**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Electronic Medical Record (EMR) for R8 recorded diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), a need for assistance with personal care, heart failure, hypertension (high blood pressure), and cardiac arrhythmia (improper beating of the heart, whether irregular, too fast, or too slow). The Significant Change Minimum Data Set (MDS), dated [DATE], documented that R8 had moderately impaired cognition. R8 required partial assistance with upper and lower dressing and showers. R8 required supervision with personal hygiene, mobility, and transfers. R8's Care Plan, dated 08/01/24 and initiated on 06/26/23, documented R8's need for assistance with grooming and personal hygiene and directed staff to encourage care in the morning, afternoon, and at bedtime. On 10/29/24 at 10:32 AM, observation revealed R8's hair was disheveled and greasy. R8 had dried food on her sweatshirt. On 10/29/24 at 03:41 PM, observation revealed that R8's hair was disheveled and greasy. Her chin hair was approximately one-half inch long, and her sweatshirt had dried food on it. On 10/30/24 at 08:29 AM, observation revealed that the front of R8's hair was disheveled, and it was flattened to the back of her head. R8 had chin hair approximately one-half inch long. On 10/3124 at 10:43 AM, Certified Nurse Aide M stated staff should make sure R8's hair was combed before she was brought out of her room. On 10/31/24 at 11:00 AM, Administrative Nurse D stated that staff were to make sure R8's hair was combed and should make sure she was shaved during her showers. The facility's Dignity policy, dated 02/22, documented that each resident should be cared for in a manner that promoted and enhanced his or her sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem. Residents are to be treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights and are groomed as they wish to be groomed. The facility failed to promote dignity for R8 when they did not adequately provide grooming assistance before bringing the resident out to the common area. This placed the resident at risk for impaired dignity. The facility had a census of 31. The sample included 12 residents. Based on record review, interview, and observation the facility failed to provide care for Resident (R)26 and R8 in a manner that protected and promoted resident dignity. This placed the residents at risk for impaired psychosocial well-being. Findings included: - On 10/29/24 at 11:15 AM, observation revealed R26 sat in a wheelchair right outside the medication room, in between the dining room and the common hall. Licensed Nurse (LN) G obtained R26's blood sugar reading using a glucometer (an instrument used to calculate blood glucose) from R26's right index finger. LN G then stated to the resident Your blood sugar reading is 277. Continued observation revealed ten residents were seated in the dining room awaiting lunch to be served, while staff and other residents were in the hallways adjacent to the medication room. Ongoing observation revealed LN G lifted R26's shirt and administered insulin (a hormone that lowers the level of glucose in the blood) shot in the resident's abdomen. On 10/30/24 at 04:00 PM, Administrative Nurse D stated staff should not check residents' blood sugar or give the residents insulin injections in a common area; staff should take the residents to their room or to a private area. The facility's Residents Dignity policy, dated February 2021, documented each resident would be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The residents are treated with dignity and respect at all times and their privacy is respected at all times. The facility failed to promote care for R26 in a manner to maintain and enhance dignity and respect placing the resident at risk of impaired psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to notify the State Long term Care Ombudsman (LTCO) of Resident (R)25's facility-initiated discharge to the hospital. This placed R25 at risk for impaired rights. Findings included: - R25's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness), and traumatic subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain.) R25's Quarterly Minimum Data Set (MDS), dated [DATE] recorded that R25 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS recorded R25 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Care Area Assessment (CAA), dated 06/05/24, recorded R25 had MDD, a craniotomy (an operation in which a small hole is made in the skull or a piece of one from the skull is removed to show part of the brain) on 04/21/24 and was alert and oriented with intermittent confusion. R25 had a history of depression and received medications for the diagnosis that were monitored monthly by the pharmacist. R25's Care Plan, dated 10/29/24 recorded R25 received antipsychotic medication for the diagnosis of MDD, and staff monitored for side effects and effectiveness every shift. The care plan documented a gradual dose reduction (GDR) review would be completed by the pharmacist and physician per facility protocol. The Physician's Order, initial order date 08/29/24, directed the staff to administer Seroquel (antipsychotic) 100 milligrams (mg), twice daily for a diagnosis of MDD. On 06/06/24 at 09:28 AM, the late entry nurse's note, documented on 06/05/24 at 06:20 PM, R25 was observed trying to sharpen a shaving razor with a red door hanger. The Certified Nurse Aide alerted the nurse. The nurse assessed the resident and asked him if he wanted to hurt himself and he stated, Why not. Staff notified the primary care physician and received an order to send the resident to the emergency department for an evaluation. R25 was evaluated at the hospital and returned to the facility at 02:00 AM the hospital documented that the resident stated he did not want to hurt himself he wanted to go home and thought if he went to the hospital, they would discharge him and he would not return to the facility. The facility continued 15-minute checks and continued to seek mental health services and/or acute mental health hospitalization. On 06/07/24 at 12:41 PM, the nurses' notes documented that R25 was transported to a behavioral health hospital for an inpatient stay and psychiatric evaluation. R25's clinical record lacked documentation staff notified the LTCO of the resident's discharge from the facility. On 10/30/24 at 01:00 PM, Social Services X stated the facility sent a report monthly to the LTCO that included the residents who were discharged home but stated she had never included residents who were discharged to the hospital. Social Service X stated she had been in the position for two years and was not aware she needed to send that information to the LTCO. Upon request, the facility did not provide a policy regarding the discharge of a resident or the Ombudsman notification policy. The facility failed to notify the LTCO of R25's facility-initiated discharge to the hospital. This placed the resident at risk for impaired rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents, with one reviewed for toileting. Based on observation, record review, and interview, The facility failed to revise the care plan to address the toileting needs of one resident, Resident (R) 2. This placed the resident at risk for impaired care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), pain in the thoracic spine (the middle section of the spine, located between the cervical spine (neck) and the lumbar spine (low back), and hyperthyroidism (a condition characterized by hyperactivity of the thyroid gland). The Annual Minimum Data Set (MDS), dated [DATE], documented R2 had severely impaired cognition. R2 was independent with mobility and ambulation. R2 required supervision with showers, upper and lower body dressing, transfers, toileting, and personal hygiene. The MDS documented R2 was frequently incontinent of bladder and occasionally incontinent of the bowel. R2's Quarterly MDS, dated 08/09/24, documented R2 had severely impaired cognition. R2 was independent with mobility, toileting, and ambulation. R2 required supervision with showers, upper and lower dressing, transfers, and personal hygiene. The MDS documented R2 was frequently incontinent of bladder and bowel. The Quarterly Bowel and Bladder Assessment, dated 08/08/24, documented R2 had no decline in incontinence and was always incontinent of bowel and frequently incontinent of bladder. R2's Care Plan, dated 08/09/24 and initiated on 11/13/23 documented R2 required one-person assistance with toileting, and directed staff to provide peri-care with every incontinent episode. Staff were to ensure she had an unobstructed path to the bathroom. The care plan lacked direction to staff that R2 required toileting after every meal. On 10/30/24 at 09:20 AM, observation revealed R2 walked with Certified Nurse Aide (CNA) O down the hallway. R2 stated, I have to go to the bathroom, oh, I'm going in my pants! CNA O told R2 staff would change her pants and told her not to worry. CNA O told R2 staff would take her into the shower room and get her cleaned up. R2 told staff she did not think she would have a bowel movement in her pants and asked staff to please get her to a bathroom. On 10/31/24 at 10:43 AM, CNA M stated R2 required assistance with toileting before and after meals. On 10/31/24 at 12:30 PM, Administrative Nurse E stated staff should assist R2 with toileting before and after meals. On 10/31/24 at 3:00 PM, Administrative Nurse D stated staff were aware R2 required toileting assistance before and after meals and confirmed the care plan should reflect that. The facility's Care Plans-Comprehensive policy, dated 11/10, documented an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. Care plan interventions were designed after careful consideration of the relationship between the resident's problem areas and concerns. Identifying problem areas and their cases and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events, and complex clinical decision-making. The care planning interdisciplinary team was responsible for the review and updating of the care plan if there was a significant change, a desired outcome was not met, a resident was readmitted to the facility from the hospital, and at least quarterly. The facility failed to revise R2's Care Plan with directions to staff on when to assist R2 with her toileting needs. This placed R2 at risk for impaired care due to uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents, with four reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing and toileting for Resident (R)2. This placed the resident at risk for poor personal hygiene and related complications. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), pain in the thoracic spine (the middle section of the spine, located between the cervical spine (neck) and the lumbar spine (low back), and hyperthyroidism (a condition characterized by hyperactivity of the thyroid gland). The Annual Minimum Data Set (MDS), dated [DATE], documented R2 had severely impaired cognition. R2 was independent with mobility and ambulation. R2 required supervision with showers, upper and lower body dressing, transfers, toileting, and personal hygiene. The MDS documented R2 was frequently incontinent of bladder and occasionally incontinent of bowel. R2's Quarterly MDS, dated 08/09/24, documented R2 had severely impaired cognition. R2 was independent with mobility, toileting, and ambulation. R2 required supervision with showers, upper and lower dressing, transfers, and personal hygiene. The MDS documented R2 was frequently incontinent of bladder and bowel. The Quarterly Bowel and Bladder Assessment, dated 08/08/24, documented R2 had no decline in incontinence and was always incontinent of bowel and frequently incontinent of bladder. R2's Care Plan, dated 08/09/24 and initiated on 06/29/23, directed staff to encourage bathing two times per week, inspect her skin during showers, and alert the nurse of any skin issues. The care plan directed staff to reassure R2 that she would not get pneumonia (infection of the lungs) from taking a bath or shower and that staff would try to keep her warm throughout. The update dated 11/13/23 documented R2 required one-person assistance with toileting, and directed staff to provide peri-care with every incontinent episode. Staff were to ensure she had an unobstructed path to the bathroom. The care plan lacked direction to staff that R2 required toileting after every meal. R2's September 2024 Bathing Record and October 2024 Bathing Record, documented R2 requested showers on Wednesday and Saturday dayshift and documented R2 had not received a bath or shower the following days: 09/29/24-10/11/24 (14 days) 10/14/24-10/29/24 (16 days) The EMR documented R2 refused a shower on 10/02/24, 10/05/24, and 10/09/24. On 10/29/24 at 12:53 PM, observation revealed R2 had very disheveled hair. On 10/30/24 at 09:20 AM, observation revealed R2 walked with Certified Nurse Aide (CNA) O down the hallway. R2 stated, I have to go to the bathroom, oh, I'm going in my pants! CNA O told R2 staff would change her pants and told her not to worry. CNA O told R2 staff would take her into the shower room and get her cleaned up. R2 told staff she did not think she would have a bowel movement in her pants and asked staff to please get her to a bathroom. On 10/31/24 at 10:43 AM, CNA M stated R2 would tell staff she was cold and didn't want a shower, but staff would continue to ask her. CNA M said that when R2 refused a shower, she would tell the charge nurse. CNA M stated R2 required assistance with toileting before and after meals. On 10/31/24 at 12:30 PM, Administrative Nurse E stated R2 often refused her shower because she got cold very easily. Administrative Nurse E further verified the facility had not offered different types of bathing. On 10/31/24 at 3:00 PM, Administrative Nurse D stated R2 did not like to shower and thought there had been an incident in her life relating to being in water. Administrative Nurse D stated R2 did not like her hair combed and when staff combed her hair, she would often take her hands and mess up her hair. Administrative Nurse D stated staff were aware R2 required toileting assistance before and after meals and the care plan should reflect that. The facility's Activities of Daily Living (ADL), Supporting policy, dated 03/18, documented the residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition grooming, and personal and oral hygiene. Residents would receive appropriate support and assistance with bathing, dressing, toileting, and grooming to prevent and/or minimize functional decline. If residents with cognitive impairment resist care, staff would attempt to identify the underlying cause of the problem and not just assume the resident was refusing or declining care. Approaching the resident in a different way or different manner, or just another staff member speaking with the resident may be appropriate. The facility failed to provide cognitively impaired R2 with consistent bathing opportunities and alternatives that incorporated her needs and preferences. The facility further failed to assist R2 with toileting after meals. This placed her at risk for poor hygiene and related complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents, with one reviewed for pain. Based on observation, record review, and interview, the facility failed to adequately respond to Resident (R)2's complaints of pain. This placed R2 at risk for unresolved pain and discomfort. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), pain in the thoracic spine (the middle section of the spine, located between the cervical spine (neck) and the lumbar spine (low back), and hyperthyroidism (a condition characterized by hyperactivity of the thyroid gland). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had severely impaired cognition. R2 required supervision for showers, personal hygiene, upper and lower dressing, and oral hygiene. The MDS documented R2 had no scheduled or as-needed pain medication. R2's Care Plan, dated 08/09/24 and initiated on 06/29/23, directed staff to administer pain medications as ordered, attempt and document any use of non-pharmacological interventions used, evaluate the effectiveness of pain interventions or medications, monitor and document pain level every shift, and notify the physician if interventions are unsuccessful. R2's Pain Assessment, dated 08/08/24, documented R2 complained of mild pain daily and did not receive scheduled or as-needed pain medication. The Physician's Order, dated 10/03/19, directed staff to assess R2's pain every shift, before and after administering pain medication, and document what non-pharmacological interventions were attempted. The Physician's Order, dated 05/26/24, directed staff to administer Tylenol (pain medication), 500 milligrams (mg), by mouth, every four hours, as needed, for pain. The Physician's Order, dated 10/20/24, directed staff to apply Biofreeze (topical pain analgesic), 10%, to R2's back, every eight hours, as needed for pain in the thoracic spine. The Physician's Order, dated 10/25/24, directed staff to administer acetaminophen (pain medication), 650 mg, two tablets, by mouth, three times per day for pain. A review of R2's Medication Administration Record (MAR) for October 2024, documented the scheduled acetaminophen was to be given at 08:00 AM, 02:00 PM, and 08:00 PM. On 10/30/24 at 07:45 AM, observation revealed Certified Nurse Aide (CNA) N assisted R2 into the dining room for breakfast. R2 stated she did not understand why her back hurt so much when she stood up. Ongoing observation revealed at 08:30 AM, CNA N stood R2 up from the dining table and R2 stated Oh my God, my back hurts so much. CNA N assisted R2 into the commons area and R2 sat down into a chair. Continued observation revealed at 09:20 AM, R2 ambulated down the hall with CNA O and stated again that her back hurt. On 10/30/24 at 09:25 AM, Certified Nurse Aide (CNA) N verified she had not informed the nurse that R2 had complained of back pain. On 10/30/24 at 09:30 AM, Certified Medication Aide (CMA) R stated she was unaware R2 had back pain as staff had not told her. CMA R further stated she had been on vacation for the last two weeks and was unaware R2 had a scheduled pain medication. On 10/30/24 at 09:35 AM, Administrative Nurse E stated the CNA staff should report to the CMA or the nurse when R2 had pain. On 10/30/24 at 10:00 AM, Administrative Nurse D stated R2 had as-needed pain medication and had recently been started on scheduled medication but often refused it. Administrative Nurse D further stated that CNA staff still should report to the charge nurse or CMA that R2 had pain. The facility's Pain-Clinical Protocol, dated 03/18, documented that nursing staff would assess each individual for pain upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain. The staff and physician would identify the characteristics of pain such as location intensity, frequency, pattern, and severity. The physician would order appropriate non-pharmacologic and medication interventions to address the individual's pain. The facility failed to adequately respond to R2's complaints of pain. This placed R2 at risk for unresolved pain and discomfort.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Electronic Medical Record (EMR) for R14 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), venous insufficiency (poor circulation), hypertension (high blood pressure), and dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented R14 had severely impaired cognition. R14 was independent with toileting, personal hygiene, mobility, upper and lower dressing, and transfers; R14 did not ambulate. The assessment revealed R14 received hypoglycemic (low blood sugar) medication. The Quarterly MDS, dated 08/02/24, documented R14 had severely impaired cognition. R14 required supervision for toileting, personal hygiene, upper and lower dressing, and set-up assistance with mobility and transfers. The MDS documented R14 received hypoglycemic medication. R14's Care Plan, dated 08/02/24 and initiated 08/14/23, directed staff to administer diabetic medication as ordered, monitor and obtain blood glucose levels as ordered, and report any signs and symptoms of hypoglycemia and hyperglycemia (high blood sugar). The Physician's Order, dated 03/19/24, directed staff to administer Novolog (a rapid-acting insulin that helps lower blood sugar), five units (U), subcutaneous (SQ-beneath the skin), before meals for DM. The order directed staff to notify the physician if R14's blood sugar was below 60 milliliters (ml) per deciliter (dl) or over 350 mm/dl. The order was discontinued on 09/12/24. The Diabetic Monitoring Record, dated August 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 08/05/24 at 05:00 PM-366 mm/dl 08/13/24 at 05:00 PM- 396 mm/dl 08/14/24 at 11:00 AM-370 mm/dl 08/27/24 at 07:00 AM-360 mm/dl 08/30/24 at 11:00 AM-366 mm/dl The Physician's Order, dated 09/12/24, directed staff to administer Novolog, six U SQ, before meals for DM. The order directed staff to notify the physician if R14's blood sugar was below 60 ml/dl or over 350 mm/dl. The Diabetic Monitoring Record, dated September 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 09/13/24 at 07:00 AM-395 mm/dl 09/30/24 at 11:00 AM-388 mm/dl The Diabetic Monitoring Record, dated October 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 10/04/24 at 05:00 PM- lacked documentation R14's blood sugar was obtained as ordered. 10/18/24 at 07:00 AM- 407 mm/dl 10/19/24 at 05:00 PM- lacked documentation R14's blood sugar was obtained as ordered. 10/21/24 at 07:00 AM-413 mm/dd The CP Medication Regimen Review for the months of August and September 2024 lacked evidence the CCP identified and reported the out-of-parameter blood sugars. On 10/30/24 at 07:40 AM, observation revealed Certified Medication Aide (CMA) R administered R14's medication without difficulty. On 10/30/24 at 09:43 AM, Administrative Nurse E stated she did not know why there were blanks in the blood sugar documentation and said staff should follow the physician's orders. On 10/30/24 at 10:00 AM, Administrative Nurse D stated she thought the order was changed a few months ago to notify the physician if the blood sugar was over 400 ml/dl but verified the order did not get documented in the EMR. Administrative Nurse D said she would contact the physician to get a new order. Administrative Nurse D further stated the CP had not notified her of the errors. The facility's Consultant Pharmacist Services Provider Requirements policy, dated 11/17, documented the Medication Regimen Review (MRR) for each resident was completed at least monthly, or more frequently under certain conditions, incorporating the federally mandated standards of care in addition to other applicable professional standards. The pharmacist communicates to the responsible prescriber, the facility's medical director, and the director of nursing potential or actual problems detected and other findings related to medication therapy orders at least monthly. They communicate recommendations for changes in medication therapy and the monitoring of medication therapy. The facility failed to ensure the CP identified and reported irregularities in R14's blood sugar monitoring. This placed the resident at risk for physical decline, ineffective medication regimen, and side effects from unnecessary medication. The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R) 25's antipsychotic (medications used to treat any major mental disorder characterized by gross impairment in reality) medication. The facility further failed to ensure the CP identified and reported irregularities in R14's blood sugar monitoring. This placed the residents at risk for physical decline, ineffective medication regimen, and side effects from unnecessary medication. Findings included: - R25's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness), and traumatic subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain.) R25's Quarterly Minimum Data Set (MDS), dated [DATE] recorded R25 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS recorded R25 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received antipsychotic medication during the observation period. The Care Area Assessment (CAA), dated 06/05/24, recorded R25 had MDD, and had a craniotomy (an operation in which a small hole is made in the skull or a piece of one from the skull is removed to show part of the brain) on 04/21/24 and was alert and oriented with intermittent confusion. R25 had a history of depression and received medications for the diagnosis that were monitored monthly by the pharmacist. R25's Care Plan, dated 10/29/24 recorded R25 received antipsychotic medication for the diagnosis of MDD, and staff monitored for side effects and effectiveness every shift. The care plan documented a gradual dose reduction (GDR) review would be completed by the pharmacist and physician per facility protocol. The Physician's Order, initial order date 08/29/24, directed the staff to administer Seroquel (antipsychotic) 100 milligrams (mg), twice daily for a diagnosis of MDD. R25's EMR lacked a documented physician rationale which included unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued Seroquel use. The Consultant Pharmacist's Monthly Medication Review for R25 on 06/20/24, 07/29/24, 08/29/24, and 09/19/24 lacked evidence of a recommendation for an appropriate indication for the continued use of Seroquel. On 10/30/24 at 08:30 AM, observation revealed the resident sat at the dining room table. Continued observation revealed Certified Medication Aide (CMA) M administered the resident's morning medications which included the Seroquel. On 10/30/24 at 10:10 AM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, with a diagnosis of MMD which was not an approved indication for the medication. Administrative Nurse D verified the physician had been informed of the need for another diagnosis and continues to document MDD. On 10/30/24 at 10:10 AM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, with a diagnosis of MMD which was an inappropriate indication for the medication. Administrative Nurse D stated the pharmacist completed monthly reviews of the facility residents and alerted her of concerns and recommendations. The facility's Pharmacist Services-Role of the Consulting Pharmacist dated 2007, recorded the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. The pharmacist would provide a report of activities, findings, and recommendations to the administrator and the director of nursing on a monthly basis, and render the required services in accordance with local, state, and federal laws, regulations, and guidelines; nursing care center policies and procedures; community standards of practice; and professional standards of practice. The facility failed to ensure the CP identified and reported the inappropriate indication for the continued use of the antipsychotic medication Seroquel. This placed R25 at risk for unnecessary antipsychotic medication with side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for Resident (R) 18 and failed to notify the physician of blood sugars outside of physician-ordered parameters for R14. This placed the residents at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (ER) for R18 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), a need for assistance with personal care, and constipation (difficulty passing stools). The Annual Minimum Data Set (MDS), dated [DATE], documented R18 had severely impaired cognition. R18 required supervision with toileting, upper dressing, and personal hygiene. R18 required set-up assistance with mobility, transfers, and ambulation. The MDS documented R18 was always continent of bowel. The Quarterly MDS, dated 08/01/24, documented R18 had severely impaired cognition. R18 required supervision with personal hygiene. He was independent with toileting, mobility, transfers, and ambulation. The MDS documented R18 was always continent of bowel. R18's Care Plan, dated 08/01/24, initiated on 02/01/23 documented R18 had impaired cognition and directed staff to cue, orient, and supervise as needed. The update, dated 0508/23, documented R18 was independent with toileting. The update, dated 08/04/23, directed staff to monitor R18 for constipation and administer medication as directed. R18's Quarterly Bowel Assessment, dated 07/24/24, documented R18 had no abnormalities in bowel status and was always continent of bowel. The Physician's Order, dated 04/07/23, directed staff to administer Milk of Magnesia (MOM-a laxative), 1200 milligrams (mg) per milliliters (ml), 30 ml by mouth every 24 hours as needed for constipation. R18's Bowel Monitoring Record, dated July 2024, documented R18 did not have a bowel movement for the following days: 07/03/24-07/11/24 (nine consecutive days) R18's Medication Administration Record, dated July 2024 lacked documentation the staff provided the physician-ordered interventions during the lack of bowel elimination on the above dates. R18's Bowel Monitoring Record dated August 2024 documented R18 did not have a bowel movement for the following days: 08/05/24-08/10/24 (six consecutive days) 08/18/24-08/21/24 (four consecutive days) R18's Medication Administration Record dated August 2024 lacked documentation the staff provided the physician-ordered interventions during the lack of bowel elimination on the above dates. R18's Bowel Monitoring Record, dated September 2024 and October 2024 documented R18 did not have a bowel movement for the following days: 09/20/24-09/26/24 (seven consecutive days) 09/28/24-10/03/24 (seven consecutive days) 10/05/24-10/08/24 (four consecutive days) 10/21/24-10/31/24 (11 consecutive days) The Medication Administration Record dated September 2024 and October 2024 lacked documentation the staff provided the physician-ordered interventions during the lack of bowel elimination on the above dates. On 10/30/24 at 08:00 AM, observation revealed R18 ambulated with the use of her walker to the entrance door and tried to open it to go outside where a male resident was outside with staff. R18 thought the resident was her husband and wanted to be outside with him. On 10/30/24 at 09:30 AM, Administrative Nurse E stated R18 was independent with toileting and staff asked her if she had a bowel movement. Administrative Nurse E acknowledged R18 was not a good historian due to her cognition and may not remember if she had a bowel movement or not. Administrative Nurse E said staff should have administered the MOM for the extended time periods with no recorded bowel movement. On 10/30/24 at 09:400 AM, Administrative Nurse D verified staff did not provide any interventions to R18 when she did not have a bowel movement. Administrative Nurse D stated R18 was able to take herself to the bathroom but may not remember if she had a bowel movement or not so staff should have completed a bowel assessment on her. On 10/31/24 at 10:43 AM, Certified Nurse Aide (CNA) M stated R18 required assistance with toileting. CNA M said that if R18 had not had a bowel movement, she would tell the nurse. The facility's Standing Order protocol, directed staff to administer MOM 30 ml on day four. If no results on day five, administer bisacodyl (a laxative), 5 mg, and if no results, on day six, administer a Fleets enema (introduction of a solution into the rectum for cleansing or therapeutic purposes), do a bowel assessment. If no results, contact the physician. The facility failed to monitor and provide the ordered interventions for bowel management for R18. This placed the resident at risk for impaction and physical decline. - The Electronic Medical Record (EMR) for R14 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), venous insufficiency (poor circulation), hypertension (high blood pressure), and dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented R14 had severely impaired cognition. R14 was independent with toileting, personal hygiene, mobility, upper and lower dressing, and transfers; R14 did not ambulate. The assessment revealed R14 received hypoglycemic (low blood sugar) medication. The Quarterly MDS, dated 08/02/24, documented R14 had severely impaired cognition. R14 required supervision for toileting, personal hygiene, upper and lower dressing, and set-up assistance with mobility and transfers. The MDS documented R14 received hypoglycemic medication. R14's Care Plan, dated 08/02/24 and initiated 08/14/23, directed staff to administer diabetic medication as ordered, monitor and obtain blood glucose levels as ordered, and report any signs and symptoms of hypoglycemia and hyperglycemia (high blood sugar). The Physician's Order, dated 03/19/24, directed staff to administer Novolog (a rapid-acting insulin that helps lower blood sugar), five units (U), subcutaneous (SQ-beneath the skin), before meals for DM. The order directed staff to notify the physician if R14's blood sugar was below 60 milliliters (ml) per deciliter (dl) or over 350 mm/dl. The order was discontinued on 09/12/24. The Diabetic Monitoring Record, dated August 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 08/05/24 at 05:00 PM-366 mm/dl 08/13/24 at 05:00 PM- 396 mm/dl 08/14/24 at 11:00 AM-370 mm/dl 08/27/24 at 07:00 AM-360 mm/dl 08/30/24 at 11:00 AM-366 mm/dl The Physician's Order, dated 09/12/24, directed staff to administer Novolog, six U SQ, before meals for DM. The order directed staff to notify the physician if R14's blood sugar was below 60 ml/dl or over 350 mm/dl. The Diabetic Monitoring Record, dated September 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 09/13/24 at 07:00 AM-395 mm/dl 09/30/24 at 11:00 AM-388 mm/dl The Diabetic Monitoring Record, dated October 2024, documented the following days R14's blood sugar was out of parameters and the physician was not notified: 10/04/24 at 05:00 PM- lacked documentation R14's blood sugar was obtained as ordered. 10/18/24 at 07:00 AM- 407 mm/dl 10/19/24 at 05:00 PM- lacked documentation R14's blood sugar was obtained as ordered. 10/21/24 at 07:00 AM-413 mm/dd On 10/30/24 at 07:40 AM, observation revealed Certified Medication Aide (CMA) R administered R14's medication without difficulty. On 10/30/24 at 09:43 AM, Administrative Nurse E stated she did not know why there were blanks in the blood sugar documentation and said staff should follow the physician's orders. On 10/30/24 at 10:00 AM, Administrative Nurse D stated she thought the order was changed a few months ago to notify the physician if R14's blood sugar was over 400 ml/dl but verified the order did not get documented in the EMR. Administrative Nurse D said she would contact the physician to get a new order. The facility's Diabetic Care policy, dated 11/20, documented that the provider would order the frequency of glucose monitoring and establish appropriate glycemic targets for individual residents. The policy directed staff to follow the provider's orders for blood glucose monitoring. The facility failed to notify the physician when R14's blood sugar was out of the physician-ordered parameters. This placed the resident at risk for unnecessary medication side effects and other related complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)25's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R25 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings included: - R25's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness), and traumatic subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain.) R25's Quarterly Minimum Data Set (MDS), dated [DATE] recorded R25 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS recorded R25 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received antipsychotic medication during the observation period. The Care Area Assessment (CAA), dated 06/05/24, recorded R25 had MDD, and had a craniotomy (an operation in which a small hole is made in the skull or a piece of one from the skull is removed to show part of the brain) on 04/21/24 and was alert and oriented with intermittent confusion. R25 had a history of depression and received medications for the diagnosis that were monitored monthly by the pharmacist. R25's Care Plan, dated 10/29/24 recorded R25 received antipsychotic medication for the diagnosis of MDD, and staff monitored for side effects and effectiveness every shift. The care plan documented a gradual dose reduction (GDR) review would be completed by the pharmacist and physician per facility protocol. The Physician's Order, initial order date 08/29/24, directed the staff to administer Seroquel (antipsychotic) 100 milligrams (mg), twice daily for a diagnosis of MDD. R25's EMR lacked a documented physician rationale which included unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued Seroquel use. On 10/30/24 at 08:30 AM, observation revealed the resident sat at the dining room table. Continued observation revealed Certified Medication Aide (CMA) M administered the resident's morning medications which included the Seroquel. On 10/30/24 at 10:10 AM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, with a diagnosis of MMD which was not an approved indication for the medication. Administrative Nurse D verified the physician had been informed of the need for another diagnosis and continues to document MDD. The facility's Antipsychotic Medication Use policy, dated December 2016, recorded antipsychotic medication may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. The policy documented the residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for appropriateness and indications for use. The interdisciplinary team would complete a preadmission screening for mentally ill and intellectually disabled individuals if appropriate or use of the antipsychotic medication at the time of admission and or within two weeks at the initial MDS assessment to consider whether or not the medication can be reduced, tapered, or discontinued. In addition to the diagnoses antipsychotic medications would generally only be considered if the following conditions are also met; the behavioral symptoms present a danger to the resident and others and the symptoms are identified as being due to mania or psychosis or behavioral interventions have been attempted and included in the plan of care, except in an emergency. The facility failed to ensure R25 did not receive antipsychotic medication without an appropriate indication or the required physician documentation for its use placing R25 at risk for adverse side effects.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)6, R14, and R26s' insulin (a hormone that lowers the level of glucose in the blood) flex pens with opened and discard dates. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On 10/29/24 at 09:00 AM, observation of the facility's treatment cart revealed the following: R6's Basaglar (long-acting insulin) flex pen was not labeled with an open or discard date. R14's Lantus (long-acting insulin) flex pen was not labeled with an open or discard date. R26's Basaglar flex pen was not labeled with an open or discard date. On 10/29/24 at 08:35 AM, License Nurse (LN) G verified the nurses should label and date the insulin flex pens with the date opened and the expiration date. On 10/30/24 at 08:30 AM, Administrative Nurse D verified the nurses should label and date the flex pens with the date opened and the expiration date. Medlineplus.gov directs open, unrefrigerated Lantus (basaglar and glargine) can be used within 28 days; after that time, it must be discarded. The facility's Storage of Medication policy, dated November 2020, documented the facility would store all drugs and biologicals in a safe, secure, and orderly manner. The facility would not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The facility failed to date the insulin flex pens with the opened and discard dates placing the residents at risk for ineffective medication.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to correctly prepare a pureed diet for three residents that retained both nutritive value and palatability. This placed the affected residents at risk for impaired nutrition or decreased quality of life. Findings included: - On 10/30/24 at 10:00 AM, observation revealed the lunch meal included cheesy macaroni hamburger helper, carrots, pears, and garlic bread. On 10/30/24 at 10:30 AM, observation revealed Dietary Staff (DS) CC prepared three pureed diets. DS CC placed three servings of cheesy macaroni hamburger helper in the Robot-coup blender (a food processor) and added four ounces of beef base. DS CC blended the macaroni to a thin consistency and emptied the blended food into a metal pan and placed the pan into the hot water well in the hot holding cart. Observation revealed DS CC then placed three - four-ounce servings of pears in the Robot coup, with four squirts of simply thick easy mix and blended the food to a pureed texture. DS CC emptied the pureed pears into three bowls, covered them with aluminum foil, and placed them on a serving tray. Observation revealed DS CC then placed three -four-ounce servings of carrots in the Robo-t coup blender including the butter juice from the cooked carrots and blended the food to a pureed texture. DS CC emptied the pureed carrots into a metal pan and placed the pan in the hot water well in the hot holding cart. On 10/31/24 at 11:00 AM, DS BB verified DS CC did not provide the pureed diet residents with the same nutritional diet as the other residents. DS BB verified DS CC did not puree rolls or a biscuit with added milk to the pureed texture and stated DS CC was nervous and just forgot to do that. The facility's Pureed Diet policy, dated January 2014, documented a pureed diet is designed for individuals with moderate to severe dysphagia, and for individuals with poor dentition, minimal or no ability to chew. The general diet or other appropriate diet is modified in consistency by pureeing foods to a smooth consistency. Some foods may need to be thickened after they are pureed to achieve desired consistency. Add the number of pureed diets plus one to the food processor, and give a quick start. If bread/dinner rolls/crackers are on the menu for the general diet, this can be added to the meat or vegetable. If general diets get butter on their bread or roll, add butter to the bread/roll. Puree until proper final consistency is reached the food should be pudding consistency and not run when plated. Cover, label with serving size, and place in appropriate hot or cold areas. The facility failed to provide food prepared by methods that conserve nutritive value and flavor while preparing a pureed diet for three residents. This placed the affected residents at risk for impaired nutrition.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 31 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 10/29/24 at 08:30 AM, observation revealed dietary staff in the kitchen prepared the breakfast meal. On 10/29/24 at 09:40 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated the facility had six residents with mechanical soft diets and three with a pureed diet. On 10/31/24 at 02:00 PM, Administrative Staff A verified Dietary Staff BB, the dietary manager, was not certified. The facility's Dietician policy, dated 10/2017, documented a qualified, competent, and skilled dietician would help oversee the food and nutrition services in the facility. A food and nutrition services manager would oversee the production, storage, and delivery of food. The dietician would work closely with the food and nutrition services manager and clinical staff. The dietician or nutritional professional may be a full-time or part-time consultant or an employee, depending on the current requirements of the facility. These requirements are based on: a.assessments and care plans of resident's nutritional needs; and b. the overall facility assessment of the number, acuity, and diagnosis of the resident population The dietician would have the qualifications, competency, and skills to carry out the functions of the food and nutrition services. If a dietician is not employed full time (35 hours per) a director of food service management would be designated the individual would: a.Be a certified dietary manager; or b.be a certified food service manager; or c.be nationally certified in food service management and safety; or d.have an associate (or higher) degree in food service management or hospitality (must be from an accredited institution and include courses in food service or restaurant management) e.meet any state requirements for food services or dietary manager. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food for the 31 residents in the facility. This placed the residents at risk for inadequate nutrition.

