder. The Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicated cognition intact. The MDS identified Resident #2 dependent for transfers to bed and chair, and dependent with toileting hygiene. Review of the Care Plan, dated 9/8/22, revealed a Focus area for Resident #2 to address the use of a urostomy (a specific type of urinary system to collect urine outside of the body through tubing to a collection bag, may be referred to in general terms as a urinary catheter) due to bladder dysfunction with a goal to remain free of infection. Interventions included, in part: Use of enhanced barrier precautions. During an observation on 7/21/25 at 2:50 PM, a sign noted to be placed on Resident #2's bedroom door. The sign directed the use of Enhanced Barrier Precautions, which included: Everyone must: Wear gloves and a gown for the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring Changing Linens, Providing Hygiene Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressingDuring an observation on 07/22/2025 at 10:40 AM, after a group activity, Resident #2 wheeled herself through the facility while approximately 2 inches of her urostomy tubing drug on the floor under her wheelchair.During an interview on 07/24/2025 10:58 AM, Staff J, Certified Nurse Aid (CNA) said they needed to empty Resident #2's catheter (urostomy collection bag for urine) bag. Both CNA's put on the gowns, and gloves (EBP) transferred Resident #2 from her wheelchair and placed her in the bed. Staff J, removed her gloves and gown, completed hand hygiene applied gloves, gathered the supplies to empty the urinary drainage bag. Staff J, placed a plastic barrier on the floor, she set the graduate on top of the plastic barrier, unhooked the drain spout to empty the urine drainage bag in the graduate used the alcohol swab to clean the tip. The urine filled to the top of the graduate 1000 cubic centimeters (cc). Staff J, dumped the urine into the toilet and rinsed out the graduate. Staff J, failed to wear the gown during the high contact care.During an interview on 07/24/2025 at 11:07 AM, Staff J, CNA reported the EBP were needed because of the catheter (urostomy) and the wounds. During an interview on 07/29/2025 at 10:49 AM, the Director of Nursing (DON) reported staff needed the EBP if a resident required a tube feeding, a port, dialysis, a chronic wound and catheters. The DON reported she expected urinary catheter tubing kept off the floor. During an interview on 7/30/25 at 9:22 AM Staff L, CNA reported if nursing staff see catheter tubing on the floor they are expected to pick it up and adjust the tubing so it doesn't touch the floor.Review of the facility policy titled Enhanced Barrier Precautions dated 3/28/24, revealed it is the policy of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of multidrug-resistant organisms.EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.An order for EBP (in accordance with physician-approved standing orders) will be initiated for residents with any of the following:Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO.Review of the facility policy titled Infection Prevention and Control Program dated 10/2018, revealed an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policies and procedures reflect the current infection prevention and control standards of practice.

Based on staff interview, facility policy review and review of the Summary Statement of Deficiencies of previous surveys, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies. The facility reported s census of 57 residents.Review of the Statement of Deficiencies for a Recertification and Complaint Survey completed on 7/15/24, revealed the deficiencies identified included F657 (Care Plan Timing and Revision), F725 (Sufficient Nursing Staff), F812 (Food Procurement, Store/Prepare/ Serve-Sanitary), and F880 (Infection Control). The Recertification and Complaint Survey completed on 7/30/25, identified repeat deficient practices for: F657, F725, F812, and F880. During an interview on 07/30/2025 at 11:03 AM, the Administrator reported the facility worked on all the previously cited deficiencies in the Quality Assurance Performance Improvement (QAPI).The Facility provided a policy titled Quality Assurance and Performance Improvement (QAPI) Program dated march 2020, included the responsibilities of the QAPI Committee are to:a. Collect and analyze performance indicator data and other information;b. Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services;c. Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process;d. Utilize root cause analysis to help identify where identified problems point to underlying systematic problems;e. Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care;f. Establish benchmarks and goals by which to measure performance improvement;g. Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; andh. Communicate all phases of the QAPI process to the Administrator and governing body through sharing meeting minutes, committee activities and results of QAPI activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews, staff interviews, and policy review the facility failed to treat residents with dignity and respect for 2 of 6 residents reviewed for dignity (Residents #36 and #214). The facility reported a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #36, dated 4/5/24 documented a Brief Interview for Mental Status (BIMS) of 15 out of 15, which indicated intact cognition. The MDS reflected diagnoses of diabetes mellitus, morbid obesity, and need for assistance with personal care. The MDS indicated Resident #36 was dependent for toileting and transfers, and required partial to moderate assistance for sitting to lying and lying to sitting. The resident's Care Plan included a focus area dated 10/6/23 related to activities of daily living (ADL), with a goal to continue to participate during ADLs and an intervention required assist of 2 staff with toileting. A focus area dated 10/13/22 indicated the resident experienced incontinence. These focus areas lacked documentation of the urinal as an intervention and the resident's request for staff assistance with it. A document titled Documentation Survey Report v2, dated 07/11/24 at 7:48 AM, revealed the resident had incontinence episodes during the day shift July 4, 5, and 10. On 07/09/24 at 09:19 AM observed the resident lying in bed with the TV on and a urinal next to him. He stated he kept it close most of the time in case he needed it but sometimes forgot to make sure it was there. He indicated he could use it himself, but when he did not feel well it was better to have help. He mentioned about a week ago he put on his call light for help. He waited well over an hour around breakfast time. When he finally went his output was several hundred milliliters and he had been uncomfortable. He stated mornings between 6:00 AM and 8:00 AM were usually the longest wait times, and sometimes after lunch. Resident #36 described another incident where he had urinated on himself when he could not hold it any longer and described urine ending up on his stomach and legs, the bed, and the floor. He said he had put his call light on that morning, and it was 3 hours before anyone came (TV as a time reference). He reported a certified nursing assistant (CNA) told him the call light system must not be working because it was not on in the hallway. The resident recalled another time he had an accident in the morning and it was 5-6 hours and after lunch before his sheets were changed. He revealed it was embarrassing and uncomfortable to have to sit like that and just wait. On 07/09/24 at 1:40 PM Staff B, Certified Nursing Assistant, stated the resident had reported long call lights and she was aware of at least one incident where he had an accident from staff not getting there fast enough. She stated he could use the urinal alone, but she understood that it might be harder if his blood sugars were low or he did not feel well. Staff B also noted urinal was sometimes hanging on a garbage can out of the resident's reach. A policy titled Answering the Call Light, revised March 2021, documented staff should be sure that call light was plugged in and functioning at all times. It further indicated staff were expected to document any significant requests or complaints made by the resident and how the request or complaint was addressed. An interview with the Administrator on 7/10/24 at 8:05 AM determined audits are conducted every weekend. She was not aware of any documented call light complaints. She also stated Resident #36 could use the urinal himself. An interview with the Director of Nursing 7/10/24 at 8:16 AM revealed residents had spoken to her about call lights. She stated the staff were very busy and the population of the facility was younger with more needs. She was not aware of documented complaints. On 7/10/24 at 2:19 PM the Maintenance Supervisor stated he was in the building once per week, and the last couple of times he was in the building there were issues reported to him about call lights not working that he had to fix. He stated he didn't know how to run a call light report with this system and didn't think they even could. 