**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 21 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a baseline care plan within 48 hours of admission for Resident (R) 123. This placed the resident at risk for impaired care due to unidentified or uncommunicated care needs. Findings included: - R123's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), urinary incontinence, hypertension (high blood pressure), gastroesophageal reflux disease (GERD-backflow of stomach contents to the esophagus), nutritional deficiencies, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), irritable bowel syndrome (IBS- abnormally increased motility of the small and large intestines), a history of transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain) and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) without residual deficits. The Entry Tracking Record Minimal Data Set (MDS) dated [DATE] recorded R123 admitted on [DATE] from home or the community. R123's clinical record lacked a baseline care plan from the admission date of 11/08/24. The Physician Order dated 11/08/24, directed staff to admit to the nursing home long-term care with diagnoses of diabetes, urinary incontinence, and a history of stroke. The Progress Note, dated 11/08/24 at 01:38 PM, documented R123's arrival at the facility via personal vehicle. Vital signs were obtained, and a family member assisted the resident with unpacking and getting the room situated as R123 wanted. On 11/19/24 at 12:23 PM, observation revealed staff escorted R123 to her room. R123 reported she did not feel well and was dizzy. Licensed Nurse (LN) G obtained vital signs and a blood sugar level. R123's blood sugar level was low. LN G reported that R123 had a history of low blood sugar levels since admission. On 11/19/20 at 01:00 PM, LN G reviewed R123's EMR and verified there was no baseline care plan. On 11/20/24 at 11:30 AM, Administrative Nurse D verified R123's EMR lacked a baseline care plan and said one should have been developed within 48 hours of admission. The facility's undated Interim Temporary Care Plans policy documented an interim plan of care is developed and initiated on admission to the facility. Continual evaluation of interim, temporary plans of care was completed by staff members caring for the elder. Revisions to the care plan will be ongoing and the current conditions, needs, and goals of the elder change. The facility failed to develop a baseline care plan within 48 hours of admission. This placed R123 at risk for impaired care due to unidentified and uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 21 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to obtain a stop date from the physician for the use of as-needed (PRN) lorazepam (antianxiety medication) for Resident (R) 9. This placed the resident at risk for complications related to psychotropic (alters mood or thought) medications and unnecessary medication. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), and dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Significant Change Minimum Data Set (MDS), dated [DATE], documented that R9 had short- and long-term memory problems with severely impaired cognition. The MDS documented R9 received hospice (end-of-life) services and did not receive antianxiety drugs. R9's Care Plan, dated 11/14/24, documented R9 had Alzheimer's dementia and anxiety. R9 could become agitated with care at times, including hitting and slapping. The care plan directed staff to provide opportunities for positive interaction and attention and directed staff to stop and talk with her when passing by, initiated 06/13/23. The plan directed staff to monitor behavior episodes, attempt to determine underlying causes, and document behavior and potential causes, initiated on 06/13/23 and revised on 10/25/23. The plan directed to administer psychotropic medications as ordered and monitor for side effects and effectiveness every shift initiated 06/13/23. The plan directed staff to discuss with the physician and family the ongoing need for the use of medication and review behaviors and interventions and alternate therapies attempted and their effectiveness as per facility policy, initiated on 06/13/23. Staff were to monitor, document, and report any adverse reactions to psychotropic medications, initiated on 06/13/23 and revised on 10/25/23. The Physician Order, dated 11/04/24, directed staff to administer lorazepam oral concentrate 0.25 milliliter (ml) every four hours as needed for agitation or restlessness. The order stated duration was indefinite. On 11/19/24 at 08:13 AM, observation revealed Certified Nurse Aide (CNA) M woke R9 and told R9 what she was doing. While CNA M provided incontinence care, R9 frowned but did not cry out. R9 made a small noise during the transfer from her bed to a wheelchair. CNA M stated that R9 used to become more upset when staff worked with her, but she had declined. On 11/19/24 at 01:58 PM, Licensed Nurse (LN) G stated R9 was more alert before her health declined and would become agitated with care, striking out at staff. LN G said staff monitored how many times each shift R9 had restlessness, agitation, and hitting. On 11/20/24 at 09:35 AM, Administrative Nurse D verified when a physician ordered PRN lorazepam, staff