The facility had a census of 31 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the residents in the facility, who receive their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food-borne illness. Findings included: - On 10/29/24 at 8:45 AM, during the initial tour, observation revealed a one three foot by six-inch air vent grill located above the North door entrance to the kitchen was covered with a brownish grease/sticky substance and a gray fuzzy substance blowing directly on the food preparation area. Continued observation revealed two florescent light fixtures, approximately six inches by two feet located in the exhaust hood above the stovetop. One of the florescent covers was missing and exposed the florescent bulb and the other cover was partially affixed to the light fixture. On 10/29/24 at 09:15 AM, observation revealed nine ceiling-mounted fluorescent light fixtures approximately 10 inches by three feet located on the ceiling. The fixtures had metal pull chains affixed to the fixtures with a brownish-gray fuzzy substance affixed to the chains, the fixtures were located directly above the food preparation area and the dishwashing area. On 10/31/24 at 12:10 PM, Maintenance Staff U verified the dirty register grill, and the dirty overhead fluorescent light pull chains and verified the fluorescent bulb located in the stove hood was not encapsulated and should have a cover on the fixture. Maintenance Staff U verified the cover on the other fluorescent light was partially coming off the fixture. The facility's Sanitization policy, dated October 2008, stated the food service area should be maintained in a clean and sanitary manner. All kitchen areas and dining areas should be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. Utensils, counters, shelves, and equipment shall be kept clean and maintained in good repair and shall be free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent the accumulation of grime. The food service manager would be responsible for scheduling staff for regular cleaning of kitchen and dining areas. The facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 31 residents in the facility, who received their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food-borne illness.