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #214 with moderate cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 11 and had the following diagnoses: Peripheral Vascular Disease, Diabetes Mellitus and Hip Fracture. The MDS also identified Resident #214 required partial/moderate staff assistance with transfers from bed to chair and required supervision with toilet transfers. On 7/1/24, the Care Plan identified Resident #214 with the problem of a right hip fracture related to fall at home and directed staff to anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Observations on 7/8/24 which began at 4:00 PM revealed the following. 4:00 PM, the [NAME] at the end of C hall showed the call light on for Resident #214's room, surveyor observed during medication pass on C hall. 4:05 PM, assessment unchanged 4:10 PM assessment unchanged 4:14 PM Resident #214 in her room, observed sitting at the edge of her bed. Staff G, CNA exited another resident's room pushed a mechanical lift and walked by Resident #214's room and did not check on Resident #214. 4:15 PM the [NAME] at the end of the A hall showed room Resident #214's call light was still on and had been on for 15 minutes 4:17 PM, the [NAME] now showed the call light to Resident #214's room had been answered. The call light had been on for 16 minutes. In an observation and interview on 7/10/24 at 2:39 PM, Resident #214 had clock in her room that was easily visible from her bed. Resident #214 reported she has had accidents waiting for help to the bathroom which made her feel awful like a child pooping in her pants. Resident #214 reported this usually happens 2 to 3 times a week usually on night shift which she felt was embarrassing and degrading. Resident #214 also reported she was not supposed to get up by herself to go to the bathroom and thought it was ridiculous that she had to wait so long until she ends up soiling herself. In an interview on 7/11/24 at 7:52 AM, the Assistant Director of Nursing (ADON) reported no residents had reported bouts of incontinence waiting for assistance to the bathroom and that she would expect staff to answer call lights within 15 minutes. A review of the facility policy titled: Resident Rights dated as last reviewed September 2016 had documentation that resident shall be treated with respect, kindness and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interview, the facility failed to notify family of changes in the resident's condition for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #5 with moderate cognitive impairment with a BIMS (Brief Interview for Mental Status) of 10 and had the following diagnoses: Renal Insufficiency (a kidney impairment), Diabetes Mellitus, and Urinary Tract Infection. The MDS also identified Resident #5 had been totally dependent on staff for assistance with all transfers and toileting. In an interview on 7/8/24 at 2:01 PM, Resident #5's family member reported the following: a. Family notification has been a chronic problem for years. She had asked the DON (Director of Nursing) about it and she reported she would find out who is not documenting it. b. Someone from the facility had left a message that she had a fractured ankle which happened 6/29/24 which may have been caused by a transfer using a mechanical lift. c. On 7/2/24 they sent her to the hospital for an x-ray and that they would have her see an orthopedic doctor after that. No one ever called after she had the x-rays and saw the Orthopedic doctor. She called the Director of Nursing (DON) the next day and the DON said the x-ray showed an old fracture. d. When the family member asked the DON what date the incident occurred, she checked the records and found that it happened on 6/28/24. The Care Plan dated as last reviewed 5/28/24 did not direct staff to notify family with any changes in the resident's condition or medications, etc. A review of the Progress Notes revealed the following: 6/28/24 at 3:15 PM The Resident complained of right ankle pain and rated at a 8 (on the pain scale). Her right ankle was swollen with two purple bruises. Upper bruise measured 3.3 mm (millimeters) long and 6.6 mm wide. The lower bruise measured 3.5 mm long and 4.3 mm. wide. Resident stated that she was being assisted for a transfer on the EZ-stand when her ankle slipped off the stand. Resident states this happened yesterday 6/27/24. This nurse asked the CNA if this happened on her shift she reported that it did not and resident already had a bruise there yesterday. Administered Tylenol and called the Nurse Practitioner. Orders received for an x-ray of the right ankle, scheduled Tylenol 650 mg (milligrams) QID (four times daily) for 10 days and Voltaren gel 4 Grams QID. Biotech to come today. 6/28/2024 15:17 POA (Power of Attorney) aware of right ankle pain and new orders. No comments or concerns at this time. 7/2/2024 14:36 Call placed to the Orthopedic Doctor and said orders received for an appointment for an x-ray of the right ankle and to see the orthopedic doctor. The notes did not show documentation to show the family had been notified of the x-ray results or the visit with the Orthopedic Doctor. A review of the E-interact forms showing family notification revealed the last form completed was dated 5/21/24. A review of the facility policy titled: Change in a Resident's Condition or Status dated as last revised February 2021 had documentation of the following: Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. there is a significant change in the resident's physical, mental, or psychosocial status; c. there is a need to change the resident's room assignment; d. a decision has been made to discharge the resident from the facility; and/or e. it is necessary to transfer the resident to a hospital/treatment center. f. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. In an interview on 7/11/24 at 7:52 AM, the ADON (Assistant Director of Nursing) reported the following: a. She would expect the nurse to notify the family as soon as it occurs with any medication change, falls even without injuries, transfers out to the hospital. b. This should be documented in the Progress Note or E-interact note under Evaluations In an interview on 7/11/24 at 12:15 PM, Staff I, RN reported the following: a. The nurse should notify the family as soon as there is any falls, medication change, change of status, transfer to the hospital. b. This should be documented in the Progress Notes. In an interview on 7/12/24 at 9:32 AM, Staff H, RN reported If there are any changes in condition and changes in medication, etc. this should be called to family, and documented in the electronic record either in the incident report or a Progress Note. Family should be notified as soon as the change occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility records, resident interviews, and staff interviews the facility failed to maintain a homelike environment related to musty urine odors in common areas and stains on hallway carpets. The B wing was noted by Resident #27 to have more odor during humid days. The facility