Based on clinical record review and staff interview the facility failed to follow the Care Plan for 1 of 3 residents reviewed (Resident #1). The facility identified a census of 42 residents. Findings include: A Care Plan for Resident #1 directed the facility staff the resident required the following Focus and Intervention areas as dated: a. An activities of daily living (ADL) self-care deficit related to (r/t) a stroke, type II Diabetes Mellitus, peg tube (gastrostomy tube), low vision in both eyes, obesity, hemiplegia on his left side (paralyzed), and respiratory failure. (initiated 1.15.25 and revised 4.11.25). 1. Dependent on two (2) staff members with bed mobility. (initiated 1.15.25 and revised 4.11.25) b. Impaired cognition r/t a Cerebral Infarct (stroke). The resident suffered from an inability to verbalize. (initiated 1.10.25 and revised 4.30.25) c. At risk for falls r/t a stroke, psychotropic medication use, hemiplegia, immobility, poor vision in both eyes, and obesity. (initiated 1.15.25 and revised 5.13.25) 1. Bed in lowest position when positioned in bed. (initiated 5.5.25) 2. Utilized a body pillow when repositioned. (initiated and revised 4.22.25) 3. Notification of the resident, family, and care givers of any new areas of skin breakdown. (initiated 1.15.25 and revised 4.30.25) According to a Progress Note entry dated 6.3.2025 at 8:50 p.m. the resident had been found on the floor beside his bed and sustained an abrasion to his right knee that measured 4 cm x 2 cm. The new intervention directed the facility staff to have performed 2 hour staff checks when they walked past his room. During an interview 6.4.25 at 12:45 p.m. Staff C, Licensed Practical Nurse (LPN) confirmed when she received report that morning the night shift staff informed her of the fall but failed to inform her of the abrasion to the resident's left knee or the every 2 hour staff walk by his room checks. According to a Progress Note entry dated 5.2.2025 at 2:29 p.m. the nurse walked into the resident's room and found the residents' bed in a high position and the resident positioned on the floor on the left side of his bed, towards the window and on his hands and knees. The resident sustained an abrasion (superficial open areas) to both his knees. During an interview 6.4.25 at 11:15 a.m. Staff C, LPN confirmed the resident's bed as not positioned all of the way to the floor prior to his fall on 5.2.25. During an interview 6.4.25 at 10:50 a.m. Staff A, Certified Nursing Assistant (CNA) confirmed she worked 5.2.25 and when she entered the resident's room she found him positioned on the floor on all fours and the bed not in it's lowest position. The staff member confirmed staff should have absolutely followed each individual resident's Care Plan. According to an email 6.4.23 at 10:33 a.m. the Administrator confirmed she expected staff to have followed the individual resident's Care Plans.

Based on clinical record review, staff interview, and facility policy review, the facility failed to properly assess and intervene for 1 of 3 residents following a fall. (Resident #1) The facility identified a census of 42 residents. Findings include: During an interview 6.4.25 at 12:45 p.m. Staff C, Licensed Practical Nurse (LPN) indicated she received report the resident had fallen last night (6.3.25) but there had been no report of an abrasion to Resident #1 knees. The staff member felt the fall occurred yesterday afternoon but on this day, sometime after 8 a.m., the Director of Nursing (DON) came to her and asked where the Incident Report had been located and Staff C told her she did not know as the Incident Report had not been in Point Click Care (PCC) at 5:45 a.m. During an interview 6.5.25 at 11:27 a.m. Staff D, LPN was aware Staff E, LPN documented her assessment in the Progress Notes around the 8 p.m. hour but failed to complete an Incident Report per facility policy. Staff D confirmed Staff E reported the abrasion located on the resident's right knee but not the intervention of staff to have walked by the resident's room every two (2) hours. Staff D also indicated she thought Staff E conducted four (4) sets of vitals but had not performed neurological (neuro) checks as she started the neuro sheet when she arrived at work. The staff member felt there had been times staff could have provided a more thorough report to oncoming staff members. A Neurological Assessment form dated 6.3.25 at 8:50 p.m. revealed nursing staff failed to assess the resident's neuro's as follows: a. Every 15 minutes times (x) three (3) immediately post the resident's fall. b. Every four (4) hours x one (1). c. Every eight (8) hours x 1. An observation 6.4.25 at 9:50 a.m. revealed a non-dated or initialed band aide on the right knee of Resident #1 with noted dark shadowing under the dressing with the appearance of sanguineous (bloody) drainage. Clinical record review 6.4.25 at 12:05 p.m. revealed no treatment to either knee. An observation 6.4.25 at 12 p.m. revealed the Director of Nursing (DON) as she removed the bandage with sanguineous drainage that covered the pad portion of the bandage itself. The open area to the knee appeared the size of a .50 cent piece. According to an email 6.4.25 at 2:21 p.m. the Administrator confirmed she expected staff to have completed an Incident Report form immediately post a fall. The Administrator indicated the nurse on duty during the fall had been newer and had not dealt with a fall so education had been provided that morning (6.4.25) when staff called her back into the facility to complete the form as expected. A Risk Management form updated 9.27.24 included the following: a. Neurological assessments must have been completed with every unwitnessed fall or/or possible head injury. b. All Incident Reports to be completed by the end of a nurses scheduled shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview, the facility failed to provide the Dietician recommended dietary interventions to prevent weight loss for 1 of 1 residents sampled (Resident #14). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating severe cognitive loss. The resident required supervision to touch assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating. The MDS listed a diagnosis of dementia with mild psychotic disturbance and documented Resident #14 with a significant weight loss (a significant weight loss is defined as a 5 percent (%) weight loss in 30 days or 10% weight loss in 6 months) and not on a prescribed weight loss regimen. The Care Plan revised 8/08/24 identified Resident #14 with a nutritional problem related to dementia, chronic kidney disease stage 3, hypertension and need for a mechanically altered diet. The Care Plan directed the following: a. Provide and serve supplements as ordered: Premier Protein shakes twice a day - provided by family. b. Provide and serve the diet as ordered. Monitor intake and record every meal. c. Registered Dietician to evaluate and make diet change recommendations as needed. An 8/08/24 Nutritional Progress Note documented Resident #14 with a 3% weight loss in 30 days, 7.8% in 90 days and 11.5% in 180 days. The Progress Note reflected Resident #14 received Premier Protein shakes twice a day. The Dietician documented Resident #14 intake is not likely meeting estimated needs with significant weight loss related to a sore mouth and poor intake of meals. Continue with the Premier protein shakes. Recommend to add ice cream to lunch and dinner for added calories. An 8/26/24 review of Resident #14 weights revealed a weight of 164.6 pounds on 4/10/24 and a weight of 144.2 pounds on 8/06/24 resulting in a 12.39% weight loss in less than 6 months. During an observation on 8/26/24 at 12:05 PM Staff D, Dietary [NAME] served out Resident #14 lunch meal. The lunch meal did not include ice cream. Observation 8/26/24 at 12:25 PM of Resident #14 table revealed no ice cream with Resident #14 lunch meal/dishes. During an interview on 8/27/24 at 3:15 PM a certified nursing assistant observed passing the afternoon snack cart. She reported she usually always tries to give Resident #14 an afternoon snack of applesauce or pudding. Ice cream is usually not on the afternoon snack cart. On 8/27/24 at 12:00 PM Resident #14 observed seated in the dining room with drinks in front of her waiting for lunch. Further observation at 12:10 PM revealed Resident #14 eating independently with supervision. Her lunch consisted of a pureed breakfast burrito, mashed potatoes, and a pureed apple crisp dessert. Resident #14 had not been served ice cream with her lunch meal. On 8/27/24 at 12:15 PM Staff A, Licensed Practical Nurse (LPN) reported Resident #14 receives protein shakes for her weight loss. They also try to give her afternoon snacks. She loves ice cream. Her son will take her out for ice cream and she will eat all of it. They give her ice cream for an afternoon snack if they have it on the snack cart. On 8/27/24 at 12:25 PM the Dietary Manager reported the Consulting Dietician is at the facility every other Thursday. The Dietician emails the dietary recommendations back to the facility after the Thursday visit, so recommendations come to the facility later. The recommendations from the Dietician are taken care of by the Director of Nursing (DON), Assistant Director of Nursing (ADON) or by her. An 8/27/24 review of Resident #14 lunch and dinner meal slips provided by the facility noted to provide ice cream. On 8/27/24 01:08 PM Staff E, Certified Nursing Assistant (CNA) voiced Resident #14 did not get her ice cream for lunch today (8/27/24). During an interview on 8/27/24 at 1:17 PM Staff D, [NAME] reported Resident #14 is to receive ice cream at lunch and supper. She reported it is her responsibility to serve the ice cream to Resident #14 and she had not served out the ice cream the past two days at lunch. Interview on 8/27/24 at 2:03 PM Staff A, LPN, reported she was not aware Resident #14 required ice cream at lunch and supper. She stated if she had seen a physician order for it, should/would ensure it got done. She reported she had only seen the Dietician twice since the Dietician started at the facility. She didn't know if the Dietician came weekly or bi-weekly, but she doesn't see the recommendations that the Dietician makes. She reported at one time the facility had said they were not going to offer out ice cream for all residents any more. The snack cart usually has yogurt, mandarin oranges, applesauce, and canned pudding. The snack carts are very limited. During an interview on 8/27/24 at 2:15 PM the DON reported if the Dietician recommends supplements, then they proceed with getting a physician order. If the recommendation is for ice cream, she will notify dietary to update the resident's meal slip. She reported she is responsible for overseeing the dietary recommendations are being done. The DON confirmed she expects the dietary staff to serve out the Dietician recommended items and the plan of care to be implemented. The Care Plan Development Policy dated 08/15 directed individualized, comprehensive care plan using the MDS assessment will be developed for each resident, and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to follow physician orders for 1 of 3 residents sampled (Resident #32). Facility reported a census of 38 residents. Findings include: Resident #32 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS documented Resident #32 received scheduled pain medication for a pain level of 7 out of 10 (a 1-10 pain scale, 10 being the worst possible pain). The MDS listed medical diagnoses of stroke, arthritis, and osteoporosis. The Care Plan initiated 7/31/24 identified Resident #32 with chronic pain related to osteoarthritis and osteoporosis. The Care Plan goal identified a goal Resident #32 would verbalize adequate relief of pain or the ability to cope with unrelieved pain. The Care Plan directed the staff to: 1. Monitor/document for side effects of pain medication. Observe constipation; new onset or increased agitation, restlessness, confusion, hallucination, dysphoria, nausea, vomiting; dizziness and falls. Report occurrences to the physician. 2. Monitor/record/report to the nurse any signs or symptoms of non-verbal pain: changes in breathing, mood/behavior, eyes, face and body. 3. Monitor/record/report to the nurse resident complaints of pain or requests for pain treatment. 4. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents' past experience of pain. A 7/29/24 Progress Note e-signed by the primary provider on 8/7/24 identified Resident #32 with on-going pain for active chronic osteoarthritis and low back pain. The provider ordered Resident #32 to continue treatment with Lidocaine external patch 5 percent (%). Resident #32 August 2024 Treatment Administration Record (TAR) documented the following pain levels on a 1-10 pain scale where the two-digit number (00-10) indicates by the resident as corresponding to the intensity of their worst pain, where zero is no pain and 10 is the worst pain imaginable. 8/13/24 6:00 AM 4 8/13/24 2:00 PM 10 8/14/24 6:00 AM 6 8/15/24 6:00 AM 3 8/16/24 6:00 AM 4 8/16/24 2:00 PM 4 8/17/24 6:00 AM 4 8/17/24 2:00 PM 4 8/18/24 6:00 AM 10 8/19/24 6:00 AM 2 8/23/24 6:00 AM 10 8/23/24 2:00 PM 3 The National Institutes of Health define pain levels as follows: a. Mild pain: 0-3 b. Moderate pain: 4-6 c. Severe pain 7-10 Resident #32 identified a moderate level of pain 6 times and a severe level of pain 3 times when administered the incorrect dose of the prescribed medication. Observed on 8/26/24 at 7:21 AM, Staff A, Licensed Practical Nurse (LPN) place the Lidocaine external patch 4% on the lower back of Resident #32. Staff A, LPN failed to follow professional standards of medication administration (right patient, right drug, right time, right dose and right route). During an interview on 8/26/24 at 9:13 AM, Resident #32 revealed she has a lot of pain at times due to arthritis in her arms and back. Resident #32 rated her current pain level at a 3. During an interview on 8/26/24 at 9:16 AM, Staff A, LPN confirmed she applied the Lidocaine pain relief gel patch 4% patch to the lower back of Resident #32. The packaging for the Lidocaine pain relief gel patch 4% revealed the box contained 15 patches with 3 remaining patches in the box. During an interview on 8/27/24 at 9:10 AM Director of Nursing (DON) revealed physician orders are to be followed as prescribed. Staff B, DON revealed she was unaware of the discrepancy and was notified on 8/26/24 of the medication error. On 8/27/24 at approximately 9:30 AM DON revealed the facility lacked a policy for order verification/transcribing of physician orders. The DON voiced she expected the nurse will follow up with the pharmacy when a discrepancy is identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview the facility failed to have emergency equipment readily available at the bedside for 1 of 1 residents reviewed for tracheostomy care (Resident #22). The Facility identified a census of 38 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating a mild cognitive loss. The MDS documented Resident #22 with a tracheostomy (tracheostomy is an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is done through the tracheostomy tube rather than through the nose and mouth) and a diagnosis of cancer. The Care Plan revised 6/19/24 documented Resident #22 utilized a tracheostomy related to a malignant neoplasm (cancer) of the supraglottis (the supraglottis is the upper part of the voice box, that's located above the vocal cords and includes the epiglottis) and directed the nursing staff in tube out procedure: keep extra tracheostomy tube and obturator (a curved rod that fits inside the tracheal cannula) at the bedside. If the tube is coughed out, open the stoma (a surgically created opening in the neck that goes into the windpipe and allows air to reach the lungs) with a hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate the head of the bed 45 degrees and stay with resident. Obtain medical help immediately. During an observation on 8/27/24 at 9:25 AM Staff C, Licensed Practical Nurse (LPN) provided Resident #22 his tracheostomy care as physician ordered. After tracheostomy care completion, Staff C was asked what emergency equipment was available in Resident #22 room. Staff C opened the closet door and stated Resident #22 had a bag with suction equipment in it. The suction equipment observed zipped inside a bag in the closet, not set up for emergency use. Staff C searched the closet all the way to the back of the close and the three drawer bin of tracheostomy equipment and reported she could not find a hemostat (a hemostat is a surgical tool, like pliers that is used to grasp skin to secure during procedures). She would have to check with the Director of Nursing (DON) as she didn't see a hemostat in the resident's room. On 8/27/24 at 9:44 AM Staff C asked the DON about a hemostat in Resident #22 room. Staff C reported she had looked in the resident's closet and bin with his tracheostomy equipment but couldn't find a hemostat. The DON at this time reported she would expect a hemostat to be in the room and they would get a hemostat in the room. She expected staff to follow the Care Plan. On 8/27/24 at 10:32 AM Resident #22 reported Staff C had not been back to his room with any equipment. Interview on 8/27/24 at 10:35 AM the DON reported the tracheostomy care kit has forceps in the kit and she would expect the nurses to use the forceps in the tracheostomy kit to open the airway in an emergency. Staff C stood by the DON and when asked if she would know in an emergency to go get the tracheostomy care kit and she reported, no. The DON verified the tracheostomy kits were not stored and accessible in Resident #22 room if there was an emergency. When asked about emergency tracheostomy training, the DON reported the nurses did not have documented emergency training. During an interview on 8/27/24 at 10:36 AM the DON reported she would be providing the nurses with emergency education yet this week. A review of the Facility Assessment updated 7/09/24 lacked documentation of emergency training regarding tracheostomy care. The Tracheostomy Care Procedure, undated, provided by the facility under accidental decannulation directed the following: 1. Call for assistance. 