should obtain a specific stop date. The facility's Psychotropic Medication Use policy stated any resident admitted with a PRN psychoactive medication would have a 14-day stop date. Any psychotropic medication ordered by a physician as an emergency treatment for behaviors would have an automatic 72-hour stop date during which the physician and nursing staff would assess the potential root cause for the behaviors and interventions that may replace or be used as adjunct therapy for the behaviors. The physician's order must include a qualifying diagnosis and a list of specific targeted behaviors for which the staff would monitor. The attending physician must certify that a psychotropic medication was necessary to treat a specific condition or behavior. The facility failed to obtain a stop date from the physician for the use of PRN lorazepam for R9, placing the resident at risk for complications related to psychotropic medications and unnecessary medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R17's Electronic Medical Record (EMR) included diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), restlessness and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), non-displaced fractures (broken bone) of the second cervical (neck/spine) vertebra, second and third thoracic (mid back area) vertebra (bone of the spinal column), first, third, and fourth lumbar (lower spine) vertebra, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) with a current pathological fracture (a break in a bone that is caused by an underlying disease), and nutritional deficiency. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R17 had moderately impaired cognition. R17 required partial/moderate assistance with personal hygiene and upper body dressing, and substantial/extensive assistance with toileting, lower body dressing, bathing, bed mobility, and transfers; walking was not attempted due to medical condition or safety concerns. R17 was occasionally incontinent of urine. R17 received scheduled and as-needed pain medication for pain which was frequent and affected sleep and day-to-day activities. The MDS further documented that R17 received hospice services (specialized end-of-life care with a focus on comfort). R17's Care Plan dated 09/26/24, documented R17 received hospice care services. The care plan directed staff to adjust provisions of activities of daily living to compensate for the resident's changing abilities, assess and respect the resident's wishes, encourage support systems of family and friends, and keep the environment quiet and calm. The care plan further directed staff to observe R17 closely for signs of pain, administer pain medication, and work cooperatively with the hospice team to ensure the resident's, spiritual, emotional, intellectual, physical, and social needs were met. The care plan lacked specific information related to the hospice provider, services and equipment or medications that would be provided, and when to notify the hospice provider. The Hospice Order dated 09/18/24, documented R17's hospice provider, and diagnoses of CHF and fractures. R17 had her neck brace, and the hospice provider would provide pull-ups, a skilled nurse weekly, and a nurse aide two times a week. The orders included medications covered under R17's hospice benefit. The Progress Note dated 09/11/24 at 01:13 PM, documented R17's primary care practitioner asked staff to Please discuss comfort care and or hospice with R17's family and the charge nurse was to address R17's power of attorney about changes. The Progress Note dated 09/12/24 at 02:15 PM, documented the facility nurse spoke with R17's family and spouse about hospice care. The hospice social worker was in to meet with the family. The Progress Note dated 09/12/24 at 05:29 PM, documented the hospice nurse called to relay that as of 09/12/24, R17 was admitted to hospice. Upon review, R17's clinical record lacked evidence of the hospice assessment findings and hospice nurse visit notes. On 11/18/24 at 02:20 PM, observation revealed R17 sat in a recliner in her room with a family member next to her. R17 reported she was doing okay. R17 had the footrest elevated and a small, rolled blanket to the back of her neck. On 11/19/24 at 11:37 AM, Certified Nurse Aide (CNA) N reported staff received information from the charge nurse when a resident was receiving hospice services. CNA N stated the hospice provider would usually provide incontinent products, a wheelchair, and oxygen. CNA N stated the shower list had when a hospice aide would bathe the resident. On 11/19/24 at 03:31 PM, Licensed Nurse (LN) G reported the facility did not have a hospice book or chart for R17. LN G reported the facility staff signed the hospice staff's tablets confirming the hospice staff visit and that the hospice nurse and facility nurse verbally discussed the resident's condition. LN G was unable to find the hospice nurse documentation of assessments or ongoing collaboration in R17's EMR. LN G reported the hospice plan of care was sent to the facility via email every six months with the recertification of hospice services. On 11/20/24 at 10:33 AM, Administrative Nurse D verified the hospice provider should send notes from all visits made which should be scanned into the