reported a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #27 dated 4/5/24 documented a Brief Interview for Mental Status (BIMS) of 15 out of 15, which indicated intact cognition. The clinical record documented Resident #27 resided in the B hallway in room [ROOM NUMBER]. On 07/09/24 at 01:09 PM observed this resident seated in the common area at the end of the B hallway watching television. He made a slight grimace and shook his head. When asked if he was okay, the resident described a musty smell, maybe urine, but he wasn't sure. The resident revealed this was not the first time he had smelled the same odor. He said it was worse when it was humid in the building. On 07/09/24 at 01:10 PM observed 6 visible stains on the carpet between the common area and the resident's room from approximately golf ball sized to about 6 inches by 3 inches. The stains were darker than the carpet and involved unknown substances that appeared ground into the fibers. An additional observation of this hallway and hallway A on 07/11/24 at 11:59 AM revealed a milky white stain approximately 8 inches long, matted stained carpet going into 9 different rooms, and a reddish brown 4 inch by 3 inch stain that clumped the carpet fibers together. An interview with the Administrator on 7/10/24 at 8:05 AM determined housekeeping shampooed carpets until a full time maintenance person could be hired. She was not aware of the schedule for cleaning the carpets. During room visits on 7/10/24 at 2:01 PM noted a strong, musty type of odor in the B hallway by the common area TV, pop machine, and snack machines. An interview with the Maintenance Supervisor on 7/11/24 at 11:58 AM revealed carpets were spot cleaned by the facility between deep cleanings twice a year by a contracted provider. He acknowledged they were past due for a deep cleaning. He was not aware of the odor concern in the B hallway.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to update the Care Plans for 2 of 2 residents reviewed after changes in care occurred (Residents #5 and #14). The facility reported a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #5 with moderate cognitive impairment with a BIMS (Brief Interview for Mental Status) of 10 and had the following diagnoses: Renal Insufficiency (a kidney impairment), Diabetes Mellitus and Urinary Tract Infection. The MDS also identified Resident #5 had been totally dependent on staff for assistance with all transfers and toileting. In an interview on 7/8/24 at 2:01 PM, Resident #5's family member reported the facility called on 6/29/24 to inform them that Resident #5 had a fractured ankle. She was later sent to the hospital on 7/2/24 to get another x-ray and see an orthopedic doctor. The doctor said the plastic brace placed on her was to be temporary over the weekend. A review of the Progress Notes revealed the following: 6/28/24 3:15 PM The Resident complained of right ankle pain and rated at a 8 (on the pain scale). Her right ankle was swollen with two purple bruises. Upper bruise measured 3.3 mm x 6.6 mm. Lower bruise 3.5 mm x 4.3 mm. Resident stated that she was being assisted for a transfer on the EZ-stand when her ankle slipped off the stand. Resident states this happened yesterday 6/27/24. This nurse asked the CNA if this happened on her shift she reported that it did not and resident already had a bruise there yesterday. Administered Tylenol and called the nurse practitioner. Orders received for an x-ray of the right ankle, scheduled Tylenol 650 mg (milligrams) QID (four times daily) for 10 days and Voltaren gel 4 Grams QID. A review of the Physician Orders revealed the following: 6/29/24 Non Weight Bearing status every shift. 6/29/24 CAM BOOT right ankle/foot every day and evening shift for right ankle fracture. 7/3/24 Open brace to check skin every shift. 7/3/24 Follow up appointment with orthopedic doctor on July 16, 2024 at 1:45 PM. On 11/01/17, the Care Plan identified Resident #5 with the problem of being at risk for falls and dated as reviewed last 6/30/23 and no new interventions added after the incident occurred 6/28/24. 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #14 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Heart Failure, Renal Insufficiency, and COPD (Chronic Obstructive Pulmonary Disease) The MDS also identified Resident #14 to be dependent on staff assistance with putting on and taking off footwear, transfers from chair to bed, and from sitting to standing. A review of the nurse practitioner Progress Notes dated 3/25/24 had documentation of the following: On 3/22/24, a pressure ulcer noted to the left lateral lower leg which measured 4.6 cm (centimeters) long, 2.2 cm wide and no depth. No signs of infection or drainage noted. On 3/22/24, a pressure ulcer noted to the right lateral lower leg which measured 5.1 cm long, and 3 cm wide and no depth. On the surface of her leg with 1.2 cm long and 1.4 cm wide and no depth area of eschar and surrounding erythema and warmth and inflammation, mild yellow drainage on the bandage. A review of the Treatment Administration Records revealed the following orders: 4/4/24 Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to right, left outer leg topically one time a day for pressure wound clean area with wound cleaners then Santyl border. 4/10/24 Heel protectors on at all times, every shift for protection 5/24/24 Wound care to Left and Right lateral lower legs: clean wounds with soap and water, pat dry with gauze, apply Prisma (cut to fit wound) to wound beds, lightly dampen Prisma with Normal Saline, cover with Mepilex border dressing 3 times a week and PRN (as needed) for dressing dislodgement or soiling. Resident aware of new wound care orders and will tell family. every day shift every Monday, Wednesday, Friday for wound care both legs. 6/21/24 clean the right and the left bilateral leg with Vashe and and apply thin hydrocolloid to the area and change every 3 days and PRN if falls off, one time a day every Monday, Wednesday, Friday for wounds. 6/27/24 To bilateral calves: cleanse wounds well with Vashe, apply calcium alginate AG to open areas. cover with bordered foam dressing. Once lymphedema therapy starts change on lymphedema days, every day shift for wound care 7/11/24 Vashe Cleansing External Solution (Wound Cleansers) Apply to Bilateral calfs topically every day shift for wound care To bilateral calves: cleanse wounds well with Vashe, apply Medihoney to open areas. cover with bordered foam dressing. Once lymphedema therapy starts change on lymphedema days. On 7/30/20, the Care Plan identified Resident #14 with the problem of being at risk for developing pressure ulcers. It did not include the new pressure ulcers identified 3/22/24 or include new interventions ordered. In an interview on 7/11/24 at 7:52 AM, the ADON reported the following: a. If a resident develops a pressure ulcer, she would expect to have that added to the Care Plan. b. The MDS Coordinator is responsible for updating Care Plans, however, any nurse can update the Care Plans. c. She could not explain why Resident #14's Care Plan was not updated when her pressure ulcers developed. A review of the policy titled: Care Plan and Care Plan Conference dated as last revised 4/1/24 had documentation of the following: Resident care plans must be updated immediately when there is: a. Change in ADL status b. Risk Management Incident/Accident/Unusual Occurrence c. Falls d. Adding/removing devices (alarms/wander guards)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to document an assessment for 1 of 2 residents sent to the hospital (Resident #5). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #5 with moderate cognitive impairment with a BIMS (Brief Interview for Mental Status) of 10 and had the following diagnoses: Renal Insufficiency (a kidney impairment), Diabetes Mellitus, and Urinary Tract Infection. The MDS also identified Resident #5 had been totally dependent on staff for assistance with all transfers and toileting. In an observation on 7/8/24 at 10:53 AM, Resident #5 sat up in her wheelchair in her room, with an open brace to her right foot and both feet on a foot buddy on the foot pedals of her wheelchair. Resident #5 reported when the staff pushed her in her wheelchair 2 weeks ago, her right foot slid off the foot pedal and got caught underneath the pedal and she fractured her right ankle. In an interview on 7/8/24 at 2:01 PM, Resident 5's family member reported Resident #5 fell on 6/29/24 and the facility informed her that she had a fractured ankle. When asked how it happened, they said it may have been due to the mechanical lift out of the wheelchair. On 7/2/24 they sent her to the hospital for an x-ray and that they would have her see an Orthopedic Doctor after that. The Director of Nursing (DON) reported the fracture was an old fracture. A review of the Progress Notes revealed the following: 6/28/24 at 3:15 PM, Resident #5 complained of right ankle pain which she rated at a 8 (out of 10) on the pain scale. Her right ankle appeared swollen with two purple bruises. Upper bruise measures 3.3 mm x 6.6 mm. Lower bruise 3.5 mm x 4.3 mm. Resident #5 stated that she was being assisted for a transfer on the EZ-stand when her ankle slipped off the stand. Resident states this happened yesterday 6/27/24. 7/2/24 2:29 PM Call placed to the son who wanted her sent to the Hospital Emergency Room. 7/2/224 2:36 PM Call placed to Orthopedic Physician and orders received for an x-ray at of the right ankle and bring to the Orthopedic Physician's office . Resident #5 was not hospitalized . However, the Progress Note did not include documentation of an assessment of the right ankle and foot prior to being sent out. In an interview on 7/12/24 at 9:32 AM, Staff H, RN reported before she was sent to the hospital on 7/2/24, the nurse should have documented an assessment of the resident. A review of the facility policy titled: Acute Condition Changes, dated as last revised September 2017 had documentation of the following: Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the physician will authorize transfer to an acute hospital, Emergency Room, or another appropriate setting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family and staff interview, the facility failed to prevent an incident with injury for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #5 with moderate cognitive impairment with a BIMS (Brief Interview for Mental Status) of 10 and had the following diagnoses: Renal Insufficiency (a kidney impairment), Diabetes Mellitus and Urinary Tract Infection. The MDS also identified Resident #5 had been totally dependent on staff for assistance with all transfers and toileting. In an interview on 7/8/24 at 2:01, Resident #5's family member reported that the facility called and said Resident #5 fractured her ankle on 6/29/24. The doctor had been notified and orders for Tramadol (pain medication). When asked how it happened, they said it may have been due to the mechanical lift of the wheelchair. On 7/2/24, they sent her to the hospital for an X-ray and to see an Orthopedic Doctor after that. She called the DON (Director of Nursing) and said the bruise to her ankle was an old fracture. The Doctor had ordered a brace for her right foot. The Care Plan identified Resident #5 as being at risk for falls on 11/1/2017 and directed staff to encourage her to use the call light for assistance and refer her to Physical Therapy for evaluations as needed. A review of the Incident Report dated 6/28/24 at 3:01 PM had documentation of the following: Resident #5 complained of right ankle pain and rated at a 8 on the pain scale. Her right ankle was swollen with two purple bruises. Resident #5 stated on 6/27/24, she was being assisted for a transfer on the EZ stand when her ankle slipped off the stand. A review of the nurse's Progress Notes revealed the following: 6/28/24 3:15 PM Resident #5 Complained of right ankle pain and rated at a 8 on the pain scale. Her right ankle was swollen with two purple bruises. Resident #5 stated on 6/27/24, she was being assisted for a transfer on the EZ stand when her ankle slipped off the stand. 6/30/24 12:11 PM Received a written statement from Staff K, CNA on this day 6/30/24 which documentation of the following: On the 26th or 27th, Resident #5 was being pushed down the hall in her chair and as she was being pushed she took her foot off the pedal and her foot got stuck under her wheelchair. She kept taking her foot off while being pushed even after several reminders to keep feet up if being pushed. A review of the Physician Orders revealed the following: 6/29/24 Non-Weight Bearing status. 6/29/24 CAM boot right ankle/foot every day and evening shift for right ankle fracture. 7/3/24 Open brace to check skin every shift. 7/3/24 Follow up appointment with orthopedics on July 16 at 1:45 PM to evaluate right ankle. A review of the emergency room Physician Notes dated 7/2/24 had documentation of the following: [AGE] year-old female presents to the emergency department via EMS for evaluation of leg pain. Patient reports that she has an appointment with Orthopedic Doctor to evaluate ongoing right ankle pain. She reports that she re-injured the ankle and requests repeat x-rays for further evaluation. She denies any right knee pain or right hip pain. X-rays of the right foot showed diffuse severe osteopenia. No evident fracture, dislocation, or other bony abnormality. In an interview on 7/11/24 at 8:27 AM, Staff K, CNA reported the following: a. When asked how she would transport a resident in a wheelchair, she would make sure both feet are up on foot pedals. b. When asked what happened when Resident #5 had the incident with her foot in the wheelchair, she reported another CNA pushed Resident #5 in the wheelchair in the hallway. She could not recall the name of the CNA. Resident #5 somehow got her foot caught under the foot pedal of the wheelchair. c. She could not recall if Resident #5 had any injuries or fractures. She had heard a week later that she had a broken foot or broken ankle. Someone said it happened when she was transferred from the EZ stand. In an interview on 7/11/24 at 10:55 AM, Staff J, Nurse Practitioner reported the following: a. She was notified the Monday after the incident that there was swelling to Resident #5's right ankle. At that time, they did not how it happened. b. She asked Resident #5 what happened and she said when they transferred her from her wheelchair to the toilet using the EZ stand and her foot slipped off the EZ stand platform. c. There was a questionable fracture on the Biotech X-ray. Staff J was not working that day. The nurse notified the on-call Physician who ordered a brace for it and did an orthopedic referral. She went to orthopedics and had repeat X-rays done, Staff J did not know what the results of that X-ray were. In an interview on 7/11/24 at 11:19 AM, Staff M, CNA reported when asked how she would transport a resident in a wheelchair, she reported she should place both feet on the foot pedals. That the foot pedals are on the wheelchair, feet should be on the pedals. She could not recall what happened when Resident #5 had the incident with her right ankle. In an interview on 7/11/24 at 11:30 AM, Staff N, CNA/CMA reported when she transports a resident in the wheelchair, she would make sure both feet are on the foot pedals. She could not recall what happened when Resident #5 had the incident with her right ankle. In an interview on 7/11/24 at 11:45 AM, Staff O, CNA reported she could not recall what happened when Resident #5 had the incident with her right ankle. When asked about the incident Resident #5 had with her right ankle, she reported she was working that hallway when she reported that her foot was hurting her. Resident #5 said it happened when her foot fell off a pedal of the wheelchair. And her right foot folded over and got caught under the foot pedal. She said this had happened two days before and she could not remember what happened. A review of the facility policy titled: Falls - Clinical Protocol dated as last revised March 2018 had documentation of the following: The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to utilize the proper infection control techniques during wound care for 1 of 2 residents (Resident #14). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #14 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Heart Failure, Renal Insufficiency and COPD (Chronic Obstructive Pulmonary Disease) The MDS also identified Resident #14 to be dependent on staff with assistance with putting on and taking off footwear, transfers from chair to bed and from sitting to standing. On 7/30/20, the Care Plan identified Resident #14 with the problem of being at risk for pressure ulcers and has an open areas on her right shin. The Care Plan did not identify Resident #14 developed pressure ulcers to both outer calves. On 3/25/24, the Care Plan directed staff to teach her the risk factors for development of pressure ulcers. In an observation of wound care on 7/10/24 8:32 AM Staff H, LPN had donned an isolation gown and gloves, removed the soiled dressing from the wound to Resident #14's left calf area. Staff H cleansed the wound using the correct technique, then picked up the scissors with same gloves and left the scissors in the Calcium Alginate packet which had already been opened. Then Staff H changed gloves and did not disinfect the scissors (after she had picked them up with previous gloves) and cut the Calcium Alginate dressing and placed the dressing on to wound to left calf then covered with Mepilex Border Flex Lite dressing. The wound appeared to have a small necrotic area to the top of the wound, however, no signs of infection noted to the surrounding skin. 7/10/24 at 8:39 AM Staff H then used the correct technique to cleanse the wound to the right outer calf, however, she did not disinfect the scissors before she cut the Calcium Alginate dressing. Staff H placed the dressing onto the wound. The wound to the right calf did not have any necrotic areas or any redness to surrounding skin. A review of the Progress Notes revealed the following: 03/25/24 New wounds which opened up 4 days ago. The nurse called stating she has a new blister on her leg that popped up rather quickly and large, she has had these blisters before. She has no feeling on these aspects of her legs, with history of neuropathy. Her blisters seem to be where her wheelchair rubs with the footrest bars. Does have chronic edema issues, this has been slowly worsening with time, but no worse today than last week. The wound to the left outer leg On 3/22/24 the wound was 4.6 cm (centimeters) long, 2.2 cm wide and had no depth. No signs of infection (no odor or purulence, inflammation or surrounding erythema or undue warmth). The wound to the right outer leg On 3/22/2024, the wound was 5.1 cm long, 3.0 cm long and had no depth. There was surrounding erythema and warmth and inflammation, mild yellow drainage on the bandage. In an interview on 7/10/24 at 10:25 AM, the DON (Director of Nursing) reported that she would expect the nurse during wound cares to change gloves anytime they are going from dirty to clean. For example if they take dirty bandages off, take off gloves and do hand hygiene and then new gloves. And any time they are soiled. Scissors- definitely when they come out of the room. They should sanitize in between if using scissors going from a dirty bandage to a clean bandage. In an interview on 7/11/24 at 7:52 AM, the ADON (Assistant Director of Nursing) reported when providing wound care, she would expect the nurse to change her gloves any time she soils them and disinfect the scissors any time they get soiled or prior to and after using. In an interview on 7/11/24 at 12:15 PM, Staff I, RN reported when providing wound care the nurse should change her gloves any time they get soiled and they should disinfect the scissors after each use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) assessment for Resident #36, dated 4/5/24 documented a Brief Interview for Mental Status (BIMS) of 15/15, which indicated intact cognition. The MDS reflected diagnoses of diabetes mellitus, morbid obesity, and need for assistance with personal care. The MDS indicated Resident #36 was dependent for toileting and transfers, and required partial to moderate assistance for sitting to lying and lying to sitting. The resident's Care Plan included a focus area dated 10/6/23 related to activities of daily living (ADL), with a goal to continue to participate during ADLs and an intervention required assist of 2 staff with toileting. A focus area dated 10/13/22 indicated the resident experienced incontinence. These focus areas lacked documentation of the urinal as an intervention and the resident's request for staff assistance with it. A document titled Documentation Survey Report v2, dated 07/11/24 at 7:48 AM, revealed the resident had incontinence episodes during the day shift July 4, 5, and 10. On 07/09/24 at 09:19 AM observed the resident lying in bed with a urinal next to him and the TV on. He stated he kept it close most of the time in case he needed it but sometimes forgot to make sure it was there. He indicated he could use it himself, but when he did not feel well it was better to have help. Resident #36 stated he had urinated on himself in the past when he could not hold it any longer and described urine ending up on his stomach and legs, the bed, and the floor. He said he put his call light on the morning that happened, and it was 3 hours before anyone came (TV as a time reference). He reported a certified nursing assistant (CNA) told him the call light system must not be working because it was not on in the hallway. The resident could not confirm if the light had been repaired. On 07/09/24 at 1:40 PM Staff B, CNA, stated the resident had reported long call lights and she was aware of at least one incident where he 'had an accident' when staff did not get there in time to provide assistance. She stated he could use the urinal alone, but she understood it might be harder if his blood sugars were low or he did not feel well. Staff B added the resident sometimes left the urinal hanging on a garbage can out of his reach and would need help getting it. An interview with the Administrator on 7/10/24 at 8:05 AM determined audits are conducted every weekend. She was not aware of any documented call light complaints. She also stated Resident #36 could use the urinal himself. An interview with the Director of Nursing 7/10/24 at 8:16 AM revealed residents had spoken to her about call lights. She stated the staff were very busy and the population of the facility was younger with more needs. She was not aware of documented complaints. On 7/10/24 at 2:19 PM the Maintenance Supervisor stated he was in the building once per week, and the last couple of times he was in the building there were issues with call lights not working. He stated he didn't know how to run a call light report with this system and didn't think they even could. A policy titled Answering the Call Light, revised March 2021, documented staff should be sure that call light was plugged in and functioning at all times. Based on observation, record review, resident and staff interview, the facility failed to repair call lights for 2 of 2 residents (Residents #28 and #36). The facility reported a census of 58 residents. Findings include: 1. The MDS dated [DATE] identified Resident #28 as cognitively intact with a BIMS of 15 and had the following diagnoses: Diabetes Mellitus, Bipolar Disorder, and Right Below the Knee Amputation. The MDS also identified Resident #28 was completely dependent on staff for assistance with toileting, showers, putting on and taking off footwear, lower body dressing, and personal hygiene. In an interview on 7/9/24 7:41 AM, Resident #28 reported when asked if staff answer his call light timely, he stated when his call light works. The call light will not work properly and this happens at least once a month. The longest he has had to wait to get his call light answered is 3 hours. When asked if he had reported the problem to anyone, he stated the CNAs knew about it when he told them it didn't work, he assumed they would tell the maintenance supervisor. In an interview on 7/10/24 at 2:13 PM, the Maintenance Supervisor reported the following: a. When asked if he