2. Replace the old tracheostomy tube with the new tube that is the same size. 3. Be prepared to manually ventilate the resident in whom respiratory distress develops. 4. Notify emergency personnel, if necessary. 5. Continue to manually ventilate until emergency personnel arrives and take over ventilation. The Procedure lacked direction of the emergency equipment that should be maintained at the bedside for emergency tracheostomy care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview the facility failed to have eye protection readily available for enhanced barrier precautions (EBP) for 1 of 1 residents reviewed for tracheostomy care (Resident #22). The Facility identified a census of 38 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating a mild cognitive loss. The MDS documented Resident #22 with a tracheostomy (a tracheostomy is an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is done through the tracheostomy tube rather than through the nose and mouth) and a diagnosis of cancer. The Care Plan revised 6/19/24 documented Resident #22 utilized a tracheostomy related to a malignant neoplasm (cancer) of the supraglottis (the supraglottis is the upper part of the voice box, that's located above the vocal cords and includes the epiglottis). The Care Plan included a revised intervention dated 4/17/24 which directed the nurse to utilize enhanced barrier precautions (EBP) for tracheostomy care. The Center for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multi-drug resistant Organisms (MDROs) Updated: July 12, 2022 under key points listed the following: 1. Multi-drug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated for residents with any indwelling medical devices, regardless of MDRO colonization status. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care Under the CDC Summary of Personal Protective Equipment (PPE) Use and Room Restriction When Caring for Residents in Nursing Homes directed gloves and gown to be worn prior to the high contact care activity, change PPE before caring for another resident, face protection may also be needed if performing activity with risk of splash or spray. During an observation on 8/27/24 at 9:25 AM Staff C, Licensed Practical Nurse (LPN) reported she wears a gown and gloves when she performs Resident #22 tracheostomy care. Staff C washed her hands, donned an isolation gown and gloves. Observation of the PPE isolation bin as Staff C donned her PPE revealed no goggles or face shield readily available in the isolation bin. Staff C proceeded to perform Resident #22 tracheostomy care cleansing with saline soaked cotton tipped applicators around Resident #22 stoma with Staff C within 10-12 inches of the resident while performing the tracheostomy care. Resident #22 covered his tracheostomy with his finger and verbalized sometimes he coughs during his tracheostomy care and secretions go flying all over as he started to chuckle. Staff C reported she had not been told to wear eye protection or a face shield when providing tracheostomy and no eye protection was present in the isolation bin for Resident #22 care. She would need to check with the Director of Nursing (DON). On 8/27/24 at 9:44 AM Staff C asked the DON about eye protection. The DON verbalized she would expect the nurses to wear a face shield if there was potential for droplet or airborne secretions. The DON informed Staff C face shields were in the basement with the COVID 19 personal protective equipment (PPE). During an interview on 8/27/24 at 1:36 PM the Infection Preventionist (IP) reported the facility has one resident on EBP due to tracheostomy care. The nurses wear a gown and gloves for EBP. The staff should probably wear a face shield in the event of sputum or droplets. Then the IP stated, now that I say it out loud, the staff should probably have face shields on. The IP verbalized the facility follows CDC guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review and policy review the facility failed to check placement and elevate the resident's head of bed prior to flushing a g-tube for 1 of 1 resident reviewed (Resident #24); failed to follow physicians orders for insulin for 1of 1 resident reviewed (Resident #33); and failed to prime insulin pen prior to administering for 3 of 3 residents reviewed (Resident #24, #33 and #37). The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #24 documented diagnoses of hypertension, cancer, malnutrition, gastrostomy status, and dysphasia. During an observation on 4/17/24 at 10:30 AM, Staff A, Licensed Practical Nurse (LPN) set up supplies on a barrier. She did hand hygiene and applied a gown and gloves. She then drew up 30 ml of warm water with the syringe, cleaned the port to the G-tube with an alcohol wipe, unclamped the tubing and flushed the line with syringe of warm water. She did not check placement of tube prior to doing so and resident was laying flat in bed with his head not elevated. Staff A, LPN reported she does need to check placement prior to flushing the tube. During an interview on 4/17/24 at 1:20 PM, the Director of Nursing reported she expects staff to elevate the resident to a semi-Fowler's position (elevated 30-45 degrees) and check the placement of the G-tube prior to flushing. Review of the Medication Administration Record for April documents the resident is to get his G-tube flushed twice a day with 30 milliliters (ml) of warm water. Review of the facility policy Medication Administration for enteral tubes dated 1/13 directed staff to verify that that the head of the bed is 30-45 degrees and to verify tube placement prior to flushing the tube. 2. 1. The MDS Assessment for Resident #33 dated 03/13/24 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented the resident diagnoses of hypertension, diabetes, and depression. During an interview on 4/15/24 at 12:26 PM, Resident #33 reports her blood sugars have been really high frequently. Review of Resident #33's February, March and April 2024 Medication Administration Records (MAR) document the resident's blood sugars are not consistent. It documented on 12 different occasions the resident either refused her insulin or the nurse held the insulin per nursing judgement. Review of Resident #33's Progress Notes lacked documentation of the physician being notified on the 12 different occasions of insulin refusal or being held. It further lacked any documentation of staff education of the risks of not taking the insulin as prescribed by the physician. During an interview on 4/16/24 at 2:10 PM Staff B, LPN reported Resident #33 is very noncompliant with her diabetes. Resident #33 will refuse meals but then snack on high sugar and high carbohydrate snacks in her room. She reported she has held Resident #33 insulin due to nursing judgement because the blood sugar level or she has refused to eat the meal. She documents the insulin being held on the MAR but not notify the physician. During an interview on 4/16/24 at 2:25 PM Staff C, Registered Nurse (RN) reports she will ask Resident #33 if she wants to take her insulin or not due to not always eating the meal. She reports she documents the refusal on the MAR. She reports any refusal or insulin being held the physician needs to be notified right away and documented. During an interview on 4/16/24 at 2:35 PM Staff D, LPN reports if a resident is refusing their insulin or the blood sugar is very low then she would notify the physician right away. The resident will need to be educated on the risks and it all needs to be documented. During an interview on 4/16/24 at 3:45 PM, the Nurse Consultant reports she expects staff to notify the physician right away if the insulin is not given or a resident refuse. It then should be documented in the resident's chart. During an interview on 4/17/24 at 9:08 AM, the DON reports the nurse should first look and see if the resident has parameters for holding the insulin. If it is held or the resident refuses then the physician needs to be notified right away and it should be documented in the resident's Progress Notes. Review of the facility policy Refusal of Medication or Treatment dated 5/14 directed staff to notify the Physician of the refusal. The policy lacked any direct to of holding medications per nursing judgement. 3. The MDS dated [DATE] revealed Resident #24 had a diagnosis of type 1 diabetes mellitus (DM) and received insulin injections 7 out of the past 7 days. The Care Plan revised 3/19/24 revealed Resident #34 had DM and used insulin daily. The MAR dated April 2024 revealed Resident #24 had an order initiated 3/11/24 for Humalog (insulin) KwikPen solution 14 units subcutaneously in the morning. The MAR further revealed the resident had an order initiated 3/30/24 for 26 units subcutaneously solution pen-injector of Toujeo (insulin) one time a day On 4/17/24 at 9:05 AM, observed Staff A, LPN inject Resident #24 with 14 units of Lispro insulin and 26 units of Toujeo insulin and utilized insulin pen injectors. Staff A did not prime either insulin pen prior to the subcutaneous injections and left the insulin pens in place for approximately 2 seconds after both injections. 4. The MDS dated [DATE] revealed Resident #37 had a diagnosis of DM and received insulin 7 out of the past 7 days. The Care Plan revised 3/25/24 revealed Resident #37 had a diagnosis of DM and received insulin daily. The MAR dated April 2024 revealed Resident #37 had an order initiated 4/10/24 for 20 units Glargine insulin subcutaneously using a pen injector. The MAR further revealed the resident had an order initiated 4/10/24 for 15 units Fiasp insulin subcutaneously using a pen injector. On 4/17/24 at 9:15 AM, observed Staff A, LPN inject Resident #37 with 20 units of Glargine insulin subcutaneously using a pen injector and inject 15 units of Fiasp insulin subcutaneously using a pen injector. Staff A did not prime either insulin pen prior to administration of the insulin and held each pen in place for approximately 2 seconds after administration. 5. The MDS dated [DATE] revealed Resident #33 had a diagnosis of DM and received insulin injections 7 out of the past 7 days. The Care Plan revised 8/31/23 revealed Resident #33 had DM and used insulin daily. The MAR dated April 2024 revealed Resident #33 had an order initiated 3/14/24 for 56 units of Toujeo insulin subcutaneously using an insulin pen injector one time a day. The MAR further revealed the resident had an order for 30 units of Aspart insulin subcutaneously initiated 4/15/24 using an insulin pen injector one time a day. On 4/17/24 at 9:30 AM, observed Staff A, LPN inject Resident #33 with 56 units of Toujeo insulin and 30 units of Aspart insulin and utilize insulin pen injectors. Staff A did not prime either insulin pen prior to the subcutaneous injections and left the insulin pens in place for approximately 3 seconds after administration. During an interview 4/17/24 at 1:00 PM, Staff A LPN acknowledged priming of the insulin pens should have been completed and that she has been educated and moving forward she will be priming insulin pens. During an interview 4/17/24 at 1:17 PM the DON revealed it is an expectation insulin pens are primed 2 units prior to administration and kept in place for 10 seconds after administration of insulin. During an interview 4/17/24 at 1:24 PM Staff A, LPN revealed the expectation is to keep the insulin pen 10 seconds after administration of the insulin and revealed now that she had the knowledge she would do so in the future. During an interview 4/17/24 at 2:04 PM the DON revealed the 3 different insulin pens used for Residents #24, #33 and #37 had manufacturer's recommendations that mirrored one another. The DON provided a copy of the Levemir FlexPen manufacturer's recommendation. Review of the manufacturer's Quick Guide for the Levemir (insulin) FlexPen revealed the following: 3. Prime Your Pen: Before each injection, prime your pen by performing an airshot. Turn the dose selector to select 2 units. Holding your pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubble collect at the top of the cartridge. Press and hold the green push button. Make sure a drop of insulin appears at the needle tip. 5. Give your injection: Inject the dose by pressing the green push-button all the way in until the 0 lines up with the pointer. Keep the needle in the skin for at least 6 seconds, and keep the green push-button pressed all the way in until the needle has been pulled out.

Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The facility reported a census of 42 residents. Findings include: During an interview on 4/15/24 at 10:17 AM, the Administrator reported the Dietary Manager is not certified but currently enrolled in the course. During an interview on 4/15/24 at 1:38 PM, the Dietary Manager reported she is not certified, but currently enrolled in the course. She reported the dietician comes once a week.

Based on observation, staff interviews and policy review the facility failed to maintain sanitary practices by improperly storing clean dishes and maintaining a clean kitchen. The facility reported a census of 42 residents. Findings include: During initial kitchen observation on 4/15/24 at 9:45 AM, the following findings were identified. The dishes were stored on open shelving next to the prep area not inverted. The shelves were covered in dust and soiled dark spots. The front of the oven covered in dry food spills and stove top covered in dry food particles. The window in front of the prep area open with build up of dirt and dried leaves with the breeze blowing on the food on the counter. The large mixer with dried food particles on it. The open shelving next to the steam table dirty with food particles and stored dishes in which half were inverted and half were not. During an observation on 4/16/24 at 10:52 AM, the kitchen dirty areas and dishes stored improperly on 4/15/26 remained the same with no changes. Dirty window open and breeze blowing on the prep area in which the Dietary Manager was preparing the pureed food. During an interview on 4/16/24 at 1:00 PM, the Dietary Manger reported the kitchen staff have a cleaning schedule. She showed the cleaning schedule book with checklist. The last documented completed cleaning was done on 4/9/24. She reported she expected staff to do the cleaning daily and document upon completion. She reported she expects staff to store the dishes on the open shelves inverted. She reported the facility lacked a policy on kitchen sanitation or storing of dishes. Review of the facility's undated cleaning list titled Night [NAME] Tasks documents staff are to clean the stove top and outside of the oven. It lacked any direction for the shelves, how to store dishes and cleaning the large mixer.