EMR. Administrative Nurse D reported the hospice provider had a change in computerized record keeping and was unaware the hospice provider had not been sending the information from the visits until recently. Administrative Nurse D said the facility had not followed up on receiving information from the hospice provider. The facility Hospice Agreement dated 05/15/2018, last signed 5/1/20 by both parties documented that the nursing facility and hospice shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving facility and Hospice services. Each clinical record shall completely and accurately document all services provided to and events concerning (including evaluations, treatments, progress notes, and physician orders of each) hospice patient. The nursing facility and hospice provider shall each retain the records and the records shall be readily accessible and organized to facilitate retrieval by either party. The facility failed to collaborate care and services with R17's hospice provider, which placed R17 at risk of impaired end-of-life care. The facility had a census of 21 residents. The sample included 12 residents with two reviewed for hospice services. Based on observation, interview, and record review the facility failed to ensure a communication process and collaboration between the hospice provider and the facility for Resident (R) 9 and R17 to coordinate hospice services provided including visit frequency and assessment, medications, and medical equipment. This placed the residents at risk of impaired end-of-life care. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), and dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Significant Change Minimum Data Set (MDS), dated [DATE], documented that R9 had short- and long-term memory problems with severely impaired cognition. The MDS documented R9 received hospice services. R9's Care Plan, dated 11/14/24, documented R9 had Alzheimer's dementia and anxiety. R9 could become agitated with care at times, including hitting and slapping. The care plan directed staff to provide opportunities for positive interaction and attention and directed staff to stop and talk with her when passing by, initiated 06/13/23. The plan directed staff to monitor behavior episodes attempt to determine underlying causes, and document behavior and potential causes, initiated on 06/13/23 and revised on 10/25/23. The plan directed to administer psychotropic medications as ordered and monitor for side effects and effectiveness every shift initiated 06/13/23. The plan directed staff to discuss with the physician and family the ongoing need for the use of medication and review behaviors and interventions and alternate therapies attempted and their effectiveness as per facility policy, initiated on 06/13/23. Staff were to monitor, document, and report any adverse reactions to psychotropic medications, initiated on 06/13/23 and revised on 10/25/23. The care plan directed staff to allow R9 time to answer questions and to verbalize feelings, perceptions, and fears daily. The care plan directed staff to consult with pastoral care or social services, initiated on 12/06/23. The care plan lacked any mention of hospice services. A review of R9's clinical record lacked information regarding hospice staff assessments, care, or visits. On 11/19/24 at 08:13 AM, observation revealed Certified Nurse Aide (CNA) M woke R9 and told R9 what she was doing. While CNA M provided incontinence care, R9 frowned but did not cry out. R9 made a small noise during the transfer from her bed to a wheelchair. CNA M stated that R9 used to become more upset when staff worked with her, but she had declined. On 11/19/24 at 11:37 AM, Certified Nurse Aide (CNA) N and CNA O stated the charge nurse usually let CNA staff know if a resident was on hospice. They reported there was a list in the shower room that documented who hospice was giving a shower or bath and when. They also stated that the residents on hospice got incontinence products from the hospice company. They stated that the hospice also provided equipment, like wheelchairs and oxygen. On 11/19/24 at 01:25 PM, CNA M verified that R9 received hospice services. CNA M said the hospice nurse visited weekly and the hospice aide came weekly to bathe R9. On 11/19/24 at 02:20 PM, Licensed Nurse (LN) G stated the last hospice care plan was dated 11/06/24 and verified the facility's care plan did not include any hospice information. She verified the facility did not receive hospice assessment findings or visit notes. The facility's Hospice Agreement, dated 05/15/18, was last signed on 05/01/20 by both parties. The nursing facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving facility and hospice services. Each clinical record shall completely and accurately document all services provided to and events concerning (including evaluations, treatments, progress notes, and physician orders for each hospice patient. The nursing facility and hospice shall each retain the records and the records shall be readily accessible and organized. to facilitate retrieval by either party. The facility failed to ensure a communication process and collaboration between the hospice provider and the facility for R9. This placed the resident at risk of impaired end-of-life care.