The facility had a census of 31 residents. Based on interviews and record review, the facility failed to submit complete and accurate staffing information through Payroll-Based Journaling (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 & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter (Q) 4 indicated no licensed nurse coverage on eight days. The PBJ for FY 2024 Q4 recorded no licensed nurse coverage on the following dates: 07/29/23, 07/30/23, 09/09/23, 09/10/3, 09/11/23, 09/2/23, 09/28/23, and 09/29/23. The PBJ report provided by CMS for FY 2024 Q3 indicated no licensed nurse coverage on eight days. The PBJ for FY 2024 Q3 recorded no licensed nurse coverage on the following dates: 05/12/24, 05/13/24, 05/15/24, 05/16/24, 05/17/24, 05/18/24, 05/19/24, and 05/22/24. The PBJ report provided by CMS for FY 2024 Q1 indicated no licensed nurse coverage on six days. The PBJ for FY 2024 Q1 recorded no licensed nurse coverage on the following days: 10/01/24, 10/05/24, 10/06/24, 10/07/24, 10/09/24, and 10/12/24. A review of the facility licensed nurse payroll data for the dates listed above revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 10/29/24 at 09:00 AM, Administrative Staff A stated that there was maybe a time when someone was not sending in the correct information and verified the above dates as being reported incorrectly. Administrative Staff A stated that there was always a licensed nurse in the building and that there were more registered nurses than there used to be. The facility's Reporting Direct Care Staffing Information) Payroll-Based Journal) policy, dated 08/2022, documented that direct care staffing information was reported electronically to CMS through the Payroll-Based Journal system. The category of work for each person on the direct care staff (including, but not limited to, whether the individual was a registered nurse, licensed practical nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS. Direct care staffing information included staff hired directly by the facility, those hired through an agency, and contract employees. The information on direct care staff turnover and tenure, and the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual). The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility identified a census of 30 residents. The sample included three residents reviewed for dignity. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 3 was treated with dignity. This deficient practice placed R3 at risk for impaired psychosocial well-being and decreased dignity and self-worth. Findings included: - The Diagnoses tab of R3's Electronic Medical Record (EMR) documented a diagnosis of nontraumatic intracerebral hemorrhage (an emergency condition in which a blood vessel in the brain ruptures and causes bleeding inside the brain). The Significant Change Minimum Data Set (MDS) dated 02/16/24 documented that R3 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 02/26/24, documented R3 had physical and verbal behaviors directed at staff. R3's Care Plan dated 11/15/23, documented R3's preference to vape (using a device to inhale an aerosol, typically one containing nicotine) while at the facility and directed staff to observe R3 to make sure the smoking policy was followed correctly. R3's Care Plan dated 01/12/24, documented R3 had impaired communication related to aphasia (condition with disordered or absent language function) and directed staff to allow time for R3 to respond to communication and observe for nonverbal cues with communication. In a statement typed by Administrative Nurse D on 03/12/24, R3 stated he was in his wheelchair in front of the building where he vapes because Licensed Nurse (LN) H took him outside. He stated LN H was throwing her cigarette away at her car when Administrative Staff A came outside and went over to LN H's car. R3 stated Administrative Staff A asked LN H why she brought R3 outside because it was not important at that time and Administrative Staff A needed coverage on the floor, not outside smoking. R3 stated LN H sat next to him and stated she wished Administrative Staff A did not talk to her that way and that R3 had just as much of a right as anyone else. R3 stated the interaction between Administrative Staff A and LN H made him feel insecure and unimportant. R3 stated a nurse helping a resident is important and the nurses were supposed to make the residents a priority. Licensed Nurse (LN) H's notarized Witness Statement on 03/13/24 stated on 02/29/24, she took R3 outside for his scheduled vape time and since her car was parked next to the area, she took the opportunity to sit in her car with the door open and have a smoke herself. She stated Administrative Staff A went to the parking lot and asked her what she was doing outside. LN H stated she brought R3 out to vape and was taking a short break herself. LN H stated Administrative Staff A then said R3's vaping was not a priority and LN H must not be too busy if she had time to bring R3 outside. LN H stated the conversation happened in front of R3 and he was upset and stated to LN H that Administrative Staff A should not have said that in front of him. On 04/03/24 at 11:22 AM, R3 lay in bed. He stated on 02/29/24, LN H took him outside to vape and Administrative Staff A came outside to confront LN H. R3 said Administrative Staff A stated his vaping was not a priority. R3 stated that the comment made him feel terrible, belittled, unwanted, and not important. On 04/03/24 at 03:51 PM, Administrative Staff A stated on 02/29/24, LN H took R3 outside and he was sitting by the front while she was in her car. She stated she went outside and asked LN H why she was smoking and told her she would not be able to get to R3 from her car if he started rolling away. Administrative Staff A stated she did not know how R3 heard the whole conversation. She stated she would not have said vaping was not important but if a resident heard that, it would be hurtful. The facility's Dignity policy, revised in February 2021, directed residents to be treated with respect and dignity at all times and the facility culture supported dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. The facility failed to ensure R3 was treated with dignity. This deficient practice placed R3 at risk for impaired psychosocial well-being and decreased dignity and self-worth.

The facility identified a census of 30 residents. The sample included three residents reviewed for visitation rights. Based on observations, record review, and interviews, the facility failed to ensure Residents (R) 1 and R2 were able to exercise their right to receive visitors of their choosing at the time of the residents' choice. This deficient practice placed R1 and R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of 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) and weakness. The Annual Minimum Data Set (MDS) dated 10/05/23, documented that R1 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The Quarterly MDS dated 01/05/24, documented R1 had a BIMS score of six which indicated severe cognitive impairment. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 10/06/23, documented R1 had cognitive deficits and was able to make her wants and needs known to staff. R1's Care Plan dated 06/26/23, documented R1 had a potential for diversional activity due to cognitive impairment and/or physical assistance needed. The care plan documented an intervention, revised 11/22/23, that directed the facility to encourage ongoing family involvement and invite R1's family to attend special events, activities, and meals. On 04/03/24 at 02:58 PM, R1 sat in a chair in the day area next to other residents. On 04/03/24 at 12:11 PM, R1's representative stated she worked at the facility on 02/29/24 because the facility needed help. She relayed she had a situation on that date with R3 and Administrative Staff A. She said on 03/22/24, she visited R1 in the morning and then received a call that afternoon from Administrative Staff A and Administrative Nurse D. R1's representative stated the facility administrative staff told her that she had been found guilty of abuse by the State Agency (SA) and stated she could not visit R1 anymore unless she made an appointment with the facility and the visitation had to be away from other residents and had to be supervised by facility staff. R1's representative stated she called the SA and the Long-Term Care Ombudsman (LTCO) for further information. She stated R1 liked it when she visited at lunchtime, so she arrived at the facility on 04/02/24 at lunchtime and sat with R1. R1's representative stated Administrative Staff A went into the dining room, placed a hand on her (the representative's) shoulder, and directed R1's representative to leave or the facility would have her escorted out. R1's representative stated three law enforcement officers came in and one of them went into where she was visiting her mom. R1's representative stated she tried to keep the situation calm so R1 would not get upset. She said 04/02/24 had been her first visit since 03/22/24. On 04/03/24 at 03:00 PM, Administrative Nurse D stated the facility worked with the LTCO to set up visitation and said he was in the facility on 04/02/24 when R1's representative walked into the building at around 11:15 AM, before her scheduled visitation time at 01:00 PM. R1 was in the dining room along with the LTCO and R1's family sat with her. Administrative Nurse D confirmed that Administrative Staff A called law enforcement at that time. When the law enforcement officers arrived, they spoke to R1's representative outside. Administrative Nurse D stated R1's representative was supposed to call Administrative Staff A or Administrative Nurse D to schedule a visitation time and the facility offered to set up an empty room as a visitation room so R1 and her representative would both be comfortable. On 04/03/24 at 03:10 PM, Licensed Nurse (LN) G stated the only visitation restriction she knew of was for R1's representative. LN G said R1's representative was supposed to call ahead of time and schedule a visitation. On 04/03/24 at 03:15 PM, Administrative Nurse D stated the only abuse or neglect she could make out about R1's representative might be that R1's representative shared information with R3 or that she smoked in her car while R3 vaped outside. She stated she did not see R1's representative as a threat to the residents. Administrative Nurse D stated she did not think there should be restricted visitation and that R1's representative posed no threat but because of an email received from the SA, the facility staff were upset and did not know what to do. She stated she did not call the SA to clarify the email. On 04/03/24 at 03:51 PM, Administrative Staff A stated R1's representative made a complaint against her because of an incident on 02/29/24 with R3 and R1's representative and Administrative Staff A. Administrative Staff A stated she had left the state when the investigation was going on and when the facility received an email from the SA that mentioned substantiated neglect, the facility was instructed by corporate to set up restricted visitation for R1 related to R1's representative. Administrative Staff A stated the facility did not clarify the information with the SA before restricting R1's rights. The facility's Visitation policy, revised in September 2022, directed residents were permitted to have visitors of their choosing at the time of their choosing and the facility provided 24-hour access to individuals visiting with the consent of the resident. The facility failed to ensure R1 was able to exercise her right to receive visitors of her choosing at the time of her choice. This deficient practice placed R1 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation. - The Diagnoses tab of R2's Electronic Medical Record (EMR) documented diagnoses of unsteadiness on feet and need for assistance with personal care. The admission Minimum Data Set (MDS) dated 11/13/23, documented R2 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. It was very important to R3 that the family was involved in discussions about her care and very important for R3 to do her favorite activities. The Quarterly MDS dated 02/13/24, documented R2 had a BIMS score of 15 which indicated intact cognition. The Psychosocial Well-Being Care Area Assessment (CAA) dated 11/14/23, documented that R2 reported little interest or pleasure in doing things. R2's Care Plan dated 11/15/23, documented R2 had a potential for diversional activity due to cognitive impairment and/or physical assistance needed. The care plan directed the facility encouraged ongoing family involvement and invited R2's family to attend special events, activities, and meals. On 04/03/24 at 10:56 AM, R2 sat up in her bed and conversed with the surveyor. She stated the facility told her husband he could not come up to the dining room and if he went into the dining room, the facility would call law enforcement. She stated her husband no longer feels comfortable coming to the facility and she felt like her visitation was restricted. R2 stated she felt uncomfortable in the facility and her husband made her feel comfortable. R2 began crying. On 04/03/24 at 03:15 PM, Administrative Nurse D stated that R2's family was paying to eat at the facility, and Administrative Staff A gave him his money back and told him he could not eat at the facility anymore. She stated a dietary staff member felt uncomfortable with R2's family being in the dining room in the evenings because of an outburst that occurred. She stated R2's family was told he could not go into the dining room with R2 and that he had to wait until R2 was done eating. On 04/03/24 at 03:51 PM, Administrative Staff A stated R2's family wanted three meals a day and was told he could pay for food. They had set it up where R2's family was paying for meals. She stated last week, dietary staff came into her office crying because R2's family told her he wanted seconds and dietary staff told him all of the residents had not been fed yet. She stated R2's family got mad when he did not get seconds. Administrative Staff A stated she told R2's family that he could visit but he was not allowed in the dining room and R2 and he could eat in the living room if he brought food. She stated the facility gave R2's family the money back that he paid for meals and said to just call it even, but he was not to eat at the facility. She denied giving any alternative options before restricting visitation. The facility's Visitation policy, revised in September 2022, directed residents were permitted to have visitors of their choosing at the time of their choosing and the facility provided 24-hour access to individuals visiting with the consent of the resident. The facility failed to ensure R2 was able to exercise her right to receive visitors of her choosing at the time of her choice. This deficient practice placed R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation.