Based on observation, photos, and provider contract review, and resident interview revealed the facility failed to maintain clean and safe oxygen concentrator filters for 2 residents reviewed on oxygen therapy (Resident #5 and #7). The facility identified a census of 42 residents. Findings include: 1. A Diagnosis Report form dated 3.19.24 indicated Resident #5 had diagnoses that included Parkinson's, combined Systolic and Diastolic Congestive Heart Failure, and Obstructive Sleep Apnea. A Treatment Administration Record (TAR) form dated 3.1.24 thru 3.31.24 indicated the resident as on continuous oxygen set at 2-3 liters per minute related to Acute Respiratory Failure with Hypercapnia with the physician's order dated 2.19.24 at 2:27 p.m. An observation 3.24.24 at 11:28 a.m. with a photo taken revealed the filter on the oxygen concentrator for Resident #5 full of dust, dirt, and debris. 2. A Diagnosis Report form dated 3.19.24 indicated Resident #7 had diagnoses that include Chronic Obstructive Pulmonary Disease (COPD, Occlusion and Stenosis of her Carotid Artery, Obstructive Sleep Apnea, and combined Systolic and Diastolic Heart Failure. A TAR dated 3.1.24 thru 3.31.24 indicated the resident with an as needed (PRN) oxygen order for shortness of breath dated 2.20.24 at 3:35 p.m. An observation 3.24.24 at 1:22 p.m. with a photo taken revealed the filter on the oxygen concentrator for Resident #7 full of dust, dirt, and debris. During an interview 3.14.24 at 1:15 p.m. the resident confirmed she utilized her oxygen when she needed it. Review of the Service Agreement with the provider of the oxygen products and the facility, effective 9/22/2022, page 2 states the oxygen product provider assumes full responsibility for proper maintenance and repair of all oxygen equipment rented to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, photos, record review, staff interview and review of the facilities Resident Rights the facility failed to maintain an environment free of vermin. The facility identified a census of 42 residents. Findings include: 1. A photo dated 3.14.24 at 9:46 a.m. revealed multiple dead ants in random areas on the floor and along the base boards in room [ROOM NUMBER]. 2. A photo dated 3.14.24 at 9:51 a.m. revealed multiple dead ants in random areas on the floor and along the base boards in room [ROOM NUMBER]. 3. During an interview 3.14.24 at 2 p.m. Staff A, Certified Nursing Assistant (CNA) confirmed she observed ants in room [ROOM NUMBER], when it was occupied by Resident #1 and room [ROOM NUMBER] occupied by Resident #4 around the holidays when the residents received snacks and treats from their families and friends. During an interview 3.14.24 at 2:13 p.m. Staff B, CNA confirmed on 3.11.24 she observed live ants in room [ROOM NUMBER] as they climbed around a piece of food on the resident's floor. During an interview 3.14.24 at 2:53 p.m. Staff C, CNA confirmed she observed ants only in resident rooms which contained sweets and extra foods down hall 200. The staff member felt the ants could have been controlled if staff properly cleaned those resident rooms. 4. According to the facilities Resident Rights form contained in the resident's admission contract the facility assured the residents they provided a safe, clean, comfortable and homelike environment, which allowed the use of resident's personal belongings. 5. A facilities Pest Control policy revised 12.2019 included the following: The facility strived to protect the resident/patients, staff and visitors from insects and other pests by controlling infestations.

Based on observation, record review, resident, staff and family interview, and facility policy review the facility failed to report a suspected abuse allegation in a timely manner, within 2 hours, to the Department of Inspections, Appeals, and Licensing. The facility identified a census of 47 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 7.11.23 indicated Resident #1 had diagnoses that included bipolar disorder, problems related to life management, arthritis, and muscle weakness. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (moderately impaired cognitive skills and required extensive assistance of staff with transfers, ambulation in room, dressing, toilet use, personal hygiene, and bed mobility. A Care Plan identified the following Focus as dated: a. Impaired cognitive function and at risk for falls, increased depression and decreased socialization. (revised 6.21.22) A Progress Note entry dated 7.1.23 at 7:50 p.m. included the following information: a. The resident became upset with evening cares and stated a certified nursing assistant (CNA) would not take her to the bathroom and ripped her clothes off when positioned in bed. The CNA stated the resident normally requested that same CNA for cares. The resident called her daughter, the daughter called the facility and stated she planned to follow up on the incident. During an interview 7.7.23 at 11:30 a.m. a family member confirmed the resident called her last Saturday (7.1.13) at 8:02 p.m. for 17 minutes and reported having been so upset with Staff A, CNA. As the resident cried she reported having been tossed into bed. The resident also reported as the staff member wheeled her back to her room she stopped and talked to someone in the hallway so the resident asked why she stopped and chit chatted when she had to go to the bathroom and the staff member said that is your 1st mistake. The staff member then took her back to her room in her wheel chair and left her there with no call button or anything. The family member reported the resident yelled help, help me as Staff B, registered nurse (RN) came in and gave her meds and call light. Staff A re-entered and that had been when the resident stated she had to go to the bathroom when Staff A reported another resident occupied the shared restroom. The staff member stated you are going to bed right now as she forced the resident's clothes off and threw the resident into bed. The resident allegedly placed her hands out in defense and said she could call police as Staff A stated she could have charged the resident. During an interview 7.13.23 at 2:13 p.m. Staff B, confirmed when she walked past the resident's room that evening the resident called her by name at which time she noticed the resident's tray table and call light had not been positioned within reach. Staff A then entered the resident's room and provided HS cares. The next thing the staff member knew the resident's daughter called and reported the alleged incident. The staff member confirmed she failed to report the allegation to the Administrator right away. The staff member reported in hind sight she should have reported the incident to the Administrator. During an interview 7.13.23 at 1:04 p.m. Staff A confirmed on the way back from the dining room another resident told her a fall risk resident had been up independently in the hallway. As the staff member propelled the resident to her room she barely got her in the door and the staff member ran to the resident as he ambulated independently and as a means to have prevented the fall. Staff B entered the resident's room turned her around and gave her her call light. Staff C, CNA the other aide assigned to that hallway attempted to assist the resident with her hour of sleep (HS) cares but the resident refused and stated she preferred Staff A. When Staff A returned 5-10 minutes later she gave the resident a washcloth and assisted her with her pajamas. The staff member confirmed she failed to take the resident to the bathroom because someone else had been in the shared bathroom. The staff member also changed the resident's brief and provided perineal cares that night. The staff member denied she ever yanked the resident's shirt or ever touched her arms. During an interview 7.13.23 at 2:35 p.m. Staff C confirmed she observed Staff A as she propelled the resident back to her room. When the staff member dropped the resident off she requested assistance to bed right away but other residents required assistance at that time so the staff left the resident and cared for the other residents so she placed on her call light. Staff C responded and the resident requested Staff A so the staff member exited the resident's room. During an interview 7.13.23 at 1:51 p.m. the Administrator confirmed she found out about the alleged incident on 7.3.23 during morning review. The Administrator failed to grasp the extent of the allegation until she returned to work on 5th and the resident's family member had packed up her belongings and discharged her against medical advice, that is when the event had been reported and the staff member suspended. The administrator confirmed she failed to report incident timely. The facilities Abuse Prevention Program & Reporting Policy reviewed 8.2019 including the following directives on suspected abuse: a. Notification of the shift supervisor if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. b. Report the incident immediately to the administrator and director of nursing. c. Notification of the appropriate state agency immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to ensure 2 out of 16 residents (Resident #32 and #38) had up to date code status direction. Resident #32's records lacked code status direction and Resident #38's records directed staff that this resident was both a full code(perform CPR(cardiopulmonary resuscitation) when there is an absence of respirations or a pulse)) and a DNR (Do Not Resuscitate). The facility reported a census of 44 residents. Findings include: 1. On [DATE] at 3:13 PM, a record review revealed there was no direction for code status in Resident #32's electronic record's face sheet, there was no IPOST (Iowa Physician Orders for Scope of Treatment) in the hard chart, and there was no physician's order for code status in either the hard chart or in the electronic health record. On [DATE] at 4:46 PM, the Director of Nursing (DON) and the Regional Director of Clinical Services, Staff C, acknowledged that there was not an IPOST in this resident's hard chart. They also verified there was no code status in PCC (the electronic health record). They acknowledged there should have been and stated they would work on getting this done. They acknowledged there was not a doctor's order for code status. They and that this resident had been back from an emergency room Visit since [DATE]. The DON stated that when Resident #32 went to the ER she was on skilled care so her orders stopped. The DON stated this resident was in the ER for 3 days but was never admitted . The DON stated she must have returned without her IPOST and new orders were not obtained upon her return. Physician's orders printed on [DATE] documented this resident was a Full Code/CPR. These orders for Resident #32's code status were written on [DATE]. 2. On [DATE] at 1:04 PM, through record review it was determined Resident #39's code status was Full Code in this resident's electronic record's face sheet and there was not an IPOST in the PCC documents. An IPOST was found in this resident's hard chart which directed that this resident's code status was DNR. On [DATE] at 1:10 PM, Staff C was shown the IPOST in Resident #39's hard chart and the face sheet in the electronic record. The Nurse Consultant's eyes widened and she shook her head. She said she checked all of the charts the day before after obtaining a code status order and updating resident records for Resident #32. She stated she only checked the electronic health records to be sure a code status showed up, she did not do a comparison with the hard charts. She acknowledged that the IPOST documented Do Not Resuscitate and the Electronic Health Record documented she was a full code and wanted CPR. The Nurse Consultant stated she was going to take care of it right away. She verified that the IPOST was current with a date of [DATE]. Physician's orders printed on [DATE], documented that Resident #39's code status was Full Code/CPR. An IPOST dated [DATE], documented that this resident was a DNR. A CPR policy that was revised on 11/2019, directed staff that the facility provides Basic Life Support (BLS) CPR only. The physician's order for full code or Do Not Resuscitate is written based on the wishes of the resident/resident representative or legally authorized party. Advanced Directives will be honored during the code process. Do Not Resuscitate order means CPR will not be initiated in the absence of pulse or respirations.