worked full time at the facility, he reported he worked full time at another facility and tries to come to this facility once a week. b. He had trained the last 2 maintenance supervisors, and both were terminated. c. When asked how he is notified of any repairs that need to be completed, he reported there is a book that the staff will write down what repairs need to be done. When it's done it gets crossed off. They're not always good about filling out the form. Sometimes they will verbally tell me when I am here. When I come in, I will check the book first thing in the morning and before I leave. d. When asked if work orders were recorded when completed, he reported the work orders stay in the book and after he completed the orders, he crossed it off as completed and initial it. e. When asked if he had been notified of any problems with call lights not working, he reported he had been notified of some the last few times he was at the facility and repaired them before he left for the day. f. He had not been aware of the call light for Resident #28's room not functioning. On 7/10/24 at 2:31 PM, the Maintenance Supervisor returned and reported he looked at the call light for Resident #28 and it appeared to be working fine. He also reported there was a problem with the wrong room numbers showed up on the [NAME] and he repaired that today. The housekeeper had called the previous Maintenance Supervisor and he told her the transmitter has 2 wires that gets hooked up to where the call light plugs in. There is a wireless transmitter in the wall. The current Maintenance Supervisor reported he took care of that problem today because the housekeeper hooked it up wrong. In an interview on 7/11/24 at 11:19 AM, Staff M, CNA reported if a resident reports their call light isn't working, she would report it to the charge nurse, then to the maintenance supervisor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, resident interviews, and policy review the facility failed to follow Physician's Orders when administering insulin for 4 of 4 residents reviewed for diabetes mellitus medication administration (Residents #4, #36, #56, and #60). The facility reported a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #36, dated 4/5/24 documented a Brief Interview for Mental Status (BIMS) of 15/15, which indicated intact cognition. The MDS reflected diagnoses of diabetes mellitus, morbid obesity, and need for assistance with personal care. The assessment indicated Resident #36 was dependent on staff for toileting and transfers, and required partial to moderate assistance for sitting to lying and lying to sitting. The resident's Care Plan included a focus area dated 1/11/23 which documented the resident had diabetes mellitus with interventions to take diabetes medication as ordered by doctor, and to monitor for and document side effects and effectiveness. On 07/09/24 at 09:19 AM Resident #36 stated his medications were 'messed up' a lot, and that he missed his Ozempic altogether on 7/6/24. He stated they seemed short staffed and that someone told him his medication had been thrown away by mistake. He thought they reordered it but he wasn't sure, and he had not heard anything more about it. The resident stated his insulin was often late, and he sometimes received his breakfast insulin closer to lunch. A document titled Medication Administration Record for July 2024 documented the resident did not receive his scheduled semaglutide (1 mg/dose) by solution pen-injector 4 mg/3 ml (Ozempic) on 7/6/24 as scheduled. The electronic health record entry was not checked and included a number 9, which indicated there was an associated Progress Note. A Progress Note dated 7/6/2024 at 12:58 PM indicated the resident's medication was not available, and staff requested for pharmacy to send the medication. It noted the facility was awaiting delivery. As of 7/10/24 no follow up documentation was in the electronic health record. On 7/11/24 at 8:59 AM Certified Medication Aide, Staff F, confirmed the resident did not receive his semaglutide over the weekend and that some of his medications have been late. She stated the medication was requested 7/6/24 and it had not been received. A document titled Location Administration Report, dated 07/09/24 at 11:19 AM, revealed that between 7/1/24 and 7/9/24 Resident #36 received the following medications outside of the allowed one hour administration window 33 out of 43 times; Insulin Lispro Injection Solution, Insulin Lispro Solution 100 UNIT/ML, and Insulin NPH (Human) (Isophane) Subcutaneous Suspension 100 UNIT/ML. 15 of those injections were over 2 hours late, with the longest gap documented as a 7:00 AM dose of Lispro given at 10:20 AM on 7/8/24. An interview with the Director of Nursing on 7/11/24 at 9:32 AM determined she was not aware of the missed and late medications and needed to follow up. At 11:01 AM on 7/11/24 the DON stated the pen used to administer multiple doses of the resident's Ozempic was mistakenly thrown away after just the first dose was administered, so they were down a pen. When staff updated the pharmacy to let them know they needed a refill, they had updated the facility pharmacy instead of the resident's preferred pharmacy. This was corrected by the facility on 7/11/24. A policy titled Administering Medications, revised April 2019, indicated medications were to be administered in a safe and timely manner, and as prescribed. Staffing schedules were arranged to ensure medications were administered without unnecessary interruptions. Medications were administered in accordance with prescriber orders, including any required time frame. 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #4 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Coronary Artery Disease, Peripheral Vascular Disease, and Diabetes Mellitus. The MDS also identified Resident #4 as independent with most activities of daily living. On 1/23/23 the Care Plan identified Resident #4 with the problem of Diabetes Mellitus and directed staff to administer Diabetes medication as ordered by doctor. Monitor for and document side effects and effectiveness. In an observation on 7/9/24 at 7:28 AM, Staff C prepared the Novolog insulin pen using the correct technique, however, Resident #4 was not in her room. Staff C stated she would give it to her after Resident #4 had her breakfast. In an observation on 7/9/24 at 8:42 AM, Staff C, RN used the correct technique to administer Novolog 12 units subcutaneously. A review of the physician orders revealed the following order: 5/12/24 Novolog (Insulin Aspart) Inject 12 unit subcutaneously two times a day. Give with meals Hold if Blood Glucose is below 100. A review of the facility report titled: Location of Administration Report for July 2024 revealed the following: Insulin Glargine Solution scheduled to be given at 7:00 AM 07/02/24 given at 8:55 AM 07/03/24 given at 8:28 AM 07/03/24 given at 8:28 AM 07/09/24 given at 8:44 AM 07/10/24 given at 8:03 AM 3. The MDS dated [DATE] identified Resident #56 as cognitively intact with a BIMS of 14 and had the following diagnoses: Diabetes, Thyroid Disorder, and Bipolar Disorder. The MDS also identified Resident #56 as independent with most activities of daily living. On 4/26/24, the Care Plan identified Resident #56 with the problem of using insulin/hypoglycemic medications related to diabetes and directed staff to: a. Monitor blood glucose as ordered. b. Monitor for side effects (low blood sugar, headache, weakness, sweating and fainting) and effectiveness. A review of the Physician Orders revealed the following: Basaglar KwikPen Subcutaneous (Insulin Glargine) Inject 14 unit subcutaneously two times a day for diabetes. Admelog SoloStar Subcutaneous (Insulin Lispro) Inject 20 unit subcutaneously three times a day for Diabetes II give w/meals. Hold insulin if blood sugar is less than 90. In an observation on 7/9/24 at 8:52 AM, Staff C prepared Lantus 14 units and Admelog 20 units using the correct technique, however, upon entering Resident #56's room, he was in the bathroom. In an observation on 7/9/24 at 9:02 AM, Staff C used the correct technique