The facility identified a census of 30 residents. The sample included three residents reviewed for visitation rights. Based on observations, record review, and interviews, the facility failed to inform Resident (R) 1 and R2 and/or their representative of their visitation rights and any visitation restrictions placed on them. This deficient practice placed R1 and R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of 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) and weakness. The Annual Minimum Data Set (MDS) dated 10/05/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The Quarterly MDS dated 01/05/24, documented R1 had a BIMS score of six which indicated severe cognitive impairment. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 10/06/23, documented R1 had cognitive deficits and was able to make her wants and needs known to staff. R1's Care Plan dated 06/26/23, documented R1 had a potential for diversional activity due to cognitive impairment and/or physical assistance needed. The care plan documented an intervention, revised 11/22/23, that directed the facility to encourage ongoing family involvement and invite R1's family to attend special events, activities, and meals. Upon request, the facility was unable to provide evidence a notice was issued to R1's durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) stating that her visitation was restricted, what the restrictions were and why. On 04/03/24 at 02:58 PM, R1 sat in a chair in the day area next to other residents. On 04/03/24 at 12:11 PM, R1's representative stated she worked at the facility on 02/29/24 because the facility needed help. She relayed she had a situation on that date with R3 and Administrative Staff A. She said on 03/22/24, she visited R1 in the morning and then received a call that afternoon from Administrative Staff A and Administrative Nurse D. R1's representative stated the facility administrative staff told her that she had been found guilty of abuse by the State Agency (SA) and stated she could not visit R1 anymore unless she made an appointment with the facility and the visitation had to be away from other residents and had to be supervised by facility staff. R1's representative stated she called the SA and the Long-Term Care Ombudsman (LTCO) for further information. She stated R1 liked it when she visited at lunchtime, so she arrived at the facility on 04/02/24 at lunchtime and sat with R1. R1's representative stated Administrative Staff A went into the dining room, placed a hand on the representative's shoulder, and directed R1's representative to leave or the facility would have her escorted out. R1's representative stated three law enforcement officers came in and one of them went into where she was visiting her mom. R1's representative stated she tried to keep the situation calm so R1 would not get upset. She said 04/02/24 had been her first visit since 03/22/24. On 04/03/24 at 03:00 PM, Administrative Nurse D stated the facility worked with the LTCO to set up visitation and said he was in the facility on 04/02/24 when R1's representative walked into the building at around 11:15 AM, before her scheduled visitation time at 01:00 PM. R1 was in the dining room along with the LTCO and R1's family sat with her. Administrative Nurse D confirmed that Administrative Staff A called law enforcement at that time. When the law enforcement officers arrived, they spoke to R1's representative outside. Administrative Nurse D stated R1's representative was supposed to call Administrative Staff A or Administrative Nurse D to schedule a visitation time and the facility offered to set up an empty room as a visitation room so R1 and her representative would both be comfortable. On 04/03/24 at 03:10 PM, Licensed Nurse (LN) G stated the only visitation restriction she knew of was for R1's representative. LN G said R1's representative was supposed to call ahead of time and schedule a visitation. On 04/03/24 at 03:51 PM, Administrative Staff A stated the facility did not send a notice out to R1's DPOA, informing him of R1's restricted visitation. The facility's Visitation policy, revised in September 2022, directed residents were permitted to have visitors of their choosing at the time of their choosing and the facility provided 24-hour access to individuals visiting with the consent of the resident. The facility failed to notify R1 and/or her DPOA of her restricted visitation as required. This deficient practice placed R1 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation. - The Diagnoses tab of R2's Electronic Medical Record (EMR) documented diagnoses of unsteadiness on feet and need for assistance with personal care. The admission Minimum Data Set (MDS) dated 11/13/23, documented R2 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. It was very important to R3 that the family was involved in discussions about her care and very important for R3 to do her favorite activities. The Quarterly MDS dated 02/13/24, documented R2 had a BIMS score of 15 which indicated intact cognition. The Psychosocial Well-Being Care Area Assessment (CAA) dated 11/14/23, documented R2 reported little interest or pleasure in doing things. R2's Care Plan dated 11/15/23, documented R2 had a potential for diversional activity due to cognitive impairment and/or physical assistance needed. The care plan directed the facility encouraged ongoing family involvement and invited R2's family to attend special events, activities, and meals. Upon request, the facility was unable to provide evidence a notice was issued to R2 and her representative that her visitation was restricted. On 04/03/24 at 10:56 AM, R2 sat up in her bed and conversed with the surveyor. She stated the facility told her husband he could not come up to the dining room and if he went into the dining room, the facility would call law enforcement. She stated her husband no longer feels comfortable coming to the facility and she felt like her visitation was restricted. R2 stated she felt uncomfortable in the facility and her husband made her feel comfortable. R2 began crying. On 04/03/24 at 03:15 PM, Administrative Nurse D stated R2's family was paying to eat at the facility, and Administrative Staff A gave him his money back and told him he could not eat at the facility anymore. She stated a dietary staff member felt uncomfortable with R2's family being in the dining room in the evenings because of an outburst that occurred. She stated R2's family was told he could not go into the dining room with R2 and that he had to wait until R2 was done eating. On 04/03/24 at 03:51 PM, Administrative Staff A stated R2's family wanted three meals a day and was told he could pay for food. They had set it up where R2's family was paying for meals. She stated last week, dietary staff came into her office crying because R2's family told her he wanted seconds and dietary staff told him all of the residents had not been fed yet. She stated R2's family got mad when he did not get seconds. Administrative Staff A stated she told R2's family that he could visit but he was not allowed in the dining room and R2 and he could eat in the living room if he brought food. She stated the facility gave R2's family the money back that he paid for meals and said to just call it even, but he was not to eat at the facility. She denied giving any alternative options before restricting visitation. She stated she should have given a notice to R2 or her representative regarding her restricted visitation. The facility's Visitation policy, revised in September 2022, directed residents were permitted to have visitors of their choosing at the time of their choosing and the facility provided 24-hour access to individuals visiting with the consent of the resident. The facility failed to notify R2 and/or her representative of her restricted visitation as required. This deficient practice placed R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation.

The facility identified a census of 29 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from verbal abuse. On 09/18/23 at approximately 07:30 PM, Certified Nurse's Aide (CNA) M and CNA N were transferring R1 with a full lift from R1's wheelchair to her recliner. During the transfer, R1 began swatting at CNA M and CNA M yelled at R1 and caalled her a derogatory name.This deficient practice placed R1 at risk for psychosocial impairment due to the verbal abuse. Findings included: - R1's Electronic Medical Record documented R1 had diagnoses of 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) and need for assistance with personal care. The Quarterly Minimum Data Set, (MDS), dated 08/10/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of twelve which indicated moderately impaired cognition. The MDS documented R1 required extensive assistance of two staff with all activities of daily living (ADL's) with the exception of eating. The MDS documented R1 had four to six days during the look back period of exhibiting verbal behaviors directed towards others. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/13/23, documented R1 had moderately impaired cognition. The ADL CAA, dated 05/13/23, documented R1 required two staff assistance with toileting, bed mobility, and transfers. R1 required one staff assistance for all other ADL's. The Behavioral Care Plan, revised 06/19/23, R1 had behaviors of being combative, having negative verbalizations, resisting cares, screaming out, and attention seeking. The care plan directed staff to minimize the potential for R1's disruptive behaviors by offering tasks which divert attention, redirect R1 by trying to assist her, and attempt to use positive reinforcement. CNA M's Witness Statement, dated 09/19/23, documented R1 started yelling at CNA M the previous night and raised her hand at CNA M so CNA M had enough and started yelling back at R1. CNA M stated R1 had verbally and physically abused her a number of times and CNA M had walked away. CNA N's Witness Statement, dated 09/19/23, documented CNA N stated she and CNA M were getting R1 back to her recliner when R1 started swatting at CNA M. CNA M was not nice to R1 about it and CNA M started yelling and cussing at R1 and going back and forth with R1. CNA M stated I swear if you hit me it will be the last thing you do, and You are a mean old [expletive]. CNA N stated she had never heard or saw anyone talk or handle a resident that way. CNA N stated she should have reported the incident to the nurse but was not sure what to do as she had not been in this kind of situation before. The undated Facility Incident Report, documented CNA N e-mailed Human Resources GG on 09/19/23 and reported while providing night cares to R1 on 09/18/23, R1 began having behaviors and started swatting at CNA M. CNA M became upset with R1 and told R1 If you hit me it will be the last thing you do, and You are a mean old [expletive]. CNA N admitted that she was unsure of how to go about reporting the issue and should have reported to the charge nurse after the incident immediately. Human Resources GG notified all parties. On 09/20/23 at 10:30 AM, observation revealed R1 sat in her recliner watching TV. R1 had a blank expression on her face and had her call light in hand with her thumb depressing the call light. R1 stated that no one had ever been mean to her at the facility, no one had ever yelled at her at the facility, and she received good care at the facility. On 09/20/23 at 11:00 AM, Human Resources GG stated he had received an e-mail from CNA N the morning of 09/19/23 telling him of an incident between CNA M and R1. CNA N stated that she should have reported the incident as soon as it happened to her charge nurse, but she wasn't really sure what to do but knew she had to do something. Human Resources GG stated CNA M worked the 02:00PM to 10:00 PM shift on 09/19/23 so he called CNA M in early and suspended her until the investigation was completed. CNA M told Human Resources GG that she had enough of being abused by R1 and nothing was being done about R1's behavior. Human Resources GG stated all staff at the facility had been trained multiple times regarding abuse and neglect but there was another education scheduled on 09/22/23 between shifts and signage had been placed in the work areas regarding staff needing to call the facility administrator immediately when any allegations of abuse or neglect occurred. On 09/20/23 at 11:30 AM, Administrative Nurse D stated that she expected all staff to know and understand the abuse and neglect policy and adhere to it. The facility Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 02/06/23, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint no required to treat the resident's medical condition. This includes prohibiting facility staff from taking acts that result in personal degradation including the taking or using photographs or recordings in nay manner that would demean or humiliate a resident and prohibits using any type of photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Training will educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, misappropriation of resident property and exploitation, and dementia management and resident abuse prevention. The facility failed to ensure R1 remained free from verbal abuse. This deficient practice placed R1 at risk for psychosocial impairment due to the verbal abuse.

The facility identified a census of 29 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff immediately reported verbal abuse to the facility administrator (LNHA). On 09/18/23 at approximately 07:30 PM, Certified Nurse's Aide (CNA) M and CNA N were transferring R1 with a full lift from R1's wheelchair to her recliner. During the transfer, R1 began swatting at CNA M and CNA M yelled at R1 and called her a derogatory name. CNA N did not report the incident until 09/19/23 in an e-mail to the Human Resources GG. This deficient practice placed R1 at risk for further mistreatment and psychosocial impairment. Findings included: - R1's Electronic Medical Record documented R1 had diagnoses of 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) and need for assistance with personal care. The Quarterly Minimum Data Set, (MDS), dated 08/10/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of twelve which indicated moderately impaired cognition. The MDS documented R1 required extensive assistance of two staff with all activities of daily living (ADL's) with the exception of eating. The MDS documented R1 had four to six days during the look back period of exhibiting verbal behaviors directed towards others. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/13/23, documented R1 had moderately impaired cognition. The ADL CAA, dated 05/13/23, documented R1 required two staff assistance with toileting, bed mobility, and transfers. R1 required one staff assistance for all other ADL's. The Behavioral Care Plan, revised 06/19/23, R1 had behaviors of being combative, having negative verbalizations, resisting cares, screaming out, and attention seeking. The care plan directed staff to minimize the potential for R1's disruptive behaviors by offering tasks which divert attention, redirect R1 by trying to assist her, and attempt to use positive reinforcement. CNA M's Witness Statement, dated 09/19/23, documented R1 started yelling at CNA M the previous night and raised her hand at CNA M so CNA M had enough and started yelling back at R1. CNA M stated R1 had verbally and physically abused her a number of times and CNA M had walked away. CNA N's Witness Statement, dated 09/19/23, documented CNA N stated she and CNA M were getting R1 back to her recliner when R1 started swatting at CNA M. CNA M was not nice to R1 about it and CNA M started yelling and cussing at R1 and going back and forth with R1. CNA M stated I swear if you hit me it will be the last thing you do, and You are a mean old [expletive]. CNA N stated she had never heard or saw anyone talk or handle a resident that way. CNA N stated she should have reported the incident to the nurse but was not sure what to do as she had not been in this kind of situation before. The undated Facility Incident Report, documented CNA N e-mailed Human Resources GG on 09/19/23 and reported while providing night cares to R1 on 09/18/23, R1 began having behaviors and started swatting at CNA M. CNA M became upset with R1 and told R1 If you hit me it will be the last thing you do, and You are a mean old [expletive]. CNA N admitted that she was unsure of how to go about reporting the issue and should have reported to the charge nurse after the incident immediately. Human Resources GG notified all parties. On 09/20/23 at 10:30 AM, observation revealed R1 sat in her recliner watching TV. R1 had a blank expression on her face and had her call light in hand with her thumb depressing the call light. R1 stated that no one had ever been mean to her at the facility, no one had ever yelled at her at the facility, and she received good care at the facility. On 09/20/23 at 11:00 AM, Human Resources GG stated he had received an e-mail from CNA N the morning of 09/19/23 telling him of an incident between CNA M and R1. CNA N stated that she should have reported the incident as soon as it happened to her charge nurse, but she wasn't really sure what to do but knew she had to do something. Human Resources GG stated CNA M worked the 02:00PM to 10:00 PM shift on 09/19/23 so he called CNA M in early and suspended her until the investigation was completed. CNA M told Human Resources GG that she had enough of being abused by R1 and nothing was being done about R1's behavior. Human Resources GG stated all staff at the facility had been trained multiple times regarding abuse and neglect but there was another education scheduled on 09/22/23 between shifts and signage had been placed in the work areas regarding staff needing to call the facility administrator immediately when any allegations of abuse or neglect occurred. On 09/20/23 at 11:30 AM, Administrative Nurse D stated that she expected all staff to know and understand the abuse and neglect policy and adhere to it. The facility Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 02/06/23, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint no required to treat the resident's medical condition. This includes prohibiting facility staff from taking acts that result in personal degradation including the taking or using photographs or recordings in nay manner that would demean or humiliate a resident and prohibits using any type of photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Training will educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, misappropriation of resident property and exploitation, and dementia management and resident abuse prevention. The facility failed to ensure staff immediately reported verbal abuse to the facility administrator. This deficient practice placed R1 at risk for further mistreatment and psychosocial impairment.