Based on clinical record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments in a timely manner using the Resident Assessment Instrument (RAI) directed by Centers for Medicaid and Medicare Services (CMS) for 2 of 18 residents reviewed (Residents #2 and #27). The facility reported a census of 44 residents. Findings include: Review of facility form titled Clinical MDS Scheduler documented the following: a. Resident #2 quarterly assessment due 10/8/22, overdue and in progress. b. Resident #27 quarterly assessment due 10/29/22 overdue 4 days. Review of facility policy titled Quarterly Care Management dated 5/14 quarterly MDS assessments are to be completed as scheduled. During an interview 11/1/22 at 4:50 PM, the Director of Nursing revealed it is an expectation MDS assessments are completed in a timely manner. During an interview 11/2/22 at 1:35 PM, the Regional Director of Clinical Services revealed the MDS is to be completed as directed in the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, facility record review and staff interview, the facility failed to provide the opportunity for the resident representative and/or resident to participate in the development, review and revision of his care plan on a quarterly basis for 1 of 12 residents reviewed (Resident #27). The facility reported a census of 44 residents. Findings include: The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #27 had an admission date of 1/3/22 and had a Brief Interview for Mental Status score of 3 out of 15 indicating severely impaired cognition. The MDS further documented the resident had a diagnoses of non-Alzheimer's dementia. During an interview 10/25/22 at 1:18PM, the power of attorney for Resident #27 reported she had not been invited to care conference since Resident #27's admission. Review of facility policy titled, Clinical Care Management-Care Review, dated May 2014 revealed the purpose of a Care Review is to align expectations of service and care and include the resident and family in the care planning process. The policy directed staff to schedule a Care Review no less than quarterly to provide the resident and family/responsible party with information and updates and discuss any revisions or changes needed to the care plan. Facility record review revealed an invitation to Resident #27's care conference dated 4/19/22 was sent to the family of Resident #27. The facility was unable to provide additional invitations to quarterly care conferences. During an interview 10/3/22 at 3:21 PM the Regional Director of Clinical Services acknowledged Resident #27's family had not received notification in regards to quarterly care conferences as expected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and observations, the facility failed to provide weekly assessments for non pressure skin impairments for 1 out of 8 residents (Resident #25). Review of this resident's record revealed weekly assessments were not documented. The facility reported a census of 44 residents. Findings include: A Minimum Data Set (MDS) dated [DATE] documented diagnoses for Resident #22 included non-Alzheimer's dementia, hip fracture and anemia. A Brief Interview for Mental Status revealed a score of 3 out of 15, which indicated severely impaired cognition. Resident #25 required extensive assist of 2 for dressing, personal hygiene, and bed mobility. A Care Plan revised on 9/7/22, documented that Resident #25 had a deep tissue injury to right heel, sacral shearing and had multiple skin tears related to immobility, cognitive decline, and need for assist with mobility. The care plan directed that a thorough head to toe skin assessment was to be performed by a licensed nurse weekly/per orders and PRN. The care plan directed that this resident had bladder incontinence related to dementia, impaired mobility, urgency and frequency due to decreased mobility, need for assist with toileting. It directed that this resident was at risk for skin impairment. An intervention directed that a thorough head to toe skin assessment was to be done weekly by licensed nurse. A Nursing admission Data Collection for reentry dated 8/25/2022 at 3:02 P.M., documented that Resident #25 had the following skin issues: - A pressure wound on her coccyx that had a dressing on it. - A right antecubital skin tear that had a dressing on it. - Bruising on his abdomen measuring the length was 5, the width was 6 and there was no depth - Right lower leg skin tear measuring the length was 3, the width was 2 and there was no depth A List of standard Weekly Skin Assessments documented assessments were done on the following dates: 10/28/2022 10/5/2022 8/11/2022 A List of Non-Pressure Weekly Skin Record documented assessments were done on the following dates: 10/5/2022 (6 assessment entries on 10/5/22) 10/5/2022 10/5/2022 10/5/2022 10/5/2022 10/5/2022 9/20/2022 (2 assessment entries on 9/20/22) 9/20/2022 8/17/2022 (3 assessment entries on 8/17/22) 8/17/2022 8/17/2022 8/8/2022 On 10/31/22 at 3:00 p.m., the Regional Director of Clinical Services, Staff B, stated the expectation is that both pressure ulcers and non pressure areas are to be measured weekly. Staff B acknowledged these were not being done. On 11/1/22 at 4:55 p.m., the Director of Nursing (DON), after a timeline of this resident's pressure ulcer and non pressure related wounds was requested, stated she could not produce one. She stated her expectation would be that weekly measurements were to be done for all wounds non pressure and pressure. She stated this was a problem and it would be of high priority for her to work on to ensure the process is consistent. A Skin Care and Wound Management policy dated 6/2015, directed staff that each resident was to be evaluated upon admission and weekly thereafter for changes in skin condition. The resident's skin condition is also re-evaluated with change in clinical condition an d upon return from hospital. New skin impairments were to be reported to supervising nurse. It directed to implement appropriate treatment protocols as ordered. It directed to evaluate effectiveness of interventions and modify interventions as needed. It directed to communicate any changes to the care giving staff, resident and/or family/responsible party and/or physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility policy review and staff interviews, the facility failed to assess and document on residents wounds for 3 of 4 residents reviewed (Resident #25, #35, #38). The facility reported a census of 44 residents. Findings include: The minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue), may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. Resident #35 admitted to the facility on [DATE]. The MDS assessment dated [DATE] had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #35 had the diagnosis of diabetes mellitus, anxiety disorder, depression, schizophrenia, and peripheral venous insufficiency. The MDS revealed resident needed extensive assistance of 2 for bed mobility, transfers, toileting and personal hygiene. Resident coded as frequently incontinent of urine and always incontinent of bowel. The MDS indicated Resident #35 had a pressure injury and was at risk for developing pressure injuries. It indicated the resident had 1 stage III pressure ulcer. Resident has a pressure reducing device for his chair and bed, nutrition or hydration interventions, pressure ulcer care, and application of ointments/medications. The Care plan dated 6/19/22 documented a focus area relating to Resident #35 being at risk for skin impairment due to incontinence and decreased mobility as well as resident having a stage III pressure wound related to venous insufficiency, diabetes mellitus and chronic skin issues. Interventions include to assist resident with positioning, encourage resident to elevate his legs in bed on pillows, use of a pressure reducing mattress on bed and cushion in wheel chair, assist with toileting/incontinence needs, observe skin with cares, and skin assessments weekly by a nurse, with bathing by a certified nursing assistant (CNA), and as needed. In an observation on 10/27/22 at 10:39 AM, Staff E, Registered Nurse (RN) completed treatments to Resident #35's right lower extremity and left lower extremity wounds. Staff E, RN removed the ace wrap, the conforming stretch gauze and the ABD pad (abdominal gauze pad-used to absorb discharges from abdominal and other heavily draining wounds) from the right lower extremity wound. Small scabbed areas noted near ankle. Aquaphor ointment applied to entire lower extremity. Covered with ABD pad, conforming stretch gauze and an ace wrap applied to hold the dressing in place. Staff E, RN then moved to the left lower extremity wound. She removed the ace wrap, conforming stretch gauze and the ABD pad from area. The wound on the shin area was open and had yellow drainage to area. The area surrounding the wound was macerated. Staff E, RN reported the area was warm to touch and the resident was nauseated and not feeling well but was afebrile. Staff E, RN measured the area at 3 centimeters (cm) x 1.5 cm and superficial in depth. The entire left lower extremity was a deep dark red color. Staff E, RN stated she needed to notify the physician of her finding and would get orders before completing the dressing change. In an observation on 10/27/22 at 11:33 AM, Staff E, RN completed the treatment to Resident #35's left buttock while resident stood in bathroom in front of the toilet. The wound area was superficial and red with no drainage or other signs of infection. The area was cleansed with normal saline and a border gauze applied to the area. Resident also had an abraded area on his left lower scrotum. Barrier cream was applied to the area. Resident was then assisted to sit back in his wheelchair with the assistance of 2 staff. In an observation on 10/27/22 at 11:40 AM, Staff E, RN reported she had spoken to the provider. She stated she was instructed to apply triple antibiotic ointment to the area and the provider was to come and check it later that day and change the order as appropriate. She was instructed to do a variance to the treatment at this time. Triple antibiotic ointment was applied to the area. Staff E, RN then covered the area with an ABD, conforming stretch gauze and an ace wrap to hold the dressing in place. Good infection control and hand washing was completed through all the dressing changes. Review of Pressure Ulcer Weekly Assessments revealed the facility did not complete weekly pressure wound assessments on the following dates since the initial pressure wound to the coccyx area was found on 7/9/22: 9/17/22, 9/24/22, 10/1/22, 10/15/22 and 10/22/22. Review of Non-Pressure Weekly Skin Records for Resident #35 revealed assessments were not being completed for the right lower leg (rear) wound (first observed on 11/3/21), left lower leg (front) wound (first observed on 2/14/22), a new left lower leg (Front) wound (first observed 6/17/22), left gluteal fold wound (first observed 9/7/22) and a new right lower extremity wound (first observed on 9/1/22). The facility failed to complete non-pressure weekly skin assessments for the following dates since January 2022: 1/12/22, 1/19/22, 3/16/22, 4/6/22, 4/13/22, 4/20/22, 4/27/22, 5/4/22, 5/11/22, 5/18/22, 5/25/22, 6/1/22, 6/8/22, 6/22/22, 7/6/22, 7/13/22, 8/3/22, 8/10/22, 8/17/22, 8/24/22, 8/31/22, 9/7/22, 9/14/22, 9/21/22, 9/28/22, 10/12/22, 10/19/22, and 10/26/22. Review of the Weekly Skin Assessments for Resident #35 since January 2022 revealed the facility failed to complete the weekly skin assessments on the following dates: 1/5/22, 1/12/22, 1/19/22, 3/9/22, 3/30/22, 4/20/22, 4/27/22, 5/4/22, 5/25/22, 6/15/22, 6/22/22, 8/3/22, 8/17/22, 9/14/22, 9/21/22, 10/12/22, and 10/22/22. 2. An MDS dated [DATE], documented diagnoses for Resident #22 included non-Alzheimer's dementia, hip fracture and anemia. The BIMS revealed a score of 3 out of 15, which indicated severely impaired cognition. Resident #25 required extensive assist of 2 for dressing, personal hygiene, and bed mobility. It documented that this resident was at risk of developing pressure ulcers and had one or more pressure ulcers. It documented that this resident had 1 unstageable pressure injury presenting as a deep tissue injury. A Care Plan revised on 9/7/22, documented that Resident #25 had a deep tissue injury to right heel, sacral shearing and had multiple skin tears related to immobility, cognitive decline, and need for assist with mobility. The care plan directed that a thorough head to toe skin assessment was to be performed by a licensed nurse weekly/per orders and PRN. The care plan directed that this resident had bladder incontinence related to dementia, impaired mobility, urgency and frequency due to decreased mobility, need for assist with toileting. It directed that this resident was at risk for skin impairment. An intervention directed that a thorough head to toe skin assessment was to be done weekly by licensed nurse. A Nursing admission Data Collection for reentry dated 8/25/2022 at 3:02 P.M., documented that Resident #25 had the following skin issues: - A pressure wound on her coccyx that had a dressing on it. - A right antecubital skin tear that had a dressing on it. - Bruising on his abdomen measuring the length was 5, the width was 6 and there was no depth - Right lower leg skin tear measuring the length was 3, the width was 2 and there was no depth A List of standard Weekly Skin Assessments documented assessments were done on the following dates: 10/28/2022 10/5/2022 8/11/2022 A List of Non-Pressure Weekly Skin Record documented assessments were done on the following dates: 10/5/2022 (6 assessment entries on 10/5/22) 10/5/2022 10/5/2022 10/5/2022 10/5/2022 10/5/2022 9/20/2022 (2 assessment entries on 9/20/22) 9/20/2022 8/17/2022 (3 assessment entries on 8/17/22) 8/17/2022 8/17/2022 8/8/2022 On 11/1/22 at 4:55 p.m., the Director of Nursing (DON), after a timeline of this resident's pressure ulcer was requested, stated she could not produce one. She stated the pressure ulcer documentation was not consistent and went from coccyx to sacrum to the upper right buttocks. She stated she verified the wound (that started out on the coccyx) at this time was on the upper right buttocks. She stated that weekly measurements had not been done. 3. An MDS dated [DATE], documented diagnoses for Resident #38 included pressure ulcer of the sacral region, diabetes and anxiety. The BIMS score was 13 out of 15 indicating intact cognition. This resident required extensive assist of 2 for bed mobility and personal hygiene. It documented that this resident was at risk of developing pressure ulcers and had one or more pressure ulcers. It documented he had 1 Stage 3 ulcer and one unstageable pressure injury presenting as a deep tissue injury. A Care Plan revised on 9/2/22, documented that this resident had a stage 4 pressure ulcer on his coccyx and a suspected deep tissue injury to his right heel and is at risk for infection and additional skin impairment due to decreased mobilization. It directed to assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. On 10/25/22 at 11:04 A.M., Resident #38 stated he had a blister on the back of his heel. He stated it developed at the facility and that it had broke open. This resident stated that there was a black patch (of skin) on his heel at this time. Resident #38 stated that they had told him that if he didn't' do what they said, he could lose his foot because he was diabetic. He stated he was supposed to elevate his foot twice a day. He stated when they did the treatment on his heel they put a heel pad on it. He stated that he had 5 toes left, 3 toes on his right foot and 2 toes on his left foot. He stated he had poor circulation in his legs. On 10/26/22 at 12:35 PM, Staff E, RN went into this resident's room to do the treatment on his heel. He was sitting in his wheelchair and did not want to lie down for the treatment. This resident's right foot was edematous. The RN measured this resident's heel and reported the following: 5 1/2 cm (centimeters) by 7 cm measurement of eschar (dead tissue) with 1 1/2 cm open area around the edging of the eschar and another approximately 1 1/2 cm of redness surrounding the open area of edging. There was yellowish sloughing skin around the redness. The resident reported pain. RN stated the area was warm to the touch. The resident became tearful during the treatment. He stated the wound hurt. The RN stated that Bactroban (an antibiotic ointment) was supposed to be used, but they were out of it. She stated she placed a call to the provider and obtained an order to use triple antibiotic ointment instead. She applied this ointment on open area around eschar. This resident stated that it burned. RN stated the necrotic piece (eschar) was not tight and it was movable a little bit and then on one end it was 'bobbing'. She stated this resident had a heel pad that was supposed to go over the heel but there wasn't any so she would have to use telfa (dressing) over the heel area. A timeline provided by the DON on 11/1/22 at 3:30 P.M., documented the following for Resident 38's right heel wound: - 8/30/22 at 11 :12 A.M. wound first noted, the Nurse Practitioner was notified at 11:47 A.M. The family was notified and treatment orders were received. The wound measurements were 4.0 cm (centimeters) x (by) 6 cm x 0 depth. -10/7/22 wound measurements were 6.6 cm x 6.7 cm x 0 depth -10/18/22 wound measurements were 7.0 cm x 6.0 cm x 0.0 cm -10/20/22 wound measurements were 7.0 cm x 6.0 cm x 0.0 cm -10/26/22 wound measurements were 7.0 cm x 6.2 cm x 0.0cm The DON acknowledged that weekly measurements had not been getting done when she provided this timeline. On 10/31/22 at 3:00 p.m., the Regional Director of Clinical Services, Staff B, stated the expectation is that pressure ulcers are to be measured weekly. Staff B acknowledged these were not being done. On 11/1/22 at 4:55 p.m., the DON stated her expectation would be that weekly measurements were to be done for all wounds non pressure and pressure. She stated this was a problem and it would be of high priority for her to work on to ensure the process is consistent. A Skin Care and Wound Management policy dated 6/2015, directed staff that each resident was to be evaluated upon admission and weekly thereafter for changes in skin condition. The resident's skin condition is also re-evaluated with change in clinical condition and upon return from hospital. New skin impairments were to be reported to supervising nurse. It directed to implement appropriate treatment protocols as ordered. It directed to evaluate effectiveness of interventions and modify interventions as needed. It directed to communicate any changes to the care giving staff, resident and/or family/responsible party and/or physician. It directed to document wound measurements and characteristics for Skin Grid-Pressure no less than weekly. More frequent documentation may be indicated based on changes in condition of wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interview, the facility failed to ensure pre and post assessments with hemodialysis treatments for one of one resident reviewed who required dialysis (Resident #10). The facility reported a census of 44 residents. Findings include: The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #10 had a brief interview for mental status (BIMS) of 12 moderate impaired cognition. The MDS documented a diagnoses of kidney failure and diabetes mellitus and revealed Resident #10 received dialysis treatment. Review of Clinical Physician Orders revised 1/26/22 revealed Resident #10 received dialysis on Tuesday, Thursday and Saturday. The Care Plan revised 3/2016 documented Resident #10 received hemodialysis related to renal (kidney) failure. Review of facility policy titled Dialysis Communication revised August 2015 revealed prior to resident departure to the dialysis center the nurse is responsible for recording the following information in the medical record to provide a method for communicating resident information between the nursing facility and the dialysis center: a. Room number b. Transportation and phone number c. Vital signs d. Departure time e. Last blood sugar f. Dietary concerns g. Any medications given pre dialysis and medications to be taken at dialysis h. Any change since last dialysis i. Special instructions to dialysis if any Review of electronic health record (EHR) assessments for Resident #10 for the past 12 months revealed Dialysis Communication assessments had been completed on the following dates: a. 7/31/22 b. 10/19/22 c. 10/24/22 d. 10/26/22 e. 10/28/22 The EHR lacked additional Dialysis Communication assessments. During an interview 10/31/22 at 2:50PM the Regional Director of Clinical Services acknowledged dialysis communication assessments had not been completed as expected for Resident #10.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and staff interview, the facility failed to ensure expired stock medications were discarded and refrigerator temperatures were checked daily to avoid compromising the potency of the medications. The facility reported a census of 44 residents. Findings include: 1. An observation on [DATE] at 2:35 PM with Staff F, Licensed Practical Nurse (LPN) present, revealed the medication room on the north end contained the following: a. One unopened bottle of Vitamin D3 XL 5,000 units that expired 5/22 b. Thirteen unopened bottles Aspirin 325 mg that expired 9/22 2. An observation on [DATE] at 2:50 PM with Staff A, Certified Medication Aide (CMA) present, revealed the medication room on the south end contained the following: a. One unopened bottle of Aspirin 325 mg that expired 5/22 b. Two unopened bottles Maximum Strength Relief Tabs that expired 9/22 c. Four unopened vials of stock COVID-19 vaccinations in the refrigerator that expired 7/22 3. In an observation of the two medication rooms on [DATE] with staff F, LPN present for the north medication room and Staff A, CMA present for the south medication room, revealed the staff had not completed refrigerator temperature checks on either medication refrigerator since August of 2022. The surveyor checked the temperatures and the north refrigerator temperature was 38 degree Fahrenheit (F) and the south refrigerator temperature was 32 degrees F. In an interview on [DATE] at 11:08 AM, Staff C, Regional Director of Clinical Services stated it was the expectation the nurse/medication aide check the expiration date on stock medications prior to removing them from the stock supply to put in use. She further stated it was the expectation the medication refrigerator temperatures be checked two times daily. Per a facility provided policy titled Storage and Expiration Dating of Medications, Biologicals last revised on [DATE], stated the facility should ensure medication and biologicals that have an expired date or have been retained longer than recommended by the manufacturer are stored separately from other medications until destroyed or returned to the pharmacy or supplier. It further stated the facility should monitor the temperature of medication storage areas at least 1 time per day and should monitor cold storage containing vaccines 2 times a day per CDC guidelines.

Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualification in the absence of a full-time dietician. The facility reported a census of 44 residents. Findings include: During an interview 10/31/22 at 10:00AM the facility Dietician revealed she is contracted out and works at the facility 1 day a week on Mondays. Facility document titled, Nutrition Services, dated June 2015 revealed the Nutrition Services Manager/Food Service Manager may be qualified as a Certified Dietary Manager or meets further qualifications per state regulations. During the entrance conference 10/25/22 at 8:00 AM, the Administrator revealed the facility did not have a Certified Dietary Manager (CDM) at the facility and they had been looking for one for over 1 year.

Based on facility record review and staff interview, the facility failed to maintain a Quality Assessment and Assurance committee to oversee the Quality Assurance Performance Improvement Plan (QAPI). The facility reported a census of 44 residents. Findings include: Interview on 11/02/22 at 11:47 the Regional Director of Clinical Services with the Director of Nursing (DON) relayed the last Quality Assurance Performance Improvement Plan (QAPI) meeting was held in early in 2022 with the former administrator. The DON could not locate any records for any QAPI meetings in 2022. The DON relayed she had not participated in any formal QAPI meetings. The DON relayed understanding of the minimum of quarterly QAPI meetings is the expectation. Record review of facility provided standard and guidelines for risk management/quality assurance performance improvement plan revealed the Risk management/QAPI committee will meet monthly and would consist of no less than five members, appointed by the administrator to include the administrator, DON, Infection Preventionist, Medical director or Physician designee and a t least two additional facility staff.

Based on facility documentation, policy review, and staff interview, the facility failed to offer an option of acceptance or refusal for the pneumovax vaccination for 1 of 5 residents reviewed (Resident #32). The facility reported a census of 44 residents. Findings Include: The vaccination record provided by the facility for resident #32 lacked documentation of the second pneumovax vaccination. On 10/27/22 at 1:20 p.m. the nurse consultant stated the facility is not able to locate documentation whether resident #32 received the second pneumovax vaccination. The policy provided by the facility subject titled Immunizations for residents, standard and guidelines titled infection prevention stated counsel on benefits, adverse effects of each vaccine, complete the request/consent each time offered and place in the medical record. The policy outlines recommendations on when the second pneumococcal vaccine dose should be given based on pneumococcal vaccine type and when the first was given.

Based on facility documentation, policy review, and staff interview, the facility failed to offer an option of acceptance or refusal, to provide education of benefits and risks of the COVID 19 vaccination for 1 of 5 residents reviewed (Resident #38). The facility reported a census of 44 residents. Findings Include: The vaccination record provided by the facility for Resident #38 the lacked COVID 19 vaccination information. On 10/27/22 at 1:20 p.m. the nurse consultant stated the facility is not able to produce a declination for the COVID 19 vaccination for Resident #38. The policy provided by the facility subject titled COVID-19 immunizations: employee, Standard and guidelines: infection prevention stated all employees will be provided education related to benefits, potential risk and side effects of the COVID-19 vaccine in a manner they can understand. All employees will be offered the COVID-19 vaccination per the CDC, FDA and manufacture guidelines, when available to the facility and/or provide information on where they can obtain the vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an environmental tour of the facility on 10/25/22 the following was identified: a. room [ROOM NUMBER]-2: wall beside bed was badly scratched b. room [ROOM NUMBER]-2: wall at the head of the resident's bed was badly scuffed c. room [ROOM NUMBER]: carpet on floor of the entire room was badly stained and black in color d. room [ROOM NUMBER]: carpet on the floor was stained e. Hallway outside room [ROOM NUMBER]: carpet on the floor had dark stains f. room [ROOM NUMBER]: bathroom doorframe and bathroom wall were badly gouged and scuffed g. Hallway outside room [ROOM NUMBER]: Carpet on the floor had a large dark stain h. room [ROOM NUMBER]: carpet on the floor had numerous dark stains i. Hallway outside room [ROOM NUMBER] - carpet on the floor had dark stains Based on observation and staff interview, the facility failed to maintain a clean, homelike environment with multiple visible stains on the carpet and walls in resident's rooms in need of repair. The facility reported a census of 44 residents. Findings Include: 1. Observations 10/25/22 at 11:35 AM revealed multiple visible stains on the carpet in the resident care area hallways. Review of the undated facility admission policy revealed the facility will provide a safe, clean, comfortable and homelike environment. The policy documented the facility is required to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. During an interview 11/2/22 at 9:31 AM, the Administrator revealed he would expect the carpet to be presentable and free of multiple large stains. During an interview 11/2/22 at 11:05 AM the Regional Director of Clinical Services revealed the expectation would be for the walls to be kept in good repair. During an interview 11/2/22 at 9:11 AM, the Regional Director of Clinical Services revealed there is not a facility policy specific to cleaning floors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, policy review and resident and staff interviews, the facility failed to provide bathing as prescribed for 7 of 12 residents reviewed (Resident #13, #15, #21, #22, #35, #39, #41). The facility reported a census of 44 residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE], identified Resident #13 had a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS documented during the 7 day observation period for gathering of information for this MDS, the resident required the supervision of 1 staff for transfers and toileting, extensive assistance of 1 staff for personal hygiene and was totally dependent on 1 staff person for bathing. The MDS documented diagnosis that included seizure disorder, depression, schizophrenia, and mild intellectual disabilities. The care plan focus area revised 8/3/22 identified a need for assistance with activities of daily living including set up assistance with dressing and personal hygiene and assistance with TED hose. The POC (plan of care) Response History (electronic documentation by staff for care) with a look back of 30 days and printed on 10/31/22 at 10:58 AM, the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: - 10/5/22 at 8:55 PM not applicable - 10/12/22 at 9:14 PM physical help in part of bathing activity - 10/19/22 at 9:09 PM physical help in part of bathing activity Per documentation Resident #13 received 2 of 9 scheduled showers for the months of October. Resident #13 was to receive showers on Wednesdays and Saturdays. The facility lacked documentation of providing the resident with a shower on 10/1, 10/5, 10/8, 10/15, 10/22, 10/26, and 10/29 and there were no documented refusals. In an interview on 10/31/22 at 11:30 AM Resident #13 reported during a Resident Council meeting, she was to receive showers on Wednesdays and Saturdays. She stated staff frequently told her they do not give showers on the weekends or they did not have enough staff to give her a shower. 2. A MDS assessment dated [DATE], identified Resident #35 had a BIMS score of 15 indicating intact cognition. The MDS documented during the 7 day observation period for gathering of information for this MDS, the bathing activity had not occurred and the resident required extensive assistance of 2 staff for bed mobility, transfers, toileting and personal hygiene. The MDS documented diagnosis that included diabetes mellitus, anxiety disorder, depression, and schizophrenia. The care plan focus area revised 6/19/22 identified a need for assistance with activities of daily living including assistance of 2 staff with transferring back to the wheelchair and changing incontinency product, changing clothing, personal hygiene and assisting out of bed. Resident requested 3 showers per week. The POC Response History with a look back of 30 days and printed on 10/31/22 at 10:50 AM, the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: - 10/3/22 at 10:39 AM total dependence - 10/5/22 at 1:29 PM physical help in part of bathing activity - 10/10/22 at 10:34 AM physical help in part of bathing activity - 10/12/22 at 10:13 AM physical help in part of bathing activity - 10/17/22 at 1:59 PM physical help in part of bathing activity - 10/19/22 at 10:52 AM physical help in part of bathing activity - 10/21/22 at 11:48 AM physical help limited to transfer only - 10/24/22 at 10:32 AM physical help in part of bathing activity - 10/28/22 at 10:54 AM physical help limited to transfer only Per documentation Resident #35 received 9 of 13 scheduled showers for the month of October. Resident #35 was to receive showers on Mondays, Wednesdays and Fridays. The facility lacked documentation of providing the resident with a shower on 10/7, 10/14. 10/26, and 10/31 and there were no documented refusals. In an interview on 10/25/22 at 10:44 AM, Resident #35 stated he was to get showers on Mondays, Wednesdays and Fridays. He stated he got his shower most of the time but the facility was short staffed and they did not always have time to give it to him. 3. A MDS assessment dated [DATE], identified Resident #41 had a BIMS score of 12 indicating moderate cognitive impairment. The MDS documented during the 7 day observation period for gathering of information for this MDS, the resident was independent with bed mobility, transfers and toileting and required supervision with personal hygiene and bathing. The MDS documented diagnosis that included transient cerebral ischemic attack, depression, polyneuropathy and muscle wasting and atrophy. The care plan focus area revised 4/27/22 identified a need for assistance with activities of daily living including assistance of 1 staff for bathing, staff assistance with nail care on bath days, and to assist the resident with a sponge bath when a full bath or shower could not be tolerated. The POC Response History with a look back of 30 days and printed on 10/26/22 at 4:07 PM, the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in-out of tub/shower (excludes washing of back and hair) documented the following: - 9/28/22 at 9:13 PM supervision-oversight help only - 10/1/22 at 9:57 PM resident refused - 10/5/22 at 8:52 PM resident refused - 10/12/22 at 9:16 PM resident refused - 10/19/22 at 9:10 PM resident refused Per documentation Resident #41 received 1 of 8 scheduled showers for the 30 days reviewed. Resident #41 was to receive showers on Wednesdays and Saturdays. The facility lacked documentation of providing the resident with a shower on 10/8/22, 10/15/22, and 10/22/22. There were 4 documented refusals. In an interview on 10/26/22 at 9:32 AM, Resident #41 stated she had not received a shower for at least 2 weeks. She stated she felt they were too short staffed. In an interview on 10/27/22 at 2:55 PM, Resident #41 reported she had not been offered a shower for greater than 2 weeks. She denied she had been refusing showers. She stated they had not asked her until the previous night. She stated she did refuse as she was already in bed when they offered the shower. She requested one the next evening but the staff told her they may not have time or the staff to complete her shower at that time. 6. A MDS dated [DATE] documented Resident #15 had a BIMS score of 15 out of 15 indicating intact cognition. The MDS documented Resident #15 required extensive physical assistance of 1 staff with hygiene. During an interview 10/25/22 at 3:00 PM, Resident #15 revealed he received showers unless the facility didn't have enough staff. Resident #15 further stated he had to wait 1 ½ weeks a couple weeks ago to get a shower. The POC Response History with a look back history of 30 days printed 10/31/22 at 10:22 AM with the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: -10/4/22 at 12:11 PM total dependence -10/7/22 at 1:52 AM not applicable -10/11/22 at 10:46 AM total dependence -10/18/22 at 10:54 AM physical help limited to transfer only -10/21/22 at 1:59 PM total dependence -10/25/22 at 1:59 PM total dependence -10/28/22 at 12:26 PM total dependence 7. A MDS dated [DATE] documented Resident #21 had a BIMS of 15 indicating intact cognition. The MDS documented Resident #21 required extensive physical assistance of 1 staff for hygiene. During an interview 10/25/22 at 2:34 PM, Resident #21 revealed there was a time he wasn't getting showers but he was now. The POC Response History for Resident #21 with a look back history of 30 days printed 11/1/22 at 9:27 AM with the prompt: Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) lacked documentation in regards to completion of bathing. Review of facility protocol titled, Bathing, dated January 2013 revealed the purpose of bathing as the following: -Clean skin and shampoo hair -Increase circulation -Exercise body parts -Reduce tension -Promote comfort while maintain safety and dignity The Bathing protocol further directed staff to provide the resident the opportunity to bathe according to preference and facility procedure. During an interview 11/01/22 at 10:04 AM, the Director of Nursing and the Regional Director of Clinical Services acknowledged Resident #21 did not have a shower in the past 30 days and he had one that morning. The Regional Director of Clinical Services further acknowledged showers not being given is an issue. During an interview 11/01/22 at 9:17 AM, the Regional Director of Clinical Services revealed showers are expected to be documented if given. 