The facility had a census of 21 residents. The sample included 12 residents and five nurse aides. Based on observation, record review, and interview, the facility failed to ensure three of the five staff members reviewed possessed the knowledge, skills, and competencies required for resident care needs. This placed the residents at risk of impaired care. Findings included: - Review of the training records and skills check for Certified Nurse Aide (CNA) O, P, and Q lacked evidence of the facility's procedure checklist related to the direct care of the residents. On 11/20/24 at 10:33 AM, Administrative Nurse D stated the facility had conducted a skills check-off the previous summer for the nursing staff, and not all employees attended. Administrative Nurse D stated the facility had not rescheduled or completed any further competencies for staff who did not attend. The facility's undated Required Training of Nurse Aides documented the facility would ensure that nurse aides demonstrate competency in skills and techniques necessary to care for residents as identified through resident assessments and described in the plan of care. The facility failed to ensure three of the five staff members reviewed possessed the knowledge, skills, and competencies required for resident care needs. This placed the residents at risk of impaired care.

The facility had a census of 21 residents. Based on record review and interview the facility failed to submit complete and accurate staffing information through Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare and Medicaid Service (CMS) for Fiscal Year (YR) 2023 Quarter (Q) 4 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days (five). A review of the facility's licensed nurse timesheet data for the dates listed on the PBJ revealed a licensed nurse was on duty 24 hours a day seven days a week. On 11/18/24 at 12:26 PM, Administrative Staff A reported the discrepancy may be related to the submission of licensed nurse break hours and this had been adjusted to capture all the hours licensed nurses worked. Administrative Staff D stated the facility had nurse coverage 24 hours a day. The facility's undated Mandatory Submission of Uniform Format Staffing Information (PBJ) policy documented the facility would electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 21 residents. Based on interviews and record review, the facility failed to implement a water management plan to mitigate risks for Legionella (a bacterium spread through the mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella). The facility failed to maintain an antibiotic tracking system and did not review its infection control policies annually. This deficient practice placed the 21 residents of the facility at risk for infection. Findings included: - The facility printed out a log that included resident names, locations, and prescriptions. The prescriptions were dated from 9/30/22 to 10/02/24. The log revealed eight prescriptions for antibiotics in 2024 but indicated the infection being treated was unknown. The log lacked documentation of onset, symptoms, or cultures. The facility's Infection Control policy was last reviewed on 07/01/21 and the facility's Vaccine policy was 02/13/23. The facility had Appendix A for Identifying Buildings at Increased Risk which indicated the facility should have a water management program for the hot and cold-water distribution system. On 11/19/24 at 01:55 PM, Administrative Staff A verified the facility had not reviewed the infection control policies annually, and that it had been a couple of years since they did. Administrative Staff A verified the facility had not followed through with setting up a water management program to address Legionella risk. On 11/20/24 at 09:55 AM, Administrative Staff D, the certified Infection Preventionist, verified the facility had not tracked infections and did not have an ongoing monitoring process in place. She stated the staff discussed any current infections during the Quality Assessment and Assurance meetings. On 11/20/24 at 09:55 AM, Administrative Staff E stated she checked for patterns if more than one infection was going on at a time. The facility's Antibiotic Stewardship policy, dated 07/15/2021, stated the center would discuss antibiotic use and resistance data. Compliance with antibiotic use algorithms and results of provider feedback during QAPI. The policy stated the Infection Preventionist would monitor antibiotic stewardship activities through a review of provider orders, clinical documentation, and pharmacy and lab reports. The ICP would track antibiotic use and resistance patterns, provide education as needed, and alert the facility if certain antibiotic-resistant organisms were