The facility identified a census of 32 residents. The sample included 17 residents with three reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Residents(R)2, R19 and R30 were treated in a dignified manner during meal service. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: On 05/17/23 at 11:40AM R2, R19, and R30 were in the dining room eating lunch. An unidentified staff stood at the table supervising and providing meal assistance with feeding. The staff member held R2's fork and fed R2 her food while standing over her. R2 complained the food was stuck in her upper denture but staff continued to insist she take a bite of her food. While feeding R2, the staff member told R19 to keep eating his meal while she stood over R2. The unidentified staff member moved over to R30 and fed him while standing. From 11:45AM to 11:53AM, during the meal, the staff member left the residents unattended to go to the nursing office. At 11:53 Activities Staff Z arrived in the dining room and immediately went to the assisted diners' table. The unidentified staff member returned and was told by Activities Staff Z that the residents at the table could not be left unsupervised during meal services. Activities Staff Z remained at the table assisting the residents for the remainder of the meal. On 05/22/23 at 02:30PM Certified Nurses Aide (CNA) M stated she was not sure if staff should stand while feeding residents. She stated staff should always be approaching residents on their level while talking or providing cares. On 05/22/23 at 03:30PM Administrative Nurse D stated staff should be seated when assisting with meals. She stated staff were expected to ensure residents that required supervision were always monitored and never left alone. A review of the facility's Resident Rights policy revised 10/2010 indicated staff will provide privacy and respect each resident's dignity during all meals, cares provided, and during activities. The facility failed to ensure R2, R19 and R30 were treated in a dignified manner during meal service. This deficient practice placed the residents at risk for decreased psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 32 residents. The sample included 17 residents with three residents reviewed for notice requirements before transfer/discharge. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R)11 or her representative. This deficient practice placed R11 at risk of delayed care or uncommunicated care needs. Findings included: - R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), artificial openings of urinary tract status, neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system, and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R11 was dependent on two staff members assistance for activities of daily living (ADLs). The MDS documented R11 had an indwelling urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). The MDS documented R11 was dependent on one staff member for bathing during the look back period. R11's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/03/23 documented R11 had nephrostomy tubes (an artificial opening between the kidney and the skin which allows urine to drain from the body) in place due to kidney stones. R11's Care Plan dated 07/28/21 documented R11 wished to remain at the facility long term and not discharge back to community. Review of the EMR under Progress Notes documented: On 02/26/22 a Health Status Note at 06:00 PM documented R11 was transferred to the hospital for elevated temperature and was admitted for pneumonia (inflammation of the lungs) and urinary tract infection (UTI-an infection in any part of the urinary system). The EMR lacked documentation in the nurses note of written notification to resident or representative. On 03/30/22 a Nursing Note at 12:24 PM documented R11 was transferred to the hospital for back pain and left hip pain. R11 was admitted to the hospital for sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock) and UTI. The EMR lacked documentation in the nurses note of written notification to resident or representative. On 05/19/22 a Nursing Note at 02:32 PM documented R11 was transferred to the hospital for displaced nephrostomy tube. R11 was admitted to the hospital and the EMR lacked documentation in the nurses note of written notification to resident or representative. On 01/01/23 a Nursing Note at 02:32 PM documented R11 was transferred to the hospital for elevated temperature and was admitted for UTI and sepsis. The EMR lacked documentation in the nurses note of written notification to resident or representative. On 02/15/23 a Nursing Note at 05:59 PM documented R11 was transferred to the hospital for elevated temperature and vomiting. R11 was admitted to the hospital for UTI. The EMR lacked documentation in the nurses note of written notification to resident or representative. On 05/22/23 at 07:27 AM R11 laid on the bed with eyes closed, the head of bed elevated, and her catheter bag attached to the bed frame in a privacy bag. On 05/18/23 at 10:40 AM Social Service X stated the facility did not provide the resident or their representative a written notification of transfer. Social Service X stated the facility notified the resident's representative by phone only. On 05/22/23 at 03:45 PM Administrative Nurse D stated the social service department was responsible for sending written notification to the resident's representatives. Administrative Nurse D said the nurse on duty would notify the family or representatives by phone at the time of the transfer. The facility's Transfer or Discharge Notice policy dated December 2016 documented the resident and/or representative (sponsor) will be notified in writing of the following information: the reason for the transfer or discharge; the effective date of the transfer or discharge; the location to which the resident is being transferred or discharged . The facility failed to provide written notification of the reason and location for the facility-initiated transfers to the hospital for R11 or her representative. This deficient practice placed R11 at risk of delayed care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 32 residents. The sample included 17 residents with two residents reviewed for treatment/services to prevent /heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to provide physician ordered pressure reducing devices for Resident (R) 10 who had an unstageable pressure injury (base of the sore is covered by a thick layer of other tissue and pus that may be yellow, grey, green, brown, or black) to the right heel. This deficient practice placed R10 at increased risk of development and or worsening of pressure related injuries for R10. Findings included: - R10's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), weakness, need for assistance with personal care, and lung transplant. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R10 required assistance of two staff members for activities of daily living (ADLs). The MDS documented R10 was at risk of development of pressure related injuries and R10 had one unstageable pressure injury presented as a deep tissue injury during the look back period. The MDS documented R10 had a pressure reducing device on her bed, pressure ulcer/injury care, and pressure device in her chair. R10's Pressure Ulcer Care Area Assessment (CAA) dated 04/28/23 documented R10 had an unstageable pressure ulcer on her right heel on admission. R10's Care Plan dated 05/04/23 documented staff would apply heel protectors when in bed. Review of the EMR under Orders tab revealed physician order: Heel protectors on while in bed dated 05/04/23. On 05/18/23 at 03:40 PM R10 laid in bed with the head of her bed elevated. R10 wore a heel protector only on her right heel, R10 stated she only had a sore area on right heel not on both heels. On 05/22/23 at 08:18 AM R10 laid on her bed. She had a heel protector on her right heel and not on her left heel. On 05/22/23 at 02:20 PM Certified Nurse Aide (CNA) M stated R10 only had a heel protector on her right heel when in bed. CNA M stated R10's spouse provided a lot of her care when he visited. CNA M stated R10 had a new area on her great toe noted. CNA M stated she was not sure if R10's care plan directed the staff for R10 to wear heel protectors on both lower extremities. On 05/22/23 at 02:57 PM Administrative Nurse F stated R10 wore a heel protector on her right heel when out of bed and wore both heel protectors when in bed. Administrative Nurse F stated the charge nurse on duty completed the weekly skin assessments. Administrative Nurse F stated the facility had not had Quality Assurance and performance Improvement meeting to discuss wounds. On 05/22/23 at 03:45 PM Administrative Nurse D stated R10 wore one heel protector on her right heel when in bed. Administrative Nurse D stated she should wear heel protectors on both heels and was not sure if that information was on the care plan to direct staff or apply heel protectors to R10's bilateral lower extremities. The facility's Wound Care policy dated October 2010 documented the purpose of this procedure was to provide guidelines for the care of wounds to promote healing. The facility failed to provide physician ordered pressure reducing heel protectors for R10 when in bed who had an unstageable pressure related injury to her right heel. This deficient practice placed R10 at increased risk of worsening or further pressure related injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 32 residents. The sample included 17 residents with two residents reviewed for range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) or mobility. Based on observation, record review, and interviews, the facility failed to identify and resolve inappropriate wheelchair positioning for Resident (R)12. This placed R12 at risk for loss of independence, and impaired mobility. Findings included: - R12's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, hemiparesis (muscular weakness of one half of the body) hemiplegia (paralysis of one side of the body) following cerebrovascular accident (CVA-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) affecting the right dominant side, and abnormal gait. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R12 required extensive assistance of two staff for activities of daily living (ADLs). The MDS documented R12 had received occupational therapy for one day on 03/28/23. R12's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 04/17/23 documented R12 required extensive assistance with ADLs. R12's Care Plan dated 07/14/21 documented R12's right sided weakness and required frequent repositioning in the wheelchair. Review of the Occupational Therapy Evaluation and Plan of Treatment dated 03/28/23 documented R12 could benefit from a manual wheelchair and was measured for a wheelchair. R12's EMR, under Miscellaneous tab, revealed physician orders dated 04/24/23 for occupational therapy for wheelchair positioning. The EMR lacked any documentation the evaluation had taken place. On 05/22/23 at 08:04 AM R12 slowly propelled her wheelchair from the dining room into the 300 hallway. R12 was leaning to the right side in her wheelchair, with her right arm under the support cushion on the inside of her wheelchair. R12's slacks were twisted and pulled tightly into her groin area. R12 stated she was very uncomfortable in wheelchair. R12 had difficulty propelling her wheelchair in the hallway. Two staff members walked by R12 as she propelled herself slowly down the hallway. On 05/22/23 at 02:20 PM Certified Nurse Aide (CNA) M stated R12 would slide down in her wheelchair frequently and required staff assistance frequently to pull her up. CNA M stated R12 was able to move her right arm by using her left hand. CNA M stated she thought R12 got a different wheelchair and said R12 had difficulty propelling herself in that new chair. On 05/22/23 at 02:57 PM Administrative Nurse F stated R12 had been evaluated by occupational therapy for wheelchair positioning a about month ago. Administrative Nurse F stated R12 had received a different wheelchair and did R12 did not like it. Administrative Nurse F stated R12's feet were too long for this wheelchair and she had difficulty propelling herself in the hallway. On 05/22/23 at 03:45 PM Administrative Nurse D stated occupational therapy had evaluated her for wheelchair positioning. Administrative Nurse D stated R12 received a different wheelchair and was not aware of any current difficulty with positioning. On 05/23/23 at 05:39 PM Consultant HH stated R12 had been evaluated on 03/28/23 for a new wheelchair. Consultant HH stated therapy received the order for wheelchair positioning on 04/26/23 and had resubmitted the evaluation from 03/28/23 related to a new wheelchair. Consultant HH stated she spoke with the administrator and the director of nursing concerning the resubmission of occupational therapy's evaluation. Consultant HH stated no new assessment was completed related to R12 wheelchair positioning. The facility's Resident Mobility and Range of Motion policy dated July 2017 documented as part of the resident's comprehensive assessment, the nurse would identify the resident's current range of motion of his or her joints, opportunities for improvement; and previous treatment and services for mobility. The facility failed to identify and resolve R12's inappropriate wheelchair positioning. This placed R12 at risk for loss of independence, and impaired mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of epilepsy (brain disorder characterized by repeated seizures), muscle weakness, cerebrovascular disease (dysfunction of the blood vessels within the brain), major depressive disorder (major mood disorder), abnormal gait, and fracture of left shoulder (broken bone). A review of R7's Significant Change Minimum Data Set (MDS) completed 05/27/22 indicated she was frequently incontinent of bladder and always continent of bowel. The MDS indicated she was not on a bowel and bladder toileting program. A review of R7's Quarterly MDS completed 01/27/23 noted she was frequently incontinent of bladder and occasionally incontinent of bowel. The indicated she was not on a toileting program for bowel and bladder. A review of R7's Annual MDS completed 04/26/23 noted she had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS noted she required extensive assistance from two staff for bed mobility, transfers, dressing, personal hygiene, and bathing. The MDS indicated she was always incontinent of bowel and bladder but no trial toileting program. The MDS indicated she had some refusal of care behaviors. R7's Cognitive Loss Care Area Assessment (CAA) completed 04/27/23 indicated she had a BIMS of 11 indicating moderate cognitive impairment related to her 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). The CAA noted she refused cares at times, but staff should re-approach later. R7's Activities of Daily Living (ADLs) CAA completed 4/27/23 indicated she required a sit-to-stand (assistive mechanical lift) until she had her shoulder fracture but then required a Hoyer lift (full body mechanical lift) with two staff assistance. R7's Fall CAA completed 4/27/23 indicated she was a high fall risk due to her cognitive deficit and balance deficits. A review of R7's Care Plan revised 08/29/22 indicated she was a high fall risk related to impaired mobility and seizure disorder. The plan noted she required a Hoyer lift with two staff members for transfers (07/05/19), was not able to self-propel wheelchair (07/05/19), and needed extensive assistance for long distances. The plan indicated extensive assist from two staff for dressing, bathing, and grooming (07/05/19). The plan instructed staff to toilet R7 upon awakening, before/after meals, at bedtime, and as needed (07/05/19). The plan noted R7 required incontinence briefs (03/03/21). The plan noted R7 required a Sit-to-Stand lift with two staff assistance for toileting 03/03/21. R7's Care Plan indicated she had continual concerns related to low staffing (09/01/21). The care plan lacked new interventions related to incontinence care since 03/03/21. A review of R7's EMR revealed her last Continence Evaluation was completed on 11/22/22. The report indicated she had bowel and bladder incontinence. The report indicated she could hold her urine for less than five minutes but did not have to rush to the bathroom when she had the urge to void. The report indicated she could feel the urge to void and was aware when urine passed. The report indicated she used urinary incontinence products. The report indicated R7 used a mechanical lift for transfers and could sit unsupported. The report indicated she could understand prompts and reminders for toileting. The report indicated R7 could ask for assistance when needed but could not remove her own clothing. The report indicated R7 was motivated to be continent. The assessment only provided incontinence products as a treatment options. R7's EMR lacked evidence of an individulaized toielting plan in response to the Continence Evaluation. On 05/18/23 at 09:45AM R7 reported she was still in bed do to not having enough staff to get her out of bed when she wanted. She stated it takes two staff and the mechanical lifts to get her out of bed. She stated staff usually get her out of bed late. R7 lay in her bed wearing her night clothes. She stated staff due not get her out of bed in time, so she had incontinent episodes. She stated she had increased incontinence over the last year On 05/22/23 at 07:30AM R7 slept in her bed. R7's room smelled like urine. On 05/22/23 at 02:20 PM Certified Nurse's Aide (CNA) M reported R7 was often incontinent and used the commode in her room. She stated R7 required total assistance with ADLs and required a Hoyer lift for all transfer. She stated all staff should review the resident's care plan and know their care needs before assisting them. CNA M reported every resident was toileted every two hours. On 05/22/23 at 03:45PM Administrative Nurse D stated every resident was toileted frequently and changed as needed. She stated that facility did not formally evaluate toileting patterns, but just got to know each resident and when the residents liked to toilet. She stated she was not sure why no recent bowel and bladder assessment were completed. She stated R7 would either use the commode or bedpan due to her shoulder injury. She stated those interventions should have been added to her care plan. She stated agency staff should be informed by the facility staff about a resident's care need. A review of the facility's Urinary Continence and Incontinence policy revised 09/2010 indicated staff will appropriate screen and manage individuals with urinary incontinence. The policy indicated staff will assess voiding patterns and associated symptoms and provide managed interventions to maintain and improve incontinence. The facility failed to implement an individualized toileting plan to attempt to address and/or prevent R7's incontinence. This deficient practice placed the resident at risk for complications related to incontinence. The facility identified a census of 39 residents. The sample included 17 residents with two residents reviewed for bowel/bladder incontinence and nephrostomy tube (an artificial opening between the kidney and the skin which allows urine to drain from the body). Based on observation, record review, and interviews, the facility failed to provide appropriate hand hygiene during peri-care for Resident (R) 11 who had a foley catheter (tube inserted into the bladder to drain urine) and history of sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock) and urinary tract infections (UTI). The facility also failed to evaluate and provide an individualized toileting plan for R7. These deficient practices placed these residents at risk increased infections, catheter related problems, and impaired dignity. Findings included: - R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), artificial openings of urinary tract status, neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system, and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R11 was dependent on two staff members assistance for activities of daily living (ADLs). The MDS documented R11 had an indwelling urinary catheter. The MDS documented R11 was dependent on one staff member for bathing during the look back period. R11's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/03/23 documented nephrostomy tubes (an artificial opening between the kidney and the skin which allows urine to drain from the body) in place due to kidney stones. R11's Care Plan dated 02/05/20 documented staff would ensure good peri-care after all incontinent episodes. The Care Plan dated 04/23/22 documented staff would check the insertion site for bleeding and/or infection signs (pain, redness, swelling, leakage). The Care Plan documented staff would ensure the drain tube was secured, patent and draining. Review of the EMR under Progress Notes documented: On 02/26/22 a Health Status Note at 06:00 PM documented R11 was transferred to the hospital for elevated temperature and was admitted for pneumonia (inflammation of the lungs) and UTI. On 03/30/22 a Nursing Note at 12:24 PM documented R11 was transferred to the hospital for back pain and left hip pain. R11 was admitted to the hospital for sepsis and UTI. On 01/01/23 a Nursing Note at 02:32 PM documented R11 was transferred to the hospital for elevated temperature and was admitted for UTI and sepsis. On 02/15/23 a Nursing Note at 05:59 PM documented R11 was transferred to the hospital for elevated temperature and vomiting. R11 was admitted to the hospital for UTI. On 05/22/23 at 07:50 AM R11 laid in bed. Certified Nurse Aide (CNA) M and CNA P washed their hands, and donned gloves. Staff explained the procedure to R11, then removed R11's bed covering, and untaped R11's incontinent brief. CNA P wiped R11's peri-area with moist wipes in a downward motion and disposed of the wipe afterwards. CNA M assisted R11 to turn onto her right side. CNA P cleansed R11's buttocks, coccyx, and rectal area. CNA P removed the soiled incontinent brief, placed the brief into the trash can, then placed a new, clean brief under R11 with the same soiled gloves. CNA P assisted R11 to roll back, and then onto R11's left side. CNA M and CNA P taped the incontinence brief. With the same gloves, CNA P placed a transfer sling onto R11's bed, CNA M and CNA P rolled R11 onto the transfer sling. CNA P pulled the Hoyer lift (total body mechanical lift used to transfer residents) over the R11's bed. CNA P then doffed the gloves, assisted with the transfer, then washed her hands. On 05/22/23 at 02:20 PM Certified Nurse Aide (CNA) M stated hand hygiene should be completed after contact with each resident, after providing care, and between doffing and donning new gloves. On 05/22/23 at 02:57 PM Administrative Nurse F stated hand hygiene should be completed between resident care, between each room, when soiled, when donning and between doffing. Administrative Nurse F stated she would expect staff to hand hygiene between dirty and clean when providing peri-care. On 05/22/23 at 03:45 PM Administrative Nurse D stated she would expect staff to always hand hygiene between providing care, when soiled, between donning and doffing gloves, and between soiled and clean. The facility's Handwashing and Hand Hygiene Policy undated policy documented all personnel would be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel would follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Before moving from a contaminated body site to a clean body site during resident care. After removing gloves. After contact with blood or bodily fluids. The facility's Catheter Care, Urinary policy dated September 2014 documented the purpose of this procedure is to prevent catheter-associated urinary tract infections. The facility failed to provide appropriate hand hygiene during peri-care for R11 who has a history of sepsis and UTI's. This deficient practice placed R11 at risk of further infection, or catheter related complication.