4. A MDS dated [DATE], documented that Resident #22's MDS score was 13 out of 15 indicating her cognition was intact. It documented during the 7 day observation period for the gathering of information for this MDS, that the bathing activity had not occurred. On 10/25/22 at 3:34 PM, Resident #22 stated that she had gone 15 days before without a shower. She stated she should have gotten a shower on this morning but the CNA that was supposed to give her a shower went home with a fever. A review of this resident's POC Response History (electronic documentation by staff for care) revealed that on 10/25/22 resident refused a shower and this was documented by Staff A, CNA. On 10/27/22 at 12:41 PM, Staff A, CNA stated that Resident #22 declined her shower on 10/25/22. She stated that Resident #22 was offered a shower by another CNA and Resident #22 refused her shower. She stated that this resident liked her shower down very early in the morning, before 6:00 a.m. When told it was Staff A's signature on the [NAME] that signed the refusal on 10/25/22, Staff A looked confused. Staff A then said that another CNA had told Staff A that Resident #22 refused her shower on 10/25/22. Staff A stated the other CNA went home sick that day and probably didn't sign the refusal before she left, so that's why this CNA would have signed the refusal. When asked if the other CNA was working on this day, Staff A said that the other CNA was not working as the other CNA was still off work sick. When asked about residents going without showers, Staff A stated that when there are only 3 CNAs instead of 4 it is difficult to get showers done. She said the following shift tries to pick them up or they try to pick up the showers the next day. When asked why the residents would say they haven't received their 2 showers a week, she repeated they try to give them their showers the next shift or next day if one is missed. When told there was greater than 7 days between some of the showers per the [NAME] for Resident #22, Staff A stated that often agency staff are part of their daily staff and they do not document like they should. Staff A stated she had told the Director of Nursing (DON) about the lack of documentation by the agency staff. Staff A understood that it is a problem when the showers weren't documented, coupled with residents voicing that they are not receiving 2 showers a week. The POC (plan of care) Response History with a look back history of 30 days and printed on 10/25/22 at 4:09 P.M., the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: -9/27/22 at 1:48 P.M. physical help limited to transfer only -9/30/22 at 11:17 A.M. resident refused -10/2/22 at 10:08 A.M. not applicable -10/9/22 at 1:47 P.M. resident refused -10/18/22 at 1:46 P.M. physical help in part of the bathing activity -10/20/22 at 9:16 P.M. physical help in part of the bathing activity -10/25/22 at 1:59 P.M. resident refused 5. A MDS dated [DATE], documented that Resident #39's MDS score was 13 out of 15, which indicated this resident's cognition was intact. It documented during the 7 day observation period for the gathering of information for this MDS, that the bathing activity had not occurred. On 10/25/22 at 11:28 AM, Resident #39 stated she wanted showers every day or maybe every other day so she could use her body wash. She stated they give showers twice a week. Resident #39 stated one time she went without showers for 3 weeks. She stated that was 4 to 5 months ago. She didn't know why she went so long without a shower. She said now she received them twice a week and she was due for one the following day. The POC (plan of care) Response History with a look back history of 30 days and printed on 10/26/22 at 3:34 P.M., the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: -9/28/22 at 1:58 P.M. not applicable -10/5/22 at 1:32 P.M. not applicable -10/8/22 at 1:59 P.M. supervision-oversight help only -10/19/22 at 9:40 P.M. supervision-oversight help only On 11/1/22 at 4:31 p.m., the Director of Nursing (DON) stated the facility's expectation was that residents received showers twice a week unless they request less or more showers. She stated they try to honor the residents' choices. The DON stated she expected documentation of resident's showers would be done and that shower refusals would get documented. In an email correspondence on 11/7/22 at 10:51 A.M., Staff B responded that the NA (not applicable) response would likely indicate the shower wasn ' t completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. In an observation on 10/26/22 at 7:47 AM, Staff D, Director of Nursing (DON) locked the medication cart and walked a way to get some supplies and left the keys sitting on top of the medication cart. Staff D, DON realized what she had done and returned for the keys at 7:48 AM acknowledging she had left the keys on top of the cart. The cart was outside a resident's room but no other residents were in the vicinity. 3. In an observation on 10/26/22 at 8:52 AM, Staff E, RN left the medication cart unlocked and unattended from 8:52 AM to 8:55 AM when she walked away to pass a medication to a resident down the hall. The medication cart was located in the entry to the dining room and 3 residents and 2 staff walked by the cart during this time. At 8:55 AM, Staff E, RN returned and acknowledged she left the cart unlocked and unattended. Review of facility policy titled, Medication Administration, revised on 2/27/20 revealed staff were to lock the medication cart before entering a resident/patient's room. They were never to leave the medication cart open and unattended. In an interview on 10/27/22 at 9:29 AM, Staff C, Regional Director of Clinical Services stated it was the expectation that anytime staff were not present at the medication cart, the cart would be locked and the screen hidden. Based on observations, interviews and record review, the facility failed to provide a safe environment, when 1 resident (Resident #43) was reviewed for a fall out of a hoyer lift, and twice the medication cart was left unattended with the ability for resident's to access the cart. A hoyer lift tipped over on to it's side during a transfer with Resident #43 in the lift. The medication cart keys were left unattended on a medication cart and a medication cart was left unlocked without staff attending to the cart. The facility reported a census of 44 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #43 included diabetes, muscle weakness and anxiety. A Brief Interview for Mental Status (BIMS), revealed a score of 15 out of 15, which indicated intact cognition. This resident required total dependence of 2 staff for transfers. A Care Plan with a revision date of 3/2/18, documented that Resident #43 had ADL Self Care Performance Deficit related to laminectomy, impaired mobility, non-ambulatory, COPD (Chronic Obstructive Pulmonary Disease), diabetes, hypertension, anxiety, ulcerative colitis, hypokalemia (low potassium), thrombocytopenia, obesity, depression, insomnia, sleep apnea and incontinence. A goal revised on 3/17/22, documented that this resident would maintain current level of function through the review date. An intervention with a revision date of 3/2/18, directed staff that an assist of 2 was to be done with transfers with hoyer lift and that this resident was non ambulatory. It documented that an assist of 2 to get in/out of bed with hoyer lift. Assist of 2 to reposition. On 10/25/22 at 12:10 PM, Resident #43 stated that he had tipped over in the hoyer (lift used for transfers). He stated it was regular staff that was transferring him and it happened about 2 months ago. This resident stated he had been at the facility for 6 years and the hoyer tipping over during a transfer had never happened. He stated he had just returned from the hospital and wasn't hurt . He stated he was a little bruised on his back and arms. An email from the Regional Director of Clinical Services (Staff B) dated 11/1/22 at 3:03 P.M., documented the following responses to questions asked in a previous email: Response from Regional Director of Clinical Services: -On 8/7/22 DE fell when the hoyer tipped over. Can I see the IR (incident report) for it and the follow up investigation? -Was there education? Yes reeducation was provided verbally by the Director of Nursing DON to the Certified Nurse Aides (CNAs) involved with the transfer and educated that the legs of the Hoyer must be opened all the way to allow for stability while using the Hoyer -Was the Hoyer removed? Yes the Hoyer was removed from use until inspected and cleared by maintenance to be put back in use. Progress Notes documented the following: -On 8/7/22 at 4:00 P.M., Called to resident's room by staff, entered room and observed resident hooked up to hoyer lift et note hoyer tipped over on floor, resident still in [NAME] sling attached to the lift. Resident lying in supine position between his wheelchair and bed, with 2 CNA's at resident's side at this time. Vital Signs obtained 96.8 was his temperature, 105 was his pulse, respirations were at 20 and Blood Pressure was 142/78. Resident requested this nurse not complete ROM (range of motion)to his legs, reported to this nurse his knees don't bend. No internal/external rotation to BLE (bilateral lower extremities) noted no shortening or lengthening noted. Noted skin tear to RFA (right forearm) surrounded by dark purple bruise, skin tear measured 4.5 x 0.4 cm (centimeters), bruise measured 4.5x4.0 cm. Resident and CNA's report that CNA's were transferring resident from his wheelchair to his bed when the hoyer lift tipped as they began to roll it towards the bed; CNA's unable to prevent hoyer lift from falling, so they attempted to ease resident's fall by holding up straps as the lift fell to prevent any equipment from hitting resident. Resident reports CNA did keep his head from hitting the floor but resident did land on his back. Resident denied any more pain than his usual. Skin tear cleansed with wound cleanser, patted dry, approximated and dressed with steri strips, and covered with Telfa (dressing). Resident's #1 notified, DON and ARNP (Advanced Registered Nurse Practitioner) notified of incident. -On 8/7/2022 at 11:44 P.M., Follow up on the fall from today. Resident explained to this nurse how his fall happened and that it scared him. He said, I'm okay though. Res ROM (range of motion) was per his usual. He was not able to move his legs. He was alert. He was having no more pain than usual. He complained of some back discmfort at a 6 (on a scale of 0-10). He has had his scheduled Lortab (pain medication). He was an assist x 2 with bed mobility. He wore a brief and was incontinent of B/B (bowel and bladder). He was pleasant with this nurse. Call light was in his reach. An incident report documented the same information as the progress note entry on 8/7/22 at 4:00 P.M. On 11/01/22 at 4:55 P.M., the Director of Nursing (DON), stated she was unable to provide education attendance after this fall. She was not able to provide notes from an investigation. She stated she needed to get better at writing stuff down. At the same time as the above interview, Staff A, CNA stated she was with another staff person when they lifted this resident up from his bed. She said they pulled the hoyer lift out from under the bed and she was trying to open the legs. She stated the resident started to sway side to side and the hoyer lift tipped over. She stated it all happened so fast. On 11/1/22 at 4:31 P.M., the DON stated Staff H, CNA was the other CNA that assisted with this resident's transfer. On 11/1/22 at 5:05 P.M., the Regional Director of Clinical Services stated they contacted the maintenance staff and he said he did not do a work order nor documentation on the hoyer lift. On 11/2/22 at 9:50 P.M., Resident #43 stated the fall scared him at first. He stated it happened so fast. He stated he did not feel the girls operated the hoyer lift the same as they usually did. He stated he was told they pulled the hoyer lift and fixed it. On 11/02/22 12:03 PM Staff H, CNA, stated that Staff A was her partner that day. Staff H stated it was really hard to explain what happened because it happened so fast. She stated they went to open the legs (on the hoyer lift) and the legs wouldn't open. She stated that both back tires (of the wheelchair (w/c)) were inside the hoyer lift's legs. She said they were transferring Resident #43 from the w/c. She said this resident could not bend his legs so they had to go from the side of the w/c. She stated this resident had a hold of the sling straps when he was in the chair and they thought he kind of pushed himself back. He had a hold of the bottom straps and was pushing back. She stated the hoyer legs were opened slightly because they had to be to get around the back tires. She stated then the hoyer legs wouldn't open any further. She stated that Staff A was running the hoyer lift and Staff H was standing in front of this resident's legs. It happened so fast. Staff H stated that Staff A was trying to open the legs on the hoyer lift and they wouldn't open. She stated that Staff A was pulling the hoyer away from the wheelchair, and he just went down. Staff H stated they had never had a problem like that before. Staff H stated the DON did education after with Staff A and Staff H. Staff H stated they took the hoyer lift out of commission right away. On 11/2/22 at 3:35 P.M., Staff G, CNA and Staff I, CNA transferred Resident #43 from his w/c to his bed. The legs of the hoyer lift were closed and on each side of the front wheels. The w/c was parallel to the bed with the hoyer perpendicular to the bed. The CNAs lifted resident up. Tipped the w/c back slightly to lift the front wheels over the hoyer lift leg, then pulled the w/c out of the way. They then pushed the hoyer forward and lowered resident to the bed. They did not widen the hoyer legs. When asked if they should have opened the legs, Staff G stated that is how this resident wants it done. Staff I stated that was how she was told to do it. When asked if they had been taught how to use a lift, Staff G stated she has worked at this facility for 26 years and if she was doing it wrong then she would like to know. Staff I repeated she just did the lift like she was told to do. This resident, when asked if he had a preference, stated he just knew that the legs were opened to get around the wheelchair. The staff were able to open the legs using the button on this lift when asked to, directly after this observation. On 11/02/22 at 3:41 P.M., the DON stated that the legs should be opened on the hoyer from the time the resident is lifted up through the transfer until a resident is lowered back down. The DON acknowledged that the above observation should have had the legs of the hoyer lift open. The DON stated she talked with the maintenance staff person and he said he does think he replaced an item on the lift. A copy of manufacturer's guidelines were requested. The Regional Director of Clinical Services acknowledged the transfer was a concern. On 11/02/22 at 4:24 P.M. the Maintenance Supervisor, Staff J, stated there were 2 hoyer lifts. He stated the lift was in the DON's office. He thought it was in the DON's office for 2 days. He stated there were 2 rods that push the legs out on the hoyer lift. One of the rods was bent. He stated he straightened the rod and then put it back into commission. He stated he did not document on this. When asked if there was a work order system in place, he said no. He stated they just leave me notes when there is something I need to work on. An undated Invacare Reliant Battery Powered Patient lift user manual, directed the following: -with the legs of the base open and locked, use the steering handle to push the patient lift into position. -lower the patient lift for easy attachment of the sling -place the straps of the sling over hooks of the hanger bar -match the correspondnig colors on each side of the sling for an even lift of the patient -use the lift -press the up button to raise the patient above the bed. The patient should be elevated high enough to clear the bed. When the patient is lifted from the bed, he/she will be raised to a sitting position. -whenthe patient is clear of the bed surface swing their feet off the bed -using the steering handle, move the lift away from the bed -when moving the patient lift away from the bed, turn the patient so that he/she faces assistant operating the patient lift -press the down button lowering patient st that his feet rest on the base of the lift stradding the mast. -pull the patient away from the bed and thenpushe it from behind with both hands firmly onthe steering hadle