identified. The policy stated the facility would implement a standard assessment and communication tool for residents suspected of having an infection SBAR. The facility would monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Monitor if cultures were obtained before antibiotics were initiated and if antibiotics changed during the course of treatment. The facility's Infection Control Policy dated 07/01/2021, stated the facility would establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility's Legionella Risk Management policy stated the facility would ensure appropriate precautions for the control of Legionella bacteria were identified through a Legionella risk assessment process and appropriate control measures implemented to ensure, as reasonably practicable, the health, safety, and welfare of residents. The minimum standards to be met included: Legionella risk assessments, a description of the building water system, and an identification of where Legionella could grow and spread. An action plan for preventing or controlling the risk. Implementation, management, monitoring, and recording of precautions. The facility failed to implement a water management plan to mitigate risk for Legionella and failed to maintain an antibiotic tracking system and review infection control policies at least annually. This placed the 21 residents of the facility at increased risk for infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 24 residents with 12 sampled. Based on interview and record review, the facility failed to review and revise the care plans for one Resident (R)17, regarding new interventions to prevent falls. Findings included: - Review of R17's diagnoses from the Electronic Health Record (EHR) documented repeated falls, weakness, amnesia (a dramatic form of memory loss) and Alzheimer's disease (a progressive dementia - loss of cognitive function such as thinking, remembering and reasoning). Review of R17's annual Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status (BIMS) of 12, indicating moderately impaired cognition. R17 required extensive assistance of two or more staff with transfers. Review of the Falls Care Area Assessment (CAA) dated 01/02/23, revealed that the resident was at increased risk for falls and injury due to impaired cognition, pain and numbness/weakness to all extremities. The care plan, dated, 02/11/22 revealed: A non-injury fall on 02/11/22, with the interventions for staff to remind the resident to use her call light and for staff to pick up dropped items from the floor. A non-injury fall on 04/02/22, with the intervention for staff to reeducate the resident to use a pendant to call for assistance. A non-injury fall on 04/29/22, with the intervention to place a floor mat next to the bed when the resident is in bed, to prevent rolling out of bed. A non-injury fall on 06/03/22, with the intervention for staff to assess for a concave mattress. A fall with minor injury on 07/06/22, with the intervention for staff to place a pressure monitor under the mat next to bed, and staff should apply non-skid socks. A non-injury, unwitnessed fall on 11/20/22, in the chapel bathroom, with intervention for staff to assist the resident to the bathroom every two hours and as needed. However, the facility lacked interventions for the non-injury fall on 12/08/22. Furthermore, the facility lacked interventions for a repeated fall with injury on 12/18/22. The Physician's orders lacked documentation of orders specific for fall prevention. Review of the resident's assessments revealed fall risk screenings, dated: On 10/20/22, with result of 65, indicating high risk for falling. On 12/18/22, with result of 75, indicating high risk for falling. On 12/27/22, with result of 75, indicating high risk for falling. On 01/02/23, with result of 65, indicating high risk for falling. On 02/16/23 at 09:30 AM, Certified Nurse Aide (CNA) N stated that R17 required a personal body alarm for her recliner and her wheelchair, but the resident learned how to disable the audible alarm alerts. Staff should attempt to keep the resident engaged in the common areas as much as possible so all staff can observe the resident, to prevent falls. On 02/16/23 at 10:06 AM, Licensed Nurse (LN) I reported R17 frequently forgot her limitations and she lacked the cognition to comprehend her limitations. Staff were to place a pressure sensor alarm on R17's recliner and wheelchair, along with a floor mat beside her bed for fall prevention. After a resident's fall, a licensed nurse on duty should implement an immediate intervention until the Interdisciplinary Team (IDT) would meet and develop a permanent intervention for the resident's care plan. On 02/16/23 at 10:13 AM, Administrative