The facility identified a census of 32 residents. The sample included 17 residents with four reviewed for nutrition. Based on observation, record review, and interviews, the facility failed toprovide consistent support during meal services for Resident (R) 19, who had unintended weight loss. This deficient practice placed R19 at risk for further weight loss and impaired nutrition. Findings Included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), cerebral infarction (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), muscle weakness, unsteadiness on feet, and chronic kidney disease. A review of R19's Quarterly Minimum Data Set (MDS) completed 01/27/23 noted a Brief Interview for Mental Status (BIMS) score of seven indicating severe cognitive impairment. The MDS indicated R19 weighed 178 pounds (lbs.). the MDS indicated no weight loss. The MDS indicated he required extensive assistance for bed mobility, transfers, dressing, toileting, and bathing. The MDS indicated a required limited assistance from one staff for meals. A review of R19's Annual MDS completed 04/26/23 noted a BIMS score of four indicating severe cognitive impairment. The MDS indicated R19 required extensive assistance from two staff for bed mobility, transfers, dressing, toileting, and bathing. The MDS noted he required extensive assistance from one staff for meals. The MDS noted he had a weight loss of five percent or more. The MDS noted he was not on a physician prescribed weight-loss regimen. The MDS indicated R19 weighed 167 lbs. A review of R19's Cognitive Loss Care Area Assessment (CAA) completed 04/26/23 indicated he had cognitive deficits related to his medical diagnoses. The CAA noted he had confusion, disorientation, and forgetfulness. The CAA indicated his cognitive loss affected his activities of daily living (ADLs) but could improve with cueing. R19's Nutrition CAA completed 04/27/23 indicated he was at risk for nutritional deficit related to his medical diagnoses. The CAA noted R19's functional inability to perform his ADLs without significant assistance from staff affected his ability to eat his meals. A review of R19's Care Plan initiated 06/12/2019 indicated he was at risk for nutritional problems related to his need for assistance and medical diagnoses. The care plan indicated he required a regular diet with ground mechanically soft meats and thin liquids (06/12/19), required a plate guard and non-skid mat (06/12/19), and was weighed monthly (06/12/19). The care plan indicated R19 often refused to get up early and have breakfast, but staff should offer breakfast (08/06/19). The plan instructed staff to sit R19 up at 90 degrees for meals to prevent choking (03/30/22). The plan instructed staff to provide R19 supplemental shacks three times a day (08/23/22). The plan indicated R19 required assistance from one staff with meals including cutting his food, unwrapping his silverware, and ensuring all items were within reach (09/09/21). The plan indicated he was at risk for choking related to his medical diagnosis. The plan instructed staff to monitor for episodes of dysphagia, choking, and coughing during meals (11/04/22). The plan instructed staff to weigh R19 monthly (12/21/22). The care plan lacked new interventions after 12/21/22 for R19's nutritional needs. A review of R19's EMR indicated he was weighed monthly since admission but changed to weekly on 05/05/23 for weight management. A review of R19's EMR under Weights indicated he weighed 178 lbs. on 03/02/23. The EMR indicated his weight decreased to 167lbs. (6.18% weight loss). The EMR indicated his weight increased to 169lbs. on 05/01/23. On 05/17/23 at 11:43AM R19 was in the dining room at the table designated for residents requiring supervision and feeding assistance. R7's meal was prepared on a divided plate and non-slip food mat under his plate. R19's meat was ground. The table had one staff assisting R2, R19, and R30. The staff member switched in between residents attempting to assist them with feeding and cueing (providing verbal reminders). The staff member stood over the residents while feeding and giving them cues. From 11:45AM to 11:53AM the staff member left the residents unattended to go to the nursing office. At 11:53 AM Activities Staff Z arrived in the dining room and went to the assisted diners' table. The unidentified staff member returned and was told by Activities Staff Z that the residents at the table could not be left unsupervised during meal services. Activities Staff Z remained at the table assisting the residents for the remainder of the meal. On 05/22/23 at 02:21 PM Certified Nursing Aides (CNA) M stated residents at the designated assist table should never be left unattended or unsupervised. She stated staff were to offer assistance with feeding and cueing them. She stated R19 required a lot of cues and assistance to get through his meals. She stated staff should staff with him the entire meal and never leave him unsupervised. She stated his level of assistance changed daily but he always required supervision. On 05/22/23 at 03:03PM Administrative Nurse F stated R19's had lost weight recently due to staying up too late at night and missing meals throughout the day. She stated staff were required to set with him and cue him during meal services. She stated all direct care staff have access to the care plans and were expected know R19's assistive needs. A review of the facility's Activities of Daily Living (ADLs) policy revised 03/2018 indicated the residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out their ADLs. The policy indicated that residents unable to carry out ADLs independently will receive the necessary services to maintain good nutrition, grooming, and health. The facility failed provide consistent support during meals services for R19, who had unintended weight loss and required staff assistance with eating. This deficient practice placed R19 at risk for altered hydration and nutrition.

The facility identified a census of 32 resident. The sample included 17 residents with one Resident (R) sampled for respiratory care. Based on observation, record review and interview, the facility failed to ensure R10 received her supplemental oxygen (O2) continuously as physician ordered. The facility failed to ensure that R10's O2 tubing and nasal cannula (NC-a hollow tube that helps provide supplemental oxygen) and continuous positive airway pressure (CPAP-machine used to deliver a stream of oxygenated air into the airways through a mask and a tube) mask and tubing were properly stored in a sanitary manner when not in use. This deficient practice placed R10 at risk for increased respiratory infection and complications. Findings included: - The electronic medical record (EMR) for R10 documented diagnoses of lung transplant (a surgical procedure where the diseased lung is replaced with a healthy lung(s) from a donor.) The admission Minimum Data Set dated 04/24/23 documented R10 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R10 required extensive assistance of one to two staff for activities of daily living (ADLs). R10 required O2 therapy. The ADL Care Area Assessment (CAA) documented R10 required extensive assistance with two staff for most ADLs. Staff propel R10's wheelchair. R10 was weak and was working with therapy to strengthen and improve self- care. R10's Oxygen Care Plan initiated 05/04/23 directed staff that R10 was to receive O2 via NC as ordered. A Physician's Order dated 04/21/23 documented continuous O2 at two liters (L) via nasal canula for lung transplant. On 05/17/23 at 12:54 R10 sat in her wheelchair in her room and stated she had a lung transplant. R10 was not wearing her supplemental O2 and the NC/tubing and CPAP tubing/mask hung laid unbagged on R10's dresser. On 05/22/23 at 08:18 AM R10's CPAP mask laid unbagged on top of the CPAP machine. On 05/22/23 at 02:20 PM Certified Nurse Aide (CNA) M stated she believed that O2 tubing was supposed to be changed weekly and the cannula and tubing should be stored in a dated plastic bag when not in use. CNA M stated she could not say for certain how the CPAP mask should be stored. On 05/22/23 at 02:56 PM Administrative Nurse F stated the O2 tubing and cannula should be changed by the night shift staff weekly. Administrative Staff F stated the tubing and CPAP mask should be stored in a plastic bag when not in use. Administrative Nurse F stated R10 mainly used her O2 at night and was not aware that the order for O2 was for continuous use. On 05/22/23 at 4:12 PM Administrative Nurse D stated the O2 tubing should be changed monthly. Administrative Nurse D stated the CPAP mask should be cleaned weekly and both should be stored in a bag when not in use. Administrative Nurse D said she would have to check R10's order to know the frequency of O2 use. The Departmental (Respiratory Therapy) - Prevention of Infection policy revised 11/2011 documented: The following equipment and supplies will be necessary when performing tasks related to this procedure. Appropriate equipment/supplies necessary for ordered therapy. Change the O2 canula and tubing every seven days, or as needed. Keep the O2 canula and tubing used as needed in a plastic bag when not in use. The CPAP/Bi-level positive airway pressure (BiPAP machines keep a user's airways open during sleep through the use of pressurized air, with higher pressure) Support facility policy revised 03/2015 documented: Clean (masks, nasal pillows and tubing) daily by placing in warm, soapy water and soaking/agitating for five minutes. Mild dish detergent was recommended. Rinse with warm water and allow to air dry between uses. The facility failed to ensure R10 received her supplemental O2 continuously as sanitary manner when not in use. This placed R10, who had a lung transplant, at increased risk for respiratory infection and complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Diagnoses tab of R30's Electronic Medical Record (EMR) documented diagnoses of intracerebral hemorrhage (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), hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body) affecting left non-dominant side, and essential hypertension (high blood pressure). The Annual Minimum Data Set (MDS) dated 11/23/22, documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that R30 was cognitively intact. The MDS documented that R30 required extensive assistance of two staff for bed mobility, dressing, and toilet use, sxtensive assistance of one staff for locomotion on and off unit, and personal hygiene. The Quarterly MDS dated 02/22/23, documented a Brief Interview for Mental Status (BIMS) score of nine indicating that R30 had moderately impaired cognition. The MDS documented that R30 required extensive assistance of two staff for dressing, toileting, and personal hygiene. The Cognitive Loss / Dementia CAA dated 11/23/22, documented that R30 had cognitive impairment due to stroke. The Care Plan dated 01/19/23, documented that R30 was at risk for declines in cognition and communication due to his stroke diagnosis. The Orders tab of R30's EMR documented an order with a start date of 11/19/22 for diclofenac sodium gel (pain reliever) to be applied four times a day. The medication order lacked a dosage. The Orders tab of R30's EMR documented an order with a start date of 02/06/23 for carvedilol (antihypertensive medication that lowers heart rate) 12.5 milligrams (mg) two times a day related to hypertension with instructions to notify the primary care provider if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 100 millimeters of mercury (mmHg) and the diastolic blood pressure (DBP- minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) was less than 50 mmHg. R30's EMR lacked documentation that his pulse was being monitored prior to the administration of carvedilol. On 05/17/23 at 11:52 AM R30 was sitting in his wheelchair at a table in the dining room. On 05/22/23 at 02:57 PM Administrative Nurse F stated that staff would be expected to obtain a pulse and a blood pressure reading prior to administering a medication like carvedilol. She stated that when documenting the administration of this medication, a pop up would generate automatically so that a pulse and blood pressure could be documented in the EMR. She further stated that the carvedilol order should have a hold parameter for a pulse. Administrative Nurse F stated that R30's diclofenac sodium gel order should have a dosage entered and without it, staff would not know how much to administer. She further stated that when a medication is missing a dosage the expectation is for the staff administering medications to report the finding. On 05/22/23 at 03:45 PM Administrative Nurse D stated that staff would be expected to obtain a pulse prior to administering a medication like carvedilol. She stated that there is an area on the medication administration record (MAR) that would create a pop up for staff to document a blood pressure and pulse before the medication can be given. She stated that she believed the pop up would generate even without a doctor needing to order monitoring. The facility's Administering Medications policy revised December 2012, documented that the individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The policy further documented that, if necessary, vital signs must be checked/verified for each resident prior to administering medications. The facility failed to provide a dosage for R30's diclofenac sodium gel order and pulse monitoring/documentation prior to administering carvedilol. This deficient practice had the risk for physical complications and unnecessary medication usage. The facility identified a census of 32 residents. The sample included 17 residents. Five residents were sampled for unnecessary medication review. Based on observation, record review and interview the facility failed to monitor Resident (R) 29's pulse before administration of the beta blocker (a type of medicine that makes the heart beat more slowly and lower blood pressure) metoprolol (a beta blocker medication used to treat heart conditions). This deficient practice place R29 at risk for unnecessary medication administration and adverse side effects. Findings included: - The electronic medical record (EMR) for R29 documented diagnoses of hypertension (an elevated blood pressure), renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys), and dementia (a progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE] for R29 documented a Brief Interview for Mental Status (BIMS) score of four which indicated severely impaired cognition. R29 required extensive to total assistance of one to two staff for her activities of daily living (ADLs). The Quarterly MDS dated 03/22/23 documented R29 had a BIMS score of five which indicated severely impaired cognition. R29 required extensive assistance of one to two staff for her activities of ADLs. The ADL Care Area Assessment (CAA) dated 11/16/22 documented R29 had cognitive loss due to dementia. The Hypertension Care Plan revised 12/09/22 directed staff to give medications as ordered. Staff was to monitor for side effects such as orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down), increased heart rate and effectiveness. The Order Summary for R29 documented an order dated 11/14/22 for metoprolol tartrate 50 milligrams (mg) by mouth twice daily for hypertension. Hold if pulse was less than 50 and notify physician. This order was discontinued on 03/14/23. The Order Summary for R29 documented an order dated 03/14/23 for metoprolol tartrate 50 mg by mouth twice daily for hypertension. Hold if pulse was less than 50 and notify physician. A review of R29's Medication Administration Report (MAR) and clinical record for vital signs for the months of March 2023, April 2023 and May 2023 revealed that R29's pulse reading was not obtained prior to administration of metoprolol twice daily. A Pharmacy Consultation dated 02/13/23 recorded a nursing recommendation that documented there was a pulse base hold parameter on metoprolol and directed to ensure that metoprolol had been entered into the EMR such that staff was required to assess and document a pulse prior to every administration. On 05/18/23 at 07:58 AM R29 sat in her wheelchair at the dining table eating breakfast with other residents. On 05/22/23 at 02:56 PM Administrative Nurse F stated she assumed R29's pulse was being documented on the MAR before R29 took her metoprolol since her blood pressure was checked before she was given her lisinopril (a medication used to lower the blood pressure). The beta blocker medications should have a pulse reading prior to administration. On 05/22/23 at 03:45 PM Administrative Nurse D stated pulse monitoring should automatically pop up when the medication was to be given and the pulse would flow over to the vital signs tab. Administrative Nurse D was not aware that R29's pulse was not being obtained prior to metoprolol administration. The facility policy Administering Medications revised 12/2012 documented: medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. The facility failed to ensure R29's pulse was assessed prior to being administered metoprolol as physician ordered. This placed R29 at risk for unnecessary medication administration and adverse side effects.