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #7 admitted to the facility on [DATE]. The MDS dated [DATE] revealed Resident #7 had a BIMS score of 15 indicating intact cognition. Resident #7 had diagnoses including hypertension, benign prostatic hyperplasia, anxiety disorder, bipolar disorder, and schizoaffective disorder. The MDS revealed the resident was independent with bed mobility and toileting and needed supervision with transfers and personal hygiene. Resident #34 admitted to the facility 9/15/22. The MDS dated [DATE] revealed Resident #34 had a BIMS score of 4 indicating severe cognitive impairment. Resident #34 had diagnoses including cancer, coronary artery disease, cirrhosis of the liver, diabetes mellitus, cerebrovascular incident, Parkinson's disease, anxiety disorder and depression. The MDS revealed the resident was independent with bed mobility and required supervision for transfers, toileting and personal hygiene. On 10/27/22 at 10:30 AM the surveyor was seated at a dining room table with Resident #7 as he had requested to see the surveyor. Resident #34 entered the dining room ambulating with a cane. He was walking into the area when Resident #7 saw him and instantly became angry. Resident #7 yelled at Resident #34 stating he had better watch himself or he would knock him on his butt. Resident #34 responded Shut the hell up! and continued to walk forward. Resident #7 then stated he would beat the hell out of him. Resident #34 then stopped at the table where Resident #7 was seated with the surveyor and raised his cane and said, Bring it on, you son of a bitch! There were no staff present or in the vicinity. The surveyor stood up and stepped between the 2 residents and asked Resident #34 to please just keep walking and ignore Resident #7. At that time Staff C, Director of Clinical Services came into the dining room after hearing the commotion and intervened and was able to separate the 2 residents. Resident #34 moved on and found a seat elsewhere in the dining room and Resident #7 calmed down and stayed seated. The facility failed to ensure staff were available and present in the vicinity to observe the area and residents in the dining room. Progress notes dated 10/27/22 at 3:41 PM by Staff E, RN for Resident #7 stated the resident had an outburst this AM in the dining room. He threatened a peer. He refused all medications this AM. No further behaviors this shift. In an interview on 11/7/22 at 11:06 AM Staff C, Regional Director of Clinical Services stated the expectation was that residents would be free of harm and altercation. If a resident had a history of altercations (behaviors), their care plan would address interventions for the behaviors as needed. The facility provided Abuse Prevention Program and Reporting policy revised 8/19 under Resident to Resident Abuse Procedures, the policy stated the facility is to ensure prevention techniques are implemented including ongoing supervision of residents through visual observation. 3. A Minimum Data Set (MDS) assessment dated [DATE], identified Resident #13 had a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS documented during the 7 day observation period for gathering of information for this MDS, the resident required the supervision of 1 staff for transfers and toileting, extensive assistance of 1 staff for personal hygiene and was totally dependent on 1 staff person for bathing. The MDS documented diagnosis that included seizure disorder, depression, schizophrenia, and mild intellectual disabilities. The care plan focus area revised 8/3/22 identified a need for assistance with activities of daily living including set up assistance with dressing and personal hygiene and assistance with TED hose. The POC (plan of care) Response History (electronic documentation by staff for care) with a look back of 30 days and printed on 10/31/22 at 10:58 AM, the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: - 10/5/22 at 8:55 PM not applicable - 10/12/22 at 9:14 PM physical help in part of bathing activity - 10/19/22 at 9:09 PM physical help in part of bathing activity Per documentation Resident #13 received 2 of 9 scheduled showers for the month of October. Resident #13 was to receive showers on Wednesdays and Saturdays. The facility lacked documentation of providing the resident with a shower on 10/1, 10/5, 10/8, 10/15, 10/22, 10/26, and 10/29 and there were no documented refusals. In an interview on 10/31/22 at 11:30 AM Resident #13 reported during a Resident Council meeting, she was to receive showers on Wednesdays and Saturdays. She stated staff frequently told her they do not give showers on the weekends or they did not have enough staff to give her a shower. 4. An MDS assessment dated [DATE], identified Resident #35 had a BIMS score of 15 indicating intact cognition. The MDS documented during the 7 day observation period for gathering of information for this MDS, the bathing activity had not occurred and the resident required extensive assistance of 2 staff for bed mobility, transfers, toileting and personal hygiene. The MDS documented diagnosis that included diabetes mellitus, anxiety disorder, depression, and schizophrenia. The care plan focus area revised 6/19/22 identified a need for assistance with activities of daily living including assistance of 2 staff with transferring back to the wheelchair and changing incontinency product, changing clothing, personal hygiene and assisting out of bed. Resident requested 3 showers per week. The POC Response History with a look back of 30 days and printed on 10/31/22 at 10:50 AM, the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: - 10/3/22 at 10:39 AM total dependence - 10/5/22 at 1:29 PM physical help in part of bathing activity - 10/10/22 at 10:34 AM physical help in part of bathing activity - 10/12/22 at 10:13 AM physical help in part of bathing activity - 10/17/22 at 1:59 PM physical help in part of bathing activity - 10/19/22 at 10:52 AM physical help in part of bathing activity - 10/21/22 at 11:48 AM physical help limited to transfer only - 10/24/22 at 10:32 AM physical help in part of bathing activity - 10/28/22 at 10:54 AM physical help limited to transfer only Per documentation Resident #35 received 9 of 13 scheduled showers for the month of October. Resident #35 was to receive showers on Mondays, Wednesdays and Fridays. The facility lacked documentation of providing the resident with a shower on 10/7, 10/14. 10/26, and 10/31 and there were no documented refusals. In an interview on 10/25/22 at 10:44 AM, Resident #35 stated he was to get showers on Mondays, Wednesdays and Fridays. He stated he got his shower most of the time but the facility was short staffed and they did not always have time to give it to him. 5. An MDS assessment dated [DATE], identified Resident #41 had a BIMS score of 12 indicating moderate cognitive impairment. The MDS documented during the 7 day observation period for gathering of information for this MDS, the resident was independent with bed mobility, transfers and toileting and required supervision with personal hygiene and bathing. The MDS documented diagnosis that included transient cerebral ischemic attack, depression, polyneuropathy and muscle wasting and atrophy. The care plan focus area revised 4/27/22 identified a need for assistance with activities of daily living including assistance of 1 staff for bathing, staff assistance with nail care on bath days, and to assist the resident with a sponge bath when a full bath or shower could not be tolerated. The POC Response History with a look back of 30 days and printed on 10/26/22 at 4:07 PM, the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in-out of tub/shower (excludes washing of back and hair) documented the following: - 9/28/22 at 9:13 PM supervision-oversight help only - 10/1/22 at 9:57 PM resident refused - 10/5/22 at 8:52 PM resident refused - 10/12/22 at 9:16 PM resident refused - 10/19/22 at 9:10 PM resident refused Per documentation Resident #41 received 1 of 8 scheduled showers for the 30 days reviewed. Resident #41 was to receive showers on Wednesdays and Saturdays. The facility lacked documentation of providing the resident with a shower on 10/8/22, 10/15/22, and 10/22/22. There were 4 documented refusals. In an interview on 10/26/22 at 9:32 AM, Resident #41 stated she had not received a shower for at least 2 weeks. She stated she felt they were too short staffed. In an interview on 10/27/22 at 2:55 PM, Resident #41 reported she had not been offered a shower for greater than 2 weeks. She denied she had been refusing showers. She stated they had not asked her until the previous night. She stated she did refuse as she was already in bed when they offered the shower. She requested one the next evening but the staff told her they may not have time or the staff to complete her shower at that time. 6. An MDS dated [DATE], documented that Resident #22's MDS score was 13 out of 15 indicating her cognition was intact. It documented during the 7 day observation period for the gathering of information for this MDS, that the bathing activity had not occurred. On 10/25/22 at 3:34 PM, Resident #22 stated that she had gone 15 days before without a shower. She stated she should have gotten a shower on this morning but the CNA that was supposed to give her a shower went home with a fever. A review of this resident's POC Response History (electronic documentation by staff for care) revealed that on 10/25/22 resident refused a shower and this was documented by Staff A, CNA. On 10/27/22 at 12:41 PM, Staff A, CNA stated that Resident #22 declined her shower on 10/25/22. She stated that Resident #22 was offered a shower by another CNA and Resident #22 refused her shower. She stated that this resident liked her shower done very early in the morning, before 6:00 a.m. When told it was Staff A's signature on the [NAME] that signed the refusal on 10/25/22, Staff A looked confused. Staff A then said that another CNA had told Staff A that Resident #22 refused her shower on 10/25/22. Staff A stated the other CNA went home sick that day and probably didn't sign the refusal before she left, so that's why this CNA would have signed the refusal. When asked if the other CNA was working on this day, Staff A said that the other CNA was not working as the other CNA was still off work sick. When asked about residents going without showers, Staff A stated that when there are only 3 CNAs instead of 4 it is difficult to get showers done. She said the following shift tries to pick them up or they try to pick up the showers the next day. When asked why the residents would say they haven't received their 2 showers a week, she repeated they try to give them their showers the next shift or next day if one is missed. When told there was greater than 7 days between some of the showers per the [NAME] for Resident #22, Staff A stated that often agency staff are part of their daily staff and they do not document like they should. Staff A stated she had told the Director of Nursing (DON) about the lack of documentation by the agency staff. Staff A understood that it is a problem when the showers weren't documented, coupled with residents voicing that they are not receiving 2 showers a week. The POC (plan of care) Response History with a look back history of 30 days and printed on 10/25/22 at 4:09 P.M., the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: -9/27/22 at 1:48 P.M. physical help limited to transfer only -9/30/22 at 11:17 A.M. resident refused -10/2/22 at 10:08 A.M. not applicable -10/9/22 at 1:47 P.M. resident refused -10/18/22 at 1:46 P.M. physical help in part of the bathing activity -10/20/22 at 9:16 P.M. physical help in part of the bathing activity -10/25/22 at 1:59 P.M. resident refused 7. An MDS dated [DATE], documented that Resident #39's MDS score was 13 out of 15, which indicated this resident's cognition was intact. It documented during the 7 day observation period for the gathering of information for this MDS, that the bathing activity had not occurred. On 10/25/22 at 11:28 AM, Resident #39 stated she wanted showers every day or maybe every other day so she could use her body wash. She stated they give showers twice a week. Resident #39 stated one time she went without showers for 3 weeks. She stated that was 4 to 5 months ago. She didn't know why she went so long without a shower. She said now she received them twice a week and she was due for one the following day. The POC (plan of care) Response History with a look back history of 30 days and printed on 10/26/22 at 3:34 P.M., the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: -9/28/22 at 1:58 P.M. not applicable -10/5/22 at 1:32 P.M. not applicable -10/8/22 at 1:59 P.M. supervision-oversight help only -10/19/22 at 9:40 P.M. supervision-oversight help only On 11/1/22 at 4:31 p.m., the Director of Nursing (DON) stated the facility's expectation was that residents received showers twice a week unless they request less or more showers. She stated they try to honor the residents' choices. The DON stated she expected documentation of resident's showers would be done and that shower refusals would get documented. In an email correspondence on 11/7/22 at 10:51 A.M., Staff B responded that the NA (not applicable) response would likely indicate the shower wasn ' t completed. 8. An MDS dated [DATE] documented Resident #15 had a BIMS score of 15 out of 15 indicating intact cognition. The MDS documented Resident #15 required extensive physical assistance of 1 staff with hygiene. During an interview 10/25/22 at 3:00 PM, Resident #15 revealed he received showers unless the facility didn't have enough staff. Resident #15 further stated he had to wait 1 ½ weeks a couple weeks ago to get a shower. The POC Response History with a look back history of 30 days printed 10/31/22 at 10:22 AM with the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: -10/4/22 at 12:11 PM total dependence -10/7/22 at 1:52 AM not applicable -10/11/22 at 10:46 AM total dependence -10/18/22 at 10:54 AM physical help limited to transfer only -10/21/22 at 1:59 PM total dependence -10/25/22 at 1:59 PM total dependence -10/28/22 at 12:26 PM total dependence 9. An MDS dated [DATE] documented Resident #21 had a BIMS of 15 indicating intact cognition. The MDS documented Resident #21 required extensive physical assistance of 1 staff for hygiene. During an interview 10/25/22 at 2:34 PM, Resident #21 revealed there was a time he wasn't getting showers but he was now. The POC Response History for Resident #21 with a look back history of 30 days printed 11/1/22 at 9:27 AM with the prompt: Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) lacked documentation in regards to completion of bathing. Review of facility protocol titled, Bathing, dated January 2013 revealed the purpose of bathing as the following: -Clean skin and shampoo hair -Increase circulation -Exercise body parts -Reduce tension -Promote comfort while maintain safety and dignity The Bathing protocol further directed staff to provide the resident the opportunity to bathe according to preference and facility procedure. During an interview 11/01/22 at 10:04 AM, the Director of Nursing and the Regional Director of Clinical Services acknowledged Resident #21 did not have a shower in the past 30 days and he had one that morning. The Regional Director of Clinical Services further acknowledged showers not being given is an issue. During an interview 11/01/22 at 9:17 AM, the Regional Director of Clinical Services revealed showers are expected to be documented if given. Based on observations, interviews and record review, the facility failed to provide sufficient staffing when interviews during resident council revealed concerns that the call lights were not answered timely, showers were not given and concerns for residents' safety related to no supervision when residents are in the dining room (Res #7, #13, #15, #21, #22, #35, #39, #41). An observation revealed 2 residents yelling at each other and threatening harm in the dining room with no staff present. The facility reported a census of 44 residents. Findings include: 1. On 10/31/22 at 10:36 AM, a Resident Council meeting was held. Concerns were raised about not getting showers, sometimes for over a week. The residents present all stated that the facility is short on staff. One resident stated he has had to wait for an hour before his call light was answered and was incontinent as a result of this. The residents stated that sometimes residents fight with each other. They stated some of them know better. The Resident Council residents stated that the facility needed more people out in the dining room to keep an eye out for this. They stated there is verbal fighting and it gets loud. They reported there is one resident that hits people sometimes. They stated they have to end up listening to it all the time and they shouldn't have to. There's a lot of bickering. They stated there is one resident that swings his cane, he uses it to express what he says, and it made them feel uncomfortable as though he was going to hit someone. Review of the last 3 months of the Resident Council minutes revealed: -8/2/22 CNAs (Certified Nurse Aides) not making beds. -9/6/22 2nd shift showers not being completed -10/11/22 2nd shift aides hiding and not helping