Nurse D reported she expected the licensed nurse on duty at the time of a fall was to implement an immediate intervention until the IDT could meet to create a permanent intervention and update the resident's care plan to prevent further falls. IDT meets at least once per week. On 02/16/23 at 11:14 AM, Administrative Nurse D confirmed the lack of new interventions on the care plan after the falls on 12/08/22 and 12/18/22. The 01/23/17 facility's policy for Fall Prevention Protocol documented that the IDT would develop a plan for services and other interventions to reduce the elder's risk for falls. The facility failed to review and revise this resident's care plan related to falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 26 residents, with 12 sampled, including one for dignity. Based on observation, interview, and record review, the facility failed to provide quality dignified care for Resident (R) 25 by allowing his fingernails to be overgrown with a dark substance under them after he requested staff trim them. Findings include: - Review of R25's Signed Physician Orders dated 06/15/21 documented the following diagnoses: diabetes mellitus without complications (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and major depressive disorder (major mood disorder). Review of the admission Minimal Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. R25 required the assistance of one staff member for personal hygiene. Review of the ADL Function/ Rehabilitation Potential Care Area Assessment (CAA) dated 07/06/21 documented staff will care plan to maintain the current level of functioning, risk factors were current disease processes. Review of the Care Plan dated 07/06/21 documented R25 required physical assistance of one staff with bathing/showering, and staff were to check nail length and trim and clean on bath day, and as necessary, and report any changes to the nurse. Review of the Electronic Health Record (EHR) under the Task tab for the CNA's, lacked information regarding bathing or nail care. On 07/27/21 at 01:58 PM, an observation of R25's fingernails revealed they were of uneven lengths and had a dark substance under them. On 07/28/21 at 09:28 AM observed R25 sat in his wheelchair in the commons area with fingernails uneven and had a dark substance under his fingernails. On 07/28/21 at 01:05 PM, R25 sat in the dining room, fingernails were still not cut or cleaned, and R25 asked if the surveyor could cut them for him. On 07/29/21 at 09:55 AM, R25 was in the commons room attending an activity and observation revealed his fingernails continued with the dark color substance under the nails, and nails were of uneven lengths. On 08/02/21 at 09:19 AM, R25 sat in the common area, nails continued to have dark substance under them and differing lengths. He stated he would not mind them being trimmed but was tired of asking for it. On 07/28/21 at 01:30 PM, Certified Nurse Aide (CNA) E stated R25 received his baths at night, day shift would brush his teeth, but staff performed nail care on his bath days. CNA E said, to find the last time his nails received care, you would look in the EHR under task, and the last task information would document that information. On 07/29/21 at 10:20 AM, CNA F revealed R25 mainly required assistance with toileting, dressing, and used a slide board to transfer. On his bath days, they would check his nails, and with being a diabetic, a CNA could not trim his nails for him, but they could clean them. CNA F stated there were forms with the bathing that they would fill out and that it had skin and nail assessment on it. If the resident had diabetes, they would inform the nurse that his nails needed trimmed. On 08/02/21 at 10:20 AM, Licensed Nurse (LN) C stated if the residents had diabetes, it would be the nurse's responsibility to trim or cut the finger and toenails. LN C stated she was unaware of R25's need for nail care but would make time to accomplish this task. On 08/02/21 at 12:06 PM, Administrative Staff B stated nails for diabetic residents were cleaned by the nurses, and she expected the nurses to keep up on diabetic resident's toe and fingernail trimming or cutting. She expected the CNAs to let the nurse know if a resident required nail care. Review of the facility's undated Right to Dignity policy documented the facility would groom the elder as they wished, including nail care. The facility failed to maintain R25's dignity by allowing his nails to become overgrown and have a dark substance under them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 26 residents, with 12 included in the sample, including one for respiratory care. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for Resident (R) 12 which included oxygen use and care. Findings Include: - Review of R12's Electronic Health Record (EHR) dated 06/11/21 documented the following diagnoses: schizophrenia (a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), chronic obstructive pulmonary disease (COPD, a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), COVID-19, shortness of breath (SOB), and localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Review of the Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. R12 utilized oxygen (O2) therapy. Review of the Quarterly MDS dated 06/08/21 documented a BIMS of 13, indicating intact cognition and he utilized O2. Review of the Care Plan dated 03/30/21 lacked documentation for the care and maintenance of R12's oxygen. On 07/29/21 at 02:18 PM, R12 participated in an activity in the dining room. The staff brought an oxygen concentrator to the dining room for R12's use. On 08/02/21at 09:45 AM, R12 sat in a recliner in his room with O2 via nasal cannula in place. R12 stated he used O2 all the time. The humidifying bottle lack a date of last change. On 07/28/21 at 01:43 PM, Certified Nursing Aide (CNA) E stated R12 used the O2 in the afternoon for his shortness of breath, like having an activity in the dining room. He used the O2 before walking to the dining room. On 07/29/21 at 10:15 AM, CNA F stated R12 was independent during the day, but towards evenings he would need a little bit of help, and he used O2 as needed. On 08/02/21 at 10:30 AM, Licensed Nurse (LN) C stated the oxygen use should be noted on the care plan for each resident using oxygen. On 08/02/21 at 12:04 PM Administrative Nurse B stated she believed the care of oxygen delivery items should be included on the care plan, when asked about oxygen use and care. The facility did not provide a policy regarding care plans, as requested on 08/02/21 at 01:04 PM. The facility failed to develop and implement a comprehensive person-centered care plan for R12 to include oxygen use and care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 26 residents, with 12 sampled, including one for discharge to the community. Based on interview and record review, the facility failed to complete a discharge summary to include the recapitulation of Resident (R) 28's stay. Findings included: - A review of the Minimum Data Set (MDS) documented R28 admitted on [DATE] and discharged on 06/18/21, with no MDS completed. Review of the Electronic Health Records (EHR) Physician Orders documented an order to discharge to Home Care and to follow up with the provider in one week dated 06/18/21. Continued review of the EHR revealed no discharge papers, including a recapitulation of stay, located within R28's record. Interview with Social Services Director (SSD) D on 07/29/21 at 08:20AM stated she did not complete a recapitulation of the stay and that it was the nurses' responsibility to do this. Interview with Administrative Nurse B on 08/02/21 at 11:54 AM confirmed the facility lacked a completed recapitulation of R28's stay. Review of the undated Admission, Transfer and Discharge Policy documented the facility staff documented in the clinical record discharge information provided to the resident including a summary of the care, treatment and services provided and progress reached toward goals. The facility failed to appropriately document the discharge summary, including the recapitulation of stay for R28.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 26 residents, with 12 sampled, including one for respiratory care. Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for Resident (R) 12. - Findings Include: Review of Resident (R) 12's Electronic Health Record (EHR) dated 06/11/21 documented the following diagnoses: Schizophrenia (a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), Chronic Obstructive Pulmonary Disease (COPD) - (a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), COVID 19, shortness of breath (SOB), and localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Review of the Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. Staff had identified R12 as utilizing oxygen (O2) therapy. Review of the Quarterly MDS dated 06/08/21 documented a BIMS of 13, indicating intact cognition. Staff had identified R12 used oxygen. Review of the Care Plan dated 03/30/21 lacked documentation for the care and maintenance of R12's oxygen. Review of Physician Orders dated 07/27/21 in EHR lacked an order for the use of oxygen or care of equipment used to provide oxygen. Review on 08/02/21 at 10:30 AM of Licensed Nursing (LN) and Certified Nursing Aide (CNA) tasks in EHR lacked documentation of oxygen tubing changes. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) in the EHR for January 2021 through July 29, 2021 lacked documentation of any oxygen care or use for R12. On 07/29/21 at 02:18 PM, R12 was participating in an activity in the dining room. Staff brought an oxygen concentrator to the dining room for R12 to use. On 08/02/21at 09:45 AM, R12 was sitting in a recliner in his room with oxygen via nasal cannula in place. R12 stated he uses oxygen all the time. Oxygen tubing and humidifying bottle lack date of last change. On 07/28/21 at 01:43 PM, CNA E stated that R12 used the oxygen in the afternoon for his shortness of breath, like having an activity in the dining room. He would use the oxygen before walking to the dining room. They believed the LN staff were responsible for changing the oxygen tubing and maintain the humidifier. On 07/29/21 at 10:15 AM, CNA F stated R12 was independent during the day, but towards evenings he would need a little bit of help, and he was on oxygen as needed. CNA F stated she thought the tubing was changed every 30 days by the nurse. On 08/02/21 at 10:30 AM, LN C stated that oxygen tubing and humidifier bottles were to be changed and dated. She believed LN staff would document on the Treatment Administration Record (TAR) on the night shift. However, she was unsure if they were all changed at once or scheduled individually. On 08/02/21 at 12:04 PM Administrative Nurse B stated the LN staff were to change the tubing and humidifier bottles weekly by the night nurse and documented it on tasks. Administrative Nurse B stated she believed the care of such things should have been care planned. She would expect that facility staff change the tubing and humidifier weekly, document the changes, and label the tubing and humifider. She confirmed there were no orders for the care of oxygen supplies for R12. The facility did not provide a policy, as requested on 08/02/21 at 01:04 PM. The facility failed to provide respiratory care consistent with professional standards of practice for R12.

The facility reported a census of 26 residents. Based on observation, interview, and record review, the facility failed to provide the residents with a way to file a grievances anonymously. Findings included: - During the initial tour of the facility on 07/27/21 at 10:00 AM, there were no grievance forms or a way to submit those forms anonymously noted in the facility. On 07/28/21 at 02:01 PM, Resident (R) 14 stated they did not have forms to fill out for a grievance during the resident council meeting. On 07/28/21 at 02:21 PM, Activity Staff D stated they did not have forms to fill out for grievances, that the residents would tell the staff what the issue was and that the residents could call the Ombudsman with any concerns. On 08/02/21 at 12:12 PM, Activity staff D stated she had not developed a procedure for residents to file an anonymous grievance. On 08/02/21 at 05:00 PM, Administrative Staff A stated she did not know they needed an anonymous way to file a grievance. Review of the facility's undated Complaints or Grievances policy documented that each resident may voice grievances to administrative staff or outside representatives of their choice, free from interference, coercion, discrimination, or reprisal. The facility failed to allow residents to exercise their right to file a grievance, including the right to file an anonymous grievance, without interference, coercion, discrimination, or reprisal.

The facility reported a census of 26 residents. Based on interview and record review the facility failed to address staffing in the Facility Assessment to document resources required to provide necessary care to the residents in regard to staffing across all shifts. This failure had the ability to affect all resident care in the facility. Findings included: - Review of the undated Facility Assessment documented no determination of facility staffing. Interview with Administrative Staff A on 08/02/21 at 01:10 PM revealed the facility assessment did not have a breakdown of how staffing was determined. Administrative Staff A stated she had not completed the facility assessment since last year. Interview with Administrative Nurse B on 08/02/21 at 01:55PM revealed she made the schedule for the nursing staff and the facility determined staffing based on the acuity of the residents. Review of the undated Facility Assessment Policy stated the facility assessment was the foundation to determine staffing levels and competencies to include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet the needs of the residents. The facility failed to address staffing in the Facility Assessment to document resources required to provide necessary care to the residents in regard to staffing across all shifts. This failure had the ability to affect all resident care in the facility.