The facility identified a census of 39 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to ensure physician ordered diagnostic laboratory test results were signed and scanned into the clinical record for Resident (R) 10 and R12. This deficient practice could result in unnecessary tests and delayed treatment. Findings included: - R10's Electronic Medical Record (EMR) under Miscellaneous tab revealed a laboratory test obtained on 05/11/23 had been scanned into the clinical record on 05/14/23 but was not signed and dated. R12's EMR lacked evidence of any laboratory results scanned into the clinical record since 2021. On 05/22/23 at 02:30 PM the facility provided laboratory tests for R12 that had been obtained on 04/13/23 that were dated and signed but not scanned into the EMR. On 05/22/23 at 02:30 PM the facility provided results of laboratory tests that had been obtained 05/03/23 for R12 and not scanned into the EMR. The test results lack a physician signature and was undated. On 05/22/23 at 02:57 PM Administrative Nurse F stated laboratory tests were ordered by the physician and the lab was obtained once every week. Administrative Nurse F stated the test results usually were faxed within two to three days and at times the nurse would have to call for the results. Administrative Nurse F stated the physician would review the results during weekly rounds, after results had been reviewed and signed the results would be scanned into the clinical record. Administrative Nurse F stated at this time she was the only one at the facility that was scanning items into the residents' clinical records. Administrative Nurse F stated she felt a reasonable time frame for4 items to be scanned into a resident's chart was a week. On 05/22/23 at 03:45 PM Administrative Nurse D stated the test results were reviewed weekly by the physician and scanned into the resident's clinical record. Administrative Nurse D stated she was going to be trained to assist in the scanning results into the resident's clinical record. Lab -weekly on Wednesday faxed and draw on Thursday and report depends on and have calls for reviewed The facility was unable to provide a policy related to medical records. The facility failed maintain physician ordered laboratory test results for R10 and R12 had been signed and scanned into the clinical record. This deficient practice could result in unnecessary tests and delayed treatment.

The facility identified a census of 32 residents. The sample included 17 residents with five sample residents reviewed for influenza (a contagious respiratory illness that infect the nose, throat, and sometimes the lungs) and pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) immunizations. Based on record review and interview the facility failed to ensure that sampled Resident (R) 29 and R30 that had consented to receive the influenza and pneumococcal vaccine were administered the vaccinations. This deficient practice placed these residents at risk for acquiring, transmitting, or experiencing complications from influenza and pneumococcal disease. Findings included: - Review of R29's Immunization tab in the EMR and a copy of R29's Influenza Immunization Informed Consent dated 09/2010 documented R29's representative signed the form on 11/15/22 for R29 to receive the Influenza Vaccine. R29 did not receive the influenza vaccine. Review of R29's Immunization tab in the EMR and a copy of R29's Pneumococcal Immunization Consent was signed by R29's representative on 11/15/22 to give permission for R29 to receive the pneumococcal vaccine. R29 did not receive the pneumococcal vaccine. Review of R30's Immunization tab in the EMR and a copy of R30's Influenza Immunization Informed Consent dated 09/2010 documented R29's representative signed the form on 11/22/22 for R30 to receive the Influenza Vaccine. R30 did not receive the influenza vaccine. Review of R30's Immunization tab in the EMR and a copy of R30's Pneumococcal Immunization Consent was signed by R30's representative on 11/15/22 to give permission for R30 to receive the pneumococcal vaccine. R30 did not receive the pneumococcal vaccine. On 05/18/23 at 02:30 PM Administrative Staff B stated the local pharmacy provided all vaccinations at the facility. Administrative Staff B stated at the time of admission to the facility each resident was offered the opportunity for immunizations. On 05/22/23 at 02:57 PM Administrative Nurse F stated she was not sure how the immunization were tracked. On 05/22/23 at 03:45 PM Administrative Nurse D stated the admission nurse or the social worker would track the resident's history for immunizations. Administrative Nurse D stated once the Infection Preventionist was caught up, she would have more time to track immunizations and infection surveillance . The facility Infection Prevention and Control Program policy updated 10/01/22 documented: policies and procedures for immunizations include the following: the process for administering the vaccines; who should be vaccinated; contraindications to vaccination; potential facility liability and release from liability; obtaining direct and proxy consent, and how often; monitoring for side effects of vaccination; and availability of the vaccine, and who pays for it. The facility Prevention and Control of Seasonal Influenza Policy dated 09/21/21 documented: The Infection Preventionist would promote and administer seasonal influenza vaccine. Unless contraindicated, all residents and staff would be offered the vaccine. The facility policy Pneumococcal Vaccine dated 09/21/21 documented: All residents would be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, would be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or if the resident had already been vaccinated. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. The facility failed to provide R29 and R30 the influenza and pneumococcal vaccine after appropriate consent was obtained. This deficient practice placed R29 and R30 at risk for acquiring, transmitting, or experiencing complications from influenza and the pneumococcal disease.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 32 residents. The sample included 17 residents with five residents sampled for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccinations. Based on record review and interviews, the facility failed toassess and document the COVID-19 vaccination status for Resident (R) 30. The facility failed to offer and obtain signed consents or declinations for COVID-19 vaccinations for R30. This deficient practice had the risk for physical complications and the risk to spread illness among residents, a high-risk population. Findings included: - R30 admitted to the facility on [DATE]. R30's clinical record lacked evidence of the COVID-19 vaccination status or evidence the vaccination was offered including a signed consent or declination of the vaccination. On 05/18/23 at 02:30 PM Administrative Staff B stated the local pharmacy provided all the vaccinations to the residents. Administrative Staff B stated residents were offered the vaccinations upon admission. On 05/22/23 at 04:30 PM Administrative Nurse D stated she thought charge nurse or social services was keeping track of the vaccination status of residents. Administrative Nurse D stated that Administrative Nurse E had started keeping a log of the vaccination status of residents recently. The facility COVID-19 Policy Guidelines updated 05/18/23 documented: The vaccine would be offered and provided directly or by arrangement with the pharmacy partner. The facility would maintain documentation/record of the vaccination status of staff and residents. Residents had the right to decline vaccination in accordance with Resident Rights requirements. The facility failed to offer the COVID-19 vaccination and obtain signed consents or declinations for and failed to provide documentation of the COVID-19 vaccination status in R30's clinical record. This deficient practice had the risk for physical complications and the risk to spread illness among the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Diagnoses tab of R30's Electronic Medical Record (EMR) documented diagnoses of intracerebral hemorrhage (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), hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body) affecting left non-dominant side. The Annual Minimum Data Set (MDS) dated 11/23/22, documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that R30 was cognitively intact. The MDS documented that R30 required extensive assistance of two staff for bed mobility, dressing, and toilet use. R30 required extensive assistance of one staff for locomotion on and off unit, and personal hygiene. The Quarterly MDS dated 02/22/23, documented a Brief Interview for Mental Status (BIMS) score of nine indicating that R30 had moderately impaired cognition. The MDS documented that R30 required extensive assistance of two staff for dressing, toileting, and personal hygiene. The Cognitive Loss / Dementia CAA dated 11/23/22, documented that R30 had cognitive impairment due to stroke. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 11/23/22, documented that R30 required a Hoyer lift (total body mechanical lift used to transfer residents) for transfers with two staff assistance. It further documented that R30 required extensive assistance of two staff members for dressing, toileting, and bathing. The Care Plan dated 12/12/22, documented that R30 was at risk for decline in his ability to complete active range of motion (AROM) and for staff to notify his nurse of any decline in his ability to complete AROM tasks. The Care Plan dated 01/19/23, documented that R30 was at risk for declines in cognition and communication due to his stroke diagnosis. Review of the EMR under Report: Documentation Survey Report tab under the daily charting look back report for R30 reviewed from 02/01/23 to 05/17/23 (105 days) revealed shower/baths were documented as activity did not occur on the following scheduled (12) dates: 02/04/23, 02/07/23, 02/11/23, 02/14/23, 02/21/23, 02/28/23, 03/11/23, 03/14/23, 03/18/23, 03/21/23, 05/06/23 and 05/09/23. The EMR further revealed that R30's scheduled shower/bath days lacked documentation on the following (18) dates: 02/18/23, 02/25/23, 03/04/23, 03/07/23, 03/25/23, 03/28/23, 04/01/23, 04/04/23, 04/08/23, 04/11/23, 04/15/23, 04/18/23, 04/22/23, 04/25/23, 04/29/23, 05/02/23, 05/13/23, and 05/16/23. On 05/17/23 at 11:52 AM R30 sat in his wheelchair at a table in the dining room. On 05/18/23 at 12:55 PM Administrative Nurse D stated weekend staffing was short at times and showers/bathing was not provided when staffing was short. On 05/22/23 at 02:20 PM Certified Nurse Aide (CNA) M stated a shower/bathing schedule was posted in the nurse's station and the CNA room. CNA M stated the resident chose their preference of which shift their shower/bath was scheduled. CNA M stated most resident received two baths/showers weekly. CNA M stated if a resident refused a bath/shower the charge was notified after several offers of bathing was attempted. CNA M stated the refusal was charted. CNA M stated baths/showers were not provided when staffing was low. On 05/22/23 at 02:57 PM Administrative Nurse F stated a bath/shower schedule was located in a binder in the nurse office and the CNA room. Administrative Nurse F stated the night nurse would make out a daily assignment schedule every day for the dayshift with baths listed that where due on that day and just started making the CNAs assigned to certain baths daily to be morse accountable. Administrative Nurse F stated she would review the bathing report to make sure residents bath/shower had been provided. Administrative Nurse F stated if a resident refused the CNA would chart the refusal and report the refusal to the charge nurse. Administrative Nurse F stated R30 doesn't like to use the shower chair and reported that R30 stated it hurts his tailbone. Administrative Nurse F stated that staff have supplied different cushions and that his doctor is aware. She stated that R30 never refuses a bed bath. On 05/22/23 at 03:45 PM Administrative Nurse D stated the night shift made a daily schedule that included the list of baths due that day. Administrative Nurse D stated if a resident refused their bath/shower several times, bathing alternatives would be offered, and if the resident refused, the staff would report it to the charge nurse. Administrative Nurse D stated the refusal would be charted. Administrative Nurse D stated R30 doesn't usually refuse showers/baths, but if he does refuse then staff will give/offer him a bed bath. The facility's Activities of Daily Living (ADL), supporting policy dated March 2018 documented the appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance wit, hygiene (bathing, dressing, grooming, and oral care). The facility failed to ensure a shower/bath was provided for R30, who required assistance with ADLs. This had the potential for complications due to poor personal hygiene and impaired psychosocial wellbeing. -The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of epilepsy (brain disorder characterized by repeated seizures), muscle weakness, cerebrovascular disease (dysfunction of the blood vessels within the brain), major depressive disorder (major mood disorder), abnormal gait, and fracture of left shoulder (broken bone). A review of R7's Annual Minimum Data Set (MDS) completed 04/26/23 noted she had a Brief Interview for Mental Status (BIMS) score of 10 indicating mild cognitive impairment. The MDS noted she required extensive assistance from two staff for bed mobility, transfers, dressing, personal hygiene, and bathing. The MDS indicated she was always incontinent of bowel and bladder but no toileting program. The MDS indicated she had some refusal of care behaviors. R7's Cognitive Loss Care Area Assessment (CAA) completed 4/27/23 indicated she had a BIMS of 11 with impairment related to her 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). The CAA noted she refused cares at times, but staff should re-approach later. R7's Activities of Daily Living (ADLs) CAA completed 4/27/23 indicated she required a sit-to-stand lift (assistive mechanical lift) until she had her shoulder fracture but then required a Hoyer lift (full body mechanical lift) with two staff assistance. R7's Fall CAA completed 4/27/23 indicated she was a high fall risk due to her cognitive deficit and balance deficits. A review of R7's Care Plan revised 08/29/22 indicated she was a high fall risk related to impaired mobility and seizure disorder. The plan noted she required a Hoyer lift with two staff members for transfers (07/05/19). The plan indicated R7 needed extensive assist from two staff for dressing, bathing, and grooming (07/05/19). The plan noted R7 required incontinence briefs (03/03/21). The plan noted R7 required a lift with two staff assistance for toileting 03/03/21. R7's Care Plan indicated she had continual concerns related to low staffing (09/01/21). review of R7's Look Back report from 02/01/23 through 05/22/23 (111 days reviewed) indicated she received bathing on 11 occurrences (2/3, 2/14, 3/3, 3/14, 3/17, 3/21, 3/24, 3/28, 4/21, 5/7, and 5/16) and had no documented refusals. On 05/18/23 at 09:45AM R7 reported she was still in bed do to not having enough staff to get her out of bed when she wanted. She stated it takes two staff and the mechanical lifts to get her out of bed. She stated staff usually get her out of bed late. R7 lay in her bed wearing her night clothes. Her hair was uncombed, and she reported her left shoulder was stabilized with a sling. She stated she often was lucky if got two showers a week like she was supposed two. She stated staff do not get her out of bed in time, so she had frequent incontinent episodes. On 05/22/23 at 07:30AM R7 slept in her bed. R7's room smelled like urine. On 05/22/23 at 02:20 PM Certified Nurse's Aide (CNA) M stated a shower/bathing schedule was posted in the nurse's station and the Certified Nurse Aide (CNA) room. CNA M stated the resident chose their preference of which shift their shower/bath was scheduled. CNA M stated most resident received two baths/showers weekly. CNA M stated if a resident refused a bath/shower the charge was notified after several offers of bathing was attempted. CNA M stated the refusal was charted. CNA M stated baths/showers were not provided when staffing was low. On 05/22/23 at 02:57 PM Administrative Nurse F stated a bath/shower schedule was located in a binder in the nurse office and the CNA room. Administrative Nurse F stated the night nurse would make out a daily assignment schedule every day for the dayshift with baths listed that where due on that day and just started making the CNAs assigned to certain baths daily to be morse accountable. Administrative Nurse F stated she would review the bathing report to make sure residents bath/shower had been provided. Administrative Nurse F stated if a resident refused the CNA would chart the refusal and report the refusal to the charge nurse. Administrative Nurse F stated R7 would sometimes refuse staff based on the staff working that day and if R7 liked them. On 05/22/23 at 03:45 PM Administrative Nurse D stated the night shift made a daily schedule that included the list of baths due that day. Administrative Nurse D stated if a resident refused their bath/shower several times, bathing alternatives would be offered, and if the resident refused, the staff would report it to the charge nurse. Administrative Nurse D stated the refusal would be charted. Administrative Nurse D stated R7 did refuse at times but would take a bed bath when offered. The facility's Activities of Daily Living (ADL), supporting policy dated March 2018 documented the appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance wit, hygiene (bathing, dressing, grooming, and oral care). The facility failed to ensure a shower/bath was provided for R7, who required assistance with ADL. This had the potential for complications due to poor personal hygiene and impaired psychosocial wellbeing. The facility identified a census of 32 residents. The sample included 17 residents. Five residents were reviewed for activities of daily living (ADLs) care. Based on observation, record review and interview the facility failed to ensure staff provided consistent bathing cares for Resident (R) 29, R7, R11, and R30 who required extensive assistance from staff with bathing. This deficient practice placed the residents at risk for complications due to poor personal hygiene and impaired psychosocial wellbeing. Findings included: - The electronic medical record (EMR) for R29 documented diagnoses of hypertension (an elevated blood pressure), renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys), and dementia (a progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE] for R29 documented a Brief Interview for Mental Status (BIMS) score of four which indicated severely impaired cognition. R29 required extensive to total assistance of one to two staff for her ADLs. The Quarterly MDS dated 03/22/23 documented R29 had a BIMS score of five which indicated severely impaired cognition. R29 required extensive assistance of one to two staff for her activities of ADLs. The ADL Care Area Assessment (CAA) dated 11/16/22 documented R29 had cognitive loss due to dementia and required extensive to total assistance of staff for ADLs. R29's Care Plan, initiated on 11/15/22, directed staff to assist theresident with ADLs and ambulation as needed. The care plan lacked staff direction specific to bathing/showering. The Documentation Survey Report v2 for January 2023 documented an ADL- Bathing task as needed 02:00 PM to 10:00 PM which documented only a refusal on 01/20/23. The Documentation Survey Report v2 for February 2023 documented an ADL- Bathing task as needed 02:00 PM to 10:00 PM with only a refusal charted on 02/02/23. The Documentation Survey Report v2 for March 2023 documented an ADL - Bathing task as needed 02:00 PM to 10:00 PM a bath/shower was given to R29 on 03/27/23 and 03/30/23. The Documentation Survey Report v2 for April 2023 documented an ADL- Bathing task as needed 02:00 PM to 10:00 PM with a refusal on 04/18/23 and a bath documented on 04/20/23. The Documentation Survey Report v2 for May 2023 lacked documentation for bathing. On 05/18/23 at 07:58 AM R29 sat in her wheelchair at the dining table eating breakfast with other residents. On 05/18/23 at 12:55 PM Administrative Nurse D stated weekend staffing was short at times and showers/bathing was not provided when staffing was short. On 05/22/23 at 02:20 PM Certified Nurse Aide (CNA) M stated a shower/bathing schedule was posted in the nurse's station and the Certified Nurse Aide (CNA) room. CNA M stated the resident chose their preference of which shift their shower/bath was scheduled. CNA M stated most residents received two baths/showers weekly. CNA M stated if a resident refused a bath/shower the charge was notified after several offers of bathing was attempted. CNA M stated bathingrefusal were chartet. CNA M stated baths/showers were not provided when staffing was low. CNA M stated R11 refused at times, different staff would offer and if she continued to refuse, staff would offer a bed bath. On 05/22/23 at 02:57 PM Administrative Nurse F stated a bath/shower schedule was located in a binder in the nurse office and the CNA room. Administrative Nurse F stated the night nurse would make out a daily assignment schedule every day for the dayshift with baths listed that where due on that day and just started making the CNAs assigned to certain baths daily to be more accountable. Administrative Nurse F stated she would review the bathing report to make sure residents bath/shower had been provided. Administrative Nurse F stated if a resident refused the CNA would chart the refusal and reported the refusal to the charge nurse. Administrative Nurse F stated R29 did not typically refuse a bath/shower but would at times more lately when R29 was sundowning (condition where a person tends to become confused or disoriented toward the end of the day) and it would take a different approach to get her to take a bath. On 05/22/23 at 03:45 PM Administrative Nurse D stated the night shift made a daily schedule that included the list of baths due that day. Administrative Nurse D stated if a resident refused their bath/shower several times, bathing alternatives would be offered, and if the resident refused, the staff would report it to the charge nurse. Administrative Nurse D stated the refusal would be charted. Administrative Nurse D stated R29 did refuse at times but would take a bed bath when offered. The facility's Activities of Daily Living(ADL), supporting policy dated March 2018 documented the appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance wit, hygiene (bathing, dressing, grooming, and oral care). The facility failed to ensure a shower/bath was consistently provided for R29, who required extensive assistance with ADLs. This had the potential for complications due to poor personal hygiene and impaired psychosocial wellbeing. - R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), artificial openings of urinary tract status, neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system, and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R11 dependent on two staff members assistance for activities of daily living (ADLs). The MDS documented R11 had an indwelling urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). The MDS documented R11 was dependent on one staff member for bathing during the look back period. R11's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 05/03/23 documented R11 required assistance of two staff for ADLs and no improvement expected related to diagnosis of MS. R11's Care Plan dated 07/28/21 documented if R11 refused her shower/bath, staff would return later and offer R11 a shower/bath again. If R11refused two times, the staff would notify the charge nurse and a bed bath would be offered. Review of the EMR under Report: Documentation Survey Report tab (POC) under daily charting looks back report for R11 reviewed from 02/01/23 to 02/15/23 (15 days) and 02/17/23 to 05/17/23) (90 days) revealed shower/bath were given on the following (10) dates 02/01/23, 02/08/23, 03/11/23, 03/15/23, 03/22/23, 03/29/23 04/02/23, 04/19/23, 04/22/23, and 05/03/23. Activity did not occur was documented on the following (11) dates 02/04/23, 02/11/23, 02/22/23, 03/01/23, 03/04/23, 03/15/23, 03/18/23, 04/06/23, 04/18/23, 05/06/23, and 05/10/23. On 05/22/23 at 07:27 AM R11 laid on the bed with eyes closed, the head of bed elevated, and the catheter bag attached to the bed frame in a privacy bag. On 05/18/23 at 12:55 PM Administrative Nurse D stated weekend staffing was short at times and showers/bathing was not provided when staffing was short. On 05/22/23 at 02:20 PM Certified Nurses Aide (CNA) M stated a shower/bathing schedule was posted in the nurses station and the Certified Nurse Aide (CNA) room. CNA M stated the resident chose their preference of which shift their shower/bath was scheduled. CNA M stated most resident received two baths/showers weekly. CNA M stated if a resident refused a bath/shower the charge was notified after several offers of bathing was attempted. CNA M stated the refusal was charted. CNA M stated baths/showers were not provided when staffing was low. CNA M stated R11 refused at times, different staff would offer and if she continued to refuse, staff would offer a bed bath. On 05/22/23 at 02:57 PM Administrative Nurse F stated a bath/shower schedule was located in a binder in the nurse office and the CNA room. Administrative Nurse F stated the night nurse would make out a daily assignment schedule every day for the dayshift with baths listed that where due on that day and just started making the CNAs assigned to certain baths daily to be morse accountable. Administrative Nurse F stated she would review the bathing report from POC to make sure residents bath/shower had been provided. Administrative Nurse F stated if a resident refused the CNA would chart the refusal and report the refusal to the charge nurse. Administrative Nurse F stated R11 refused her bath at times and would always take a bed bath over a shower. Administrative Nurse F stated a bed bath does not get her as clean as a shower/bath and she had a history of chronic urinary tract infection ( UTI-an infection in any part of the urinary system). On 05/22/23 at 03:45 PM Administrative Nurse D stated the night shift made a daily schedule that included the list of baths due that day. Administrative Nurse D stated if a resident refused their bath/shower several times, bathing alternatives would be offered, and if the resident refused, the staff would report it to the charge nurse. Administrative Nurse D stated the refusal would be charted. Administrative Nurse D stated R11 did refuse at times but would take a bed bath when offered. The facility's Activities of Daily Living(ADL), supporting policy dated March 2018 documented the appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance wit, hygiene (bathing, dressing, grooming, and oral care). The facility failed to ensure a shower/bath was provided for R11, who required assistance with ADL. This had the potential for complications due to poor personal hygiene and impaired psychosocial wellbeing.