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review and staff interview, the physician failed to respond to gradual dose reduction (GDR) recommendations for 5 of 5 residents reviewed (Residents #10, #15, #27, #35, #43). The facility reported a census of 44 residents. 1. Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating mildly impaired cognition. The MDS documented diagnoses including non-Alzheimer's dementia and depression documented the resident received and an antianxiety medication 3 days during the 7 day lookback period and an antidepressant 7 days during the 7 days lookback period. Review of Care Plan initiated 02/13/2013 for Resident #10 lacked documentation regarding current use of psychotropic medication. Review of Medication Administration Record (MAR) dated November 2022 revealed the following: a. Lorazepam (antianxiety) tablet 1 milligram (MG) give 1 tablet by mouth with a start date 9/16/2022. b. Lexapro (antianxiety) tablet 10 MG give 1 tablet by mouth with a start date 1/21/22. Review of pharmacy progress notes dated 8/20/22 revealed a recommendation for a GDR on lorazepam and Escitalopram. Review of pharmacy progress notes dated 6/21/22 revealed a recommendation for a GDR on lorazepam and Escitalopram . Review of pharmacy progress notes dated 4/21/22 revealed a recommendation for a GDR on lorazepam and Escitalopram (Lexapro). Clinical record review lacked a response from the physician in regards to the GDR recommendations. 2. Resident #15's significant change MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. The MDS documented a diagnoses of depression and resident received antidepressant medication 6 days during the 7 day lookback period. Review of Care Plan revised 6/14/22 revealed Resident #15 used an antidepressant medication related to depression. Review of the MAR dated November 2022 revealed the following order: a. Paroxetine hydrochloric acid (HCl) give 1 tablet by mouth 1 time a day for depression with a start date 4/21/21. Review of pharmacy progress notes dated 10/24/22 revealed a recommendation for a GDR on paroxetine with a note sent to the provider. Review of pharmacy progress notes dated 9/23/22 revealed a recommendation for a GDR on paroxetine with a note sent to the provider. Review of pharmacy progress notes dated 8/20/22 revealed a recommendation for a GDR on paroxetine with a note sent to the provider. Review of pharmacy progress notes dated 6/21/22 revealed a recommendation for a GDR on paroxetine with a note sent to the provider. Clinical record review lacked a response from the physician in regards to the GDR recommendations. 3. Review of #27's quarterly assessment dated [DATE] revealed a BIMS score of 3 indicating severely impaired cognition. The MDS documented a diagnoses of non-Alzheimer's dementia and other frontotemporal neurocognitive disorder. The MDS further documented the resident received an antipsychotic medication x7, an antianxiety medication x1 and an antidepressant x7 in the 7 day lookback period. Review of the Care Plan initiated 2/1/22 lacked documentation regarding the use of psychotropic medication. Review of the MAR dated November 2022 revealed the following: a. Seroquel (antipsychotic) give 100 MG at bedtime for frontotemporal dementia with agitation ordered 4/8/22. b. Seroquel give 75 MG by mouth one time for frontotemporal dementia with agitation ordered 4/8/22. c. Sertraline HCL (antidepressant) tablet give 100 MG by mouth 1 time a day for depression ordered 4/6/22. d. Lorazepam (antianxiety) 0.5 MG by mouth every 4 hours as needed for anxiety/restlessness ordered 4/8/22. Review of pharmacy progress notes dated 10/24/22 revealed a GDR recommendation on quetiapine, sertraline, and lorazepam with a note sent to the provider. Review of pharmacy progress notes dated 9/23/22 revealed a GDR recommendation on quetiapine, sertraline, and lorazepam with a note sent to the provider. Clinical record review lacked a response from the physician in regards to the GDR recommendations. During an interview 11/1/22 at 2:49 PM, the Regional Director of Clinical Services revealed she was unable to locate any additional GDRs for Resident #10, Resident #15 and Resident #25. 4. Resident #35 admitted to the facility on [DATE]. The MDS assessment dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #35 had the diagnosis of diabetes mellitus, anxiety disorder, depression, and schizophrenia. A Care Plan revised on 2/6/20, documented that Resident #35 took antianxiety and antipsychotic medications related to schizophrenia, anxiety, depression, mild intellectual disability, and borderline personality disorder. A goal for this resident documented that he would have no adverse reactions to medications through the next review date. A review of this resident's monthly DRR/MRR (Drug Regimen Review/Medication Regimen Review) revealed the following recommendations: -3/15/22 at 4:29 P.M., Pharmacist Progress Note DRR completed. Comments sent to provider: GDR quetiapine -4/21/22 at 10:17 P.M., Pharmacist Progress Note DRR completed. Comments sent to provider: GDR quetiapine -5/20/22 at 12:17 P.M., Pharmacist Progress Note DRR completed. Comments sent to provider: GDR clonazepam -7/21/22 at 5:19 P.M., Pharmacist Progress Note DRR completed. Comments sent to provider: GDR clonazepam -9/23/22 at 1:05 P.M., Pharmacist Progress Note DRR completed. Comments sent to provider: GDR clonazepam -10/24/2022 at 9:00 A.M., Pharmacist Progress Note DRR completed. Comments sent to provider: GDR quetiapine and clonazepam 5. A Minimum Data Set, dated [DATE], documented diagnoses for Resident #43 included diabetes, depression and anxiety. A Brief Interview for Mental Status (BIMS), revealed a score of 15 out of 15, which indicated intact cognition. A Care Plan revised on 3/2/18 documented that Resident #43 used psychotropic drugs related to anxiety and depression. The goal revised on 3/17/22 was that Resident #43 would have no adverse reactions to medication through the next review date. A review of this resident's monthly DRR/MRR revealed the following recommendations: -1/18/2022 at 9:57 A.M., Pharmacist Progress Note DRR completed. Irregularities noted- Due for GDR on sertraline and Previous notes from a MRR on spiriva and miralax have not yet received a response. -2/15/2022 at 4:24 P.M., Pharmacist Progress Note DRR completed. GDR on sertraline from January not addressed. Re-sent to provider. -8/19/2022 at 6:30 P.M., Pharmacist Progress Note DRR completed. Comments sent to provider: GDR sertraline -9/23/2022 at 1:27 P.M., Pharmacist Progress Note DRR completed. Comments sent to provider: GDR sertraline -10/24/2022 at 4:22 P.M., Pharmacist Progress Note DRR completed. Comments sent to provider: GDR sertraline On 11/1/22 at 5:15 p.m., the Regional Director of Clinical Services (RDCS), stated that the contracted pharmacy consultant was really was good about giving recommendations. They switched pharmacies recently. They would get to the physicians, but nothing would happen from there. She stated she could not produce physician responses to the recommendations. This RDCS stated when she was asked to look at GDR recommendation follow up, she looked at physician's orders to see if any medications had been changed as she did not have any doctor follow up notes she could refer to. This RDCS stated they do have a Nurse Practitioner (NP) in the facility every week and indicated that it would improve the process if this NP could review the recommendations and make the changes. On 11/11/07/22 at 1:09 PM, the Licensed Pharmacist Clinical Manager (LPCM) for the contracted pharmacist reviewed the above records. This Pharmacist stated that the consultant pharmacist would make recommendations and then have to make them again if there was no response. This LPCM stated the consultant pharmacist would give 60 days grace to the physician but then would submit the request again. This LPCM concurred that the following medications had to have repeated request as there was no physician response: -Resident #10-GDR for lorazepam and escitraloprom 4/21/22, in June 6/21/22 reissue from April and then reissued again on 8/20/22 -Resident #15 same thing GDR requested in August and there was no response so reissued in October. -Resident #27- No stop date for PRN Ativan. Recommendation in August and October. This LPCM stated they try to address those PRNs that don't have a rationale or stop date. She stated there was also a GDR recommendation 7/21/22 Setraline and quietipine which required a reissue 9/23/22 reissue -Resident #35-Following GDRs were requested 9/20/21 quetiapine and clonazepam GDR 3/15/22 and 4/21/22 quetiapine reduction. On 5/20/22 GDR clonazepam, repeated on 7/21/22 GDR clonazepam. And on 9/23/22 GDR quetiapine and clonazepam -Resident #43 did need to have repeat recommendations for GDR. It was more than 60 days so there was a reissuance. GDR requested 8/19/22 and reissued a GDR on 10/24/22 for Sertraline. A Medication Record Review policy revised on 3/3/20, directed the following: The facility should encourage physicianprescriber or other responsible parties receiving the MRR and the Director of Nursing (DON) to act upon the recommendations contained in the MRRs. For those issues that require physician/prescriber intervention, the facility should encourage physician/prescriber to either accept and act upon the reommendation contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. The attending physician should document in the residents' health record that the irregularity has been reviewed and what, if any, action has been taken to address it. If the attending physician has decided to make no change in the medicaiton, the attending physician should document the rationale inthe residents' health record.

Based on observation, resident and staff interview, the facility failed to carry out meal service to residents in a timely manner. The facility reported a census of 44 residents. Findings include: During an interview 10/25/22 at 3:01 PM, Resident #15 revealed he gets his meals delivered late to his room. Observation of lunch service 10/27/22 revealed the lunch meal began to be served at 12:25 PM and the last lunch room tray was served at 1:40 PM. Observation of lunch service 10/31/22 reveal the lunch meal began to be served at 12:42 PM and the last lunch room tray was served at 1:37 PM. During an interview 10/31/22 at 1:42 PM, Staff B, Dietary Aide revealed there was 1 [NAME] and 1 Dietary Aide working in the kitchen for lunch service. Review of facility meal times revealed lunch is to be served at 12:00 PM. During an interview 11/1/22 at 4:53 PM, the Administrator revealed his expectation is for meals to be served on time.

Based on observation, review of planned menu and staff interviews, the facility failed to follow the planned menu as approved by the Dietician. The facility reported a census of 44 residents. Findings include: The facility's menu approved by the Dietician 10/24/22 identified the following items for the lunch meal 10/27/22: meatloaf slice, macaroni and cheese, peas, roll/margarine, brownie and milk. Observation 10/27/22 at 11:51 AM revealed the lunch being prepared by the Dietary Manager (DM) consisted of grilled hamburgers on a bun, macaroni and cheese, peas brownie and milk. The DM revealed she received approval for the change in menu from the Administrator. The DM further revealed there was a call-in so grilling hamburgers was quicker than making meatloaf. The facility's menu approved by the Dietician 10/31/22 identified the following items for supper 11/1/22: Cheeseburger on bun, potato wedges, mixed vegetables, bread/margarine and pears. Observation 11/2/22 at 10:15 AM revealed Casey's pizza was posted on the white menu board outside the kitchen for supper on 11/1/22. Review of facility form titled Hot and Cold Food Holding Temperature Log for 11/1/22 lacked documentation regarding product that was served for supper. Review of facility policy titled, Nutrition Services, dated June 2015 revealed staff are to follow preplanned written menus. During an interview 11/1/22 at 4:53 PM, the Administrator revealed it is an expectation changes in the menu are to be reviewed with the Dietician to ensure substitutions are appropriate. During an interview 11/2/22 at 10:27 AM, the Dietician revealed she did not approve the change in menu for lunch 10/27/22 or the change in menu for supper 11/1/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, the facility failed to hold hot food at a temperature high enough to ensure prevention of bacterial pathogen growth. The facility reported a census of 44 residents. Findings include: During an interview 10/25/22 at 3:01 PM, Resident #15 stated the hot food is not hot during meals. Observation 10/27/22 at 12:25 PM revealed grilled hamburgers were being served in place of meatloaf as the main lunch item and the grilled hamburger that was temped had an internal temperature of 160 degrees. Observation 10/27/22 at 1:49 PM revealed the grilled hamburger on the last room tray to be served had an internal temperature of 120 degrees. Observation 10/27/22 at 1:49 PM revealed 36 residents received grilled hamburgers for lunch. Review of facility policy titled, Nutrition Services, dated June 2015, directed staff to prepare and serve hot and cold food at proper temperatures. During an interview 11/2/22 at 2:42 PM, the Dietary Manager revealed the facility is to follow the temperatures as directed by their supplier [NAME]. Review of [NAME]. form titled, End Cooking Temperatures, revealed ground beef is to be 155 degrees. During an interview 11/2/22 at 5:39PM the Dietician revealed she would expect holding temperatures for meat to be 140 degrees and above. The FDA 2013 Food Code, deemed that a standard practice in the foodservice industry is all potentially hazardous hot food must be held for service at a minimum of 135 degrees Fahrenheit.