to administer Lantus 14 units and Admelog 20 units subcutaneously. A review of the facility report titled: Location of Administration Report for July 2024 revealed the following scheduled to be given at 7:00 AM Basaglar KwikPen Subcutaneous 7/2/24 given at 9:04 AM 7/3/24 given at 9:34 AM 7/5/24 given at 8:18 AM 7/6/24 given at 8:29 AM 7/9/24 given at 9:09 AM 7/10/24 given at 9:45 AM Admelog 7/2/24 given at 9:04 AM 7/3/24 given at 9:34 AM 7/5/24 given at 8:18 AM 7/6/24 given at 8:29 AM 7/9/24 given at 9:10 AM 7/10/24 given at 9:45 AM 4. The MDS dated [DATE] identified Resident #60 as cognitively intact with a BIMS of 15 and had the following diagnoses: Diabetes Mellitus, Osteomyelitis, and Sleep Apnea. The MDS also identified Resident #60 required staff supervision or partial assistance with most activities of daily living. On 6/21/24, the Care Plan identified Resident #60 with the problem of using insulin /hypoglycemic medications related to diabetes and directed staff to: a. Monitor blood glucose as ordered. b. Monitor for side effects (low blood sugar, headache, weakness, sweating and fainting) and effectiveness. A review of the Physician Orders revealed the following: 6/21/24 Insulin Lispro Inject 5 unit subcutaneously three times a day for Diabetes Mellitus with meals. Update physician if blood glucose is less than 60 or greater than 400. In an observation during medication pass task on 7/9/24 at 8:47 AM, Staff C RN administered Lispro 5 units subcutaneously. A review of the facility report titled: Location of Administration Report for July 2024 revealed the following: Insulin Lispro Injection scheduled to be given at 7:00 AM were given at the following dates and times: 7/2/24 given at 9:02 AM 7/3/24 given at 9:32 AM 7/4/24 given at 9:01 AM 7/5/24 given at 8:55 AM 7/7/24 given at 8:41 AM 7/9/24 given at 8:52 AM 7/10/24 given at 9:44 AM In an interview on 7/11/24 at 7:52 AM, the ADON (Assistant Director of Nursing) reported the following: a. When insulin is scheduled to be given in the morning, it is usually given before breakfast or right after breakfast. b. When asked if there would be any reason why insulin was being given 2 hours late, the ADON reported only if it is per resident's choice or doctor order. c. This has not been a problem identified by the QA Committee and she was not aware of any new interventions to correct the problem. In an interview on 7/11/24 at 10:55 AM, Staff J, Nurse Practitioner reported she would expect morning doses of insulin to be given before meals or at least within an hour after breakfast. In an interview on 7/11/24 at 12:15 PM, Staff I, RN reported morning doses of insulin should be given with breakfast and that there should not be any reason for insulin to be given 2 hours late.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The Minimum Data Set (MDS) assessment for Resident #36, dated 4/5/24 documented a Brief Interview for Mental Status (BIMS) of 15/15, which indicated intact cognition. The MDS reflected diagnoses of diabetes mellitus, morbid obesity, and need for assistance with personal care. The assessment indicated Resident #36 was dependent for toileting and transfers, and required partial to moderate assistance for sitting to lying and lying to sitting. The resident's Care Plan included a focus area dated 10/6/23 related to activities of daily living (ADL), with a goal to continue to participate during ADLs and an intervention required assist of 2 staff with toileting. A focus area dated 10/13/22 indicated the resident experienced incontinence. Another section dated 1/11/23 documented the resident had diabetes mellitus with interventions to take diabetes medication as ordered by doctor, and to monitor for and document side effects and effectiveness. On 07/09/24 at 09:19 AM Resident #36 stated his medications were 'messed up' a lot, and that he missed his Ozempic altogether the Saturday before (7/6/24). He stated they seemed short staffed and that someone told him his medication had been thrown away by mistake. He thought they reordered it but he wasn't sure, and he had not heard anything more about it. The resident stated his insulin was often late, and he sometimes received his breakfast insulin closer to lunch. A document titled Hallway Assignments dated 7/6/24 revealed 2 of the 6:00 AM to 2:00 PM staff called off, 2 CNAs on the 2:00 PM -10:00 PM shift did not come in, and another 2nd shift CNA was late. A document titled Medication Administration Record for July 2024 documented the resident did not receive his scheduled semaglutide (1 mg/dose) by solution pen-injector 4 mg/3 ml (Ozempic) on 7/6/24 as scheduled. The box included a number 9, which indicated there was an associated Progress Note. A Progress Note dated 7/6/2024 at 12:58 indicated the resident's medication was not available, and staff requested for pharmacy to send in medication. It noted the facility was awaiting delivery. As of 7/10/24 no follow up documentation was in the electronic health record. A document titled Location Administration Report, dated 07/09/24 at 11:19 AM, revealed that between 7/1/24 and 7/9/24 Resident #36 received the following medications outside of the allowed one hour administration window 33 out of 43 times; Insulin Lispro Injection Solution, Insulin Lispro Solution 100 UNIT/ML, and Insulin NPH (Human) (Isophane) Subcutaneous Suspension 100 UNIT/ML. 15 of those injections were over 2 hours late, with the longest gap documented as a 7:00 AM dose of Lispro given at 10:20 AM on 7/8/24. On 7/11/24 at 8:59 AM Certified Medication Aide, Staff F, confirmed the resident did not receive his semaglutide over the weekend and that some of his medications have been late. She stated the semaglutide medication was requested 7/6/24 and it had not been received. An interview with the Director of Nursing on 7/11/24 at 9:32 AM determined she was not aware of the missed medication and needed to follow up. A policy titled Administering Medications, revised April 2019, indicated medications were to be administered in a safe and timely manner, and as prescribed. Staffing schedules were arranged to ensure medications were administered without unnecessary interruptions. Medications were administered in accordance with prescriber orders, including any required time frame. Based on observation, record review, resident and staff interview, the facility failed to answer call lights in a timely manner for 4 of 4 residents observed. (Residents #14, #28, #36 and #214). The facility reported a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #14 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Heart Failure, Renal Insufficiency, and COPD (Chronic Obstructive Pulmonary Disease) The MDS also identified Resident #14 to be dependent on staff assistance with putting on and taking off footwear, transfers from chair to bed and from sitting to standing. An observation of Resident #14's call light on 7/29/24 revealed the following: 6:50 AM [NAME] at end of C hall showed Resident #14's call light was on. Currently no staff in the hallway. 6:56 AM Staff S, CNA entered room C 11 to assist that resident then pushed that resident out to the main dining room without checking on Resident #14. 7:00 AM Staff S, CNA returned to C hall and knocked on door to room C 7. Call light to Resident #14's room had been on for 10 minutes now. No other staff in hallway. Resident #14 sat up in her wheelchair in her room and did not appear to be in any distress. 7:05 AM Resident #14's call light had been on for 15 minutes now. Staff S, CNA entered room C 14, however, did not check on Resident #14. 7:07 AM [NAME] now showing call lights on to Resident #14's room now off. It had been on for 17 minutes. The Care Plan with the last revision date of 5/17/24 did not address the need to answer Resident 14's call light in a timely manner despite requiring staff assistance with transfers. During an observation and interview on 7/10/24 at 2:46 PM , Resident #14 sat up in her wheelchair, properly positioned and appeared comfortable. She had a clock above the bathroom door which was visible from her bed. She also had a cell phone on her tray table that has a clock to show her the time. 2. The MDS dated [DATE] identified Resident #28 as cognitively intact with a BIMS of 15 and had the following diagnoses: Diabetes Mellitus, Bipolar Disorder, and Right Below the Knee Amputation. The MDS also identified Resident #28 was completely dependent on staff for assistance with toileting, showers, putting on and taking off footwear, lower body dressing, and personal hygiene. In an interview on 7/9/24 7:41 AM, Resident #28 reported when asked if staff answer his call light timely, he stated when his call light works. The call light will not work properly and this happened at least once a month. The longest he has had to wait to get his call light answered was 3 hours In an observation of Resident #28 in his room on 7/10/24 at 2:44 PM, he was asleep in bed, had a cell phone on a tray table next to him which shows a clock where he can see the time. There was also a clock above the bathroom door, that can be seen from his bed. The Care Plan identified Resident #28 with requiring assistance with most activities of daily living however, it did not address the need to answer Resident 14's call light in a timely manner. 3. The Minimum Data Set (MDS) dated [DATE] identified Resident #214 with moderate cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 11 and had the following diagnoses: Peripheral Vascular Disease, Diabetes Mellitus, and Hip Fracture. The MDS also identified Resident #214 required partial/moderate staff assistance with transfers from bed to chair and required supervision with toilet transfers. On 7/1/24, the Care Plan identified Resident #214 with the problem of a right hip fracture related to fall at home and directed staff to anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Observations on 7/8/24 which began at 4:00 PM revealed the following. 4:00 PM, the [NAME] at the end of C hall showed the call light on for Resident #214's room which surveyor observed during medication pass on C hall. 4:05 PM, assessment unchanged. 4:10 PM assessment unchanged. 4:14 PM Resident #214 observed sitting at the edge of her bed. Staff G, CNA exited another resident's room pushing a mechanical lift and walked by room A 4 and did not check on the resident. 4:15 PM the [NAME] at the end of the A hall showed Resident #214's call light was still on and had been on for 15 minutes. 4:17 PM, the [NAME] now showed Resident #214's call light had been answered. The call light had been on for 16 minutes. In an observation and interview on 7/10/24 at 2:39 PM, Resident #214 had a clock in her room that was easily visible from her bed. Resident #214 reported she has had accidents waiting for help to the bathroom which made her feel awful like a child pooping in her pants. Resident #214 reported this usually happens 2 to 3 times a week usually on night shift which she felt was embarrassing and degrading. Resident #214 also reported she was not supposed to get up by herself to go to the bathroom and thought it was ridiculous that she had to wait so long until she ends up soiling herself. In an interview on 7/11/24 at 7:52 AM, the ADON reported the following: a. She would expect staff to answer call lights as soon as possible, within 15 minutes at most. b. When asked what did she feel would be the reason why call lights were not being answered timely, she reported because the [NAME] is located at the end of the hall and the aides are not looking up to check the [NAME]. Half of the CNA staff were newer. c. Staff call in at least once a month, shifts varies. In an interview on 7/11/24 at 11:13 AM, Staff L, CNA reported the following: a. When asked when staff should answer a call light, she reported right away. b. When asked if she felt she had enough help to give the residents the care they need, she reported no. On day shift, there should be 2 CNAs and one nurse for each hall. Today, there is only one nurse out on the floor and 2 CMAs covering for the nurses in the other two halls. c. Staff call in sick daily and at least 2 people will call in. In an interview on 7/11/24 at 12:15 PM, Staff I, RN reported the following: a. Staff are expected to answer call lights right away. b. When asked why she felt call lights were not being answered timely, she reported there are a lot of agency staff that aren't familiar with the building and may not know to look up at the [NAME], however, the call lights are audible. In an interview on 7/11/24 at 11:19 AM, Staff M, CNA reported the following: a. Staff are expected to answer call lights as soon as possible. b. Staff call in sick at least two to three times a week on all shifts and more so on the weekends. In an interview on 7/11/24 at 11:30 AM, Staff N, CNA/CMA reported the following: a. Staff are expected to answer call lights within 15 minutes. b. Staff will call in sick at least 3 times a week on the days she is scheduled, however, they try to cover it by asking someone to stay over or have someone come in early. c. Staff should be checking the [NAME] every time they are in the hallway. The call lights are audible. Anyone can answer a call light. d. When call lights aren't answered timely, this usually happens before or after meals when staff are helping residents to and from the dining room to their rooms and when staff are helping residents to bed. In an interview on 7/11/24 at 11:45 AM, Staff O, CNA reported the following: All staff should be able to hear them and see the [NAME] at the end of each hall, except the D hall where there is no [NAME].

Based on observation, policy review, and staff interview the facility failed to keep fingers off the drinking surface of glasses during dining service. The facility reported a census of 58 residents. Findings include: During an observation on 7/08/24 at 11:25 AM Staff A, Dietary Aide passed 20 glasses to 14 residents with fingers over the top of the glass or touching the drinking surface on the side of the glass. She served 7 glasses to 2 residents with fingers on the inside surface of the glass. During an interview on 7/10/24 at 8:31 AM Dietary Service Manager explained staff are instructed to have no fingers on the plates, they must wear hair nets, and no gloves are worn unless cleaning. Staff can pour drinks ahead of time but they have to cover, date, and refrigerate them. Diets are right on the ticket to make sure the order matches. She further explained no hands are to be over the top on tumblers, and staff must use handles on the mugs. The facility policy titled Sanitation, updated October 2008 lacked direction for hand placement during dining service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to revise and update resident's care plans for new concerns or changes in status and treatments for 1 out of 3 residents reviewed (Resident #1). The facility identified a census of 67 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 shown diagnoses that included cerebrovascular accident, non-Alzheimer's dementia, and hemiplegia. The MDS indicated Resident #1 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderately impaired cognitive status. The MDS indicated the resident needed extensive assist of 2 staff with transfers, bed mobility, and toilet use. Review of the nurse progress notes for Resident #1 revealed on 1/20/23 a open wound on the coccyx. Review of the care plan revealed resident #1 high risk for pressure ulcers. The care plan failed to identify the unstageable pressure ulcer for Resident #1 until 2/6/23. Observation of Resident #1 on 2/8/23 at 9:53 AM during wound cares provided by Staff D, Assistant Director of Nursing (ADON) revealed an unstageable pressure area to the coccyx. During an interview on 2/8/23 at 1:59 PM the Director of Nursing stated when a pressure ulcer is discovered the care plan should be updated and the MDS nurse is responsible for getting pressure ulcers on the care plan. The facility provided a policy titled Care Plans, Comprehensive, Person Centered revised December 2016 the policy stated the comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It directed staff assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change.