The facility identified a census of 32 residents. The sample included 17 residents with five residents sampled for medication review. Based on observation, record review and interview, the facility failed to implement a system to ensure the monthly Consultant Pharmacist (CP) recommendations were addressed/followed up by the physician and facility staff for the five residents sampled for medication review. Resident (R) 5, R9, R12, R29, and R30's chart lacked physician responses to the monthly pharmacy recommendations. This placed the residents at risk for complcations related to unecessary medications. Findings included: - Review of the electronic medical record (EMR) for R5, R9, R12, R29, and R30 lacked evidence that monthly medication regimen review (MRR) were addressed by the physicians and facilty staff. The facility was unable to provide the CP's MRR's including recomemndations since the last onsite annual survey on 09/27/21. On 05/22/23 at 02:56 PM Administrative Nurse F stated that on 05/13/23 the pharmacist came to the facility to do the monthly MRR. Administrative Nurse F had been unaware that the pharmacist recommendations were not being addressed by the physician since March and that she would now be responsible for ensuring the recommendations were forwarded to the physician and addressed by staff upon return from the physician with the responses. Administrative Nurse F stated she had worked at the facility since January and could not say who had been responsible for making sure the pharmacist recommendations were being taken care. On 05/22/23 at 04:05 PM Administrative Nurse D stated the pharmacist comes to the facility monthly and the MRR were then faxed to the physician's office. Administrative Nurse D stated that there was evidence that showed the previous Director of Nursing (DON) had not been doing anything with the MRR reports that were being emailed directly to that DON. Administrative Nurse D said she had appointed Administrative Nurse F to be in charge of the MRR duties. The facility policy Medication Therapy revised 04/2007 documented: Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the CP will review and individual's current mediation regimen, to identify whether: there was a clear indication for treating that individual with the medication; the dosage was appropriate; the frequency of administration and duration of use were appropriate; and potential and suspected side effects were present. The Physician will identify situations where medications should be tapered, discontinued, or changed to another medication. The CP shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence was confirmed or suspected. The Medical Director and CP shall address issues of medication prescribing and monitoring with the practitioners and staff. The facility failed to ensure that recommendation made during the CP's monthly MRR were addressed and follow-up on by the physician and nursing staff. The facility failed to provide documentation of the physician responses and nursing follow up recommendations for R5, R9, R12, R29, and R30. This places these residents at risk for unnecessary medication administration and adverse side effects. ;

The facility identified a census of 32 residents. The sample included 17 residents. Based on observation, record review and interview, the facility failed to ensure nursing staff cleaned/sanitized shared equipment after each use. The facility failed to ensure nursing staff placed a protective barrier down when using a glucometer (a medical device used to measure the approximate concentration of glucose in the blood). The facility failed to use appropriate hand hygiene while providing care to residents. These deficient practices placed the residents at risk for increased infection and transmission of communicable disease. Findings included: - An observation on 05/18/23 at 07:36 AM revealed Administrative Nurse D entered Resident (R) 5's room to obtain his fingerstick blood sugar (FSBS). Administrative Nurse D placed items on the bedside table without placing a barrier down. Administrative Nurse D donned gloves that were in her scrub top pocket; she cleansed R5's finger with an alcohol wipe, then applied the lancet (a device that punctures the skin to obtain a blood sample). She obtained the blood drop and applied the drop to the test strip in the glucometer. Administrative Nurse D placed the soiled items onto the bedside table a she administered the insulin. Administrative Nurse D removed the soiled items from the bedside table, placed the glucometer and test items into the bag and placed them back into the medication cart without disinfecting. On 05/18/23 at 07:45 AM Administrative Nurse F entered R9's room to obtain a FSBS. Administrative Nurse F placed a barrier down on the bedside table, then placed the glucometer and other items half on the barrier and half on the bedside table. Administrative Nurse F obtained the blood sample and placed the alcohol wipe and lancet on the bedside table area that did not have a barrier. When finished, Admsinitrative Nurse F did not disinfect the table. On 05/22/23 at 07:50 AM R11 laid in bed, Certified Nurse Aide (CNA) M and CNA P washed their hands, donned gloves. Explained procedure to R11, removed bed covering. Untapped incontinent brief. CNA P wiped peri-care with moisture wipes in a downward motion and disposed of wipe after each wipe in pericarp. CNA M assisted R11 to turn onto her right side, CNA P cleansed buttocks, coccyx, and rectal area. CNA P removed soiled incontinent brief, placed brief into the trash can, then placed a new brief under R11 and CNA P assisted R 11 to roll back and then onto her left side. CNA M and CNA P tapped incontinence brief. CNA P placed transfer sling onto R11 bed, CNA M and CNA P rolled R11 onto the transfer sling. CNA P pulled the Hoyer lift (total body mechanical lift used to transfer residents) over the R11's bed. CNA P doffed her gloves, assisted CNA M with the transfer of R11 into the wheelchair. CNA M doffed her gloves and CNA P unhooked the straps from the Hoyer lift and then washed her hands. CNA M combed R11's hair and placed a lab blanket onto R11's lab and washed her hands. The Hoyer lift was not disinfected prior to R11's transfer or following the transfer. On 05/22/23 at 02:20 PM Certified Nurse Aide (CNA) M stated shared equipment should be cleaned/disinfected after use with each resident. CNA M stated the sanitizing wipes were locked in the housekeeping closet and some wipes were on the equipment in a bag. CNAM stated hand hygiene should be done all the time, before/after cares, after doffing gloves, after using the bathroom, or eating. On 05/22/23 at 03:15 PM Administrative Nurse F stated shared equipment should be sanitized after each use. Administrative Nurse F stated housekeeping was in the facility from 07:00 AM to 05:00 PM daily. Administrative Nurse F stated sanitizing wipes were available in the house keeping closet and some containers of the wipes were in a bag on the lifts/equipment. Administrative Nurse F stated a barrier should be placed on a surface before supplies or equipment was placed on it. Administrative Nurse F stated hand hygiene should be performed before/after any cares have been done and would expect staff to do hand hygiene after doffing dirty gloves and donning clean ones. The Cleaning and Disinfection of Resident - Care Items and Equipment policy revised 10/2018 documented: Resident-care equipment, including reusable items and durable medical equipment (DME) would be cleaned and disinfected according to current Centers for Disease and Control (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. Reusable items are cleaned and disinfected or sterilized between residents according to manufacturers' instructions. The facility failed to ensure nursing staff cleaned/sanitized shared equipment after each use. The facility failed to ensure nursing staff placed a protective barrier down when using a glucometer (a medical device used to measure the approximate concentration of glucose in the blood). The facility failed to use appropriate hand hygiene while providing care to residents. These deficient practices placed the residents at risk for increased infection and transmission of communicable disease.

The facility identified a census of 32 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs. Findings included: - On 05/17/23 at 11:50 AM Administrative Staff A stated that Dietary BB was currently enrolled in class to become their CDM; she reported that the facility did not currently have a CDM. She further stated that the facility's registered dietitian comes to the facility about once per month. On 05/22/23 at 11:33 AM Dietary BB stated that the facility's registered dietitian comes to the facility once a month. He further stated that he can call the dietitian when needed for assistance. The facility failed to provide a policy related to a CDM. The facility failed to ensure the director of food and nutrition services was a certified dietary manager. This deficient practice placed all residents at risk for unmet dietary and nutritional needs.

The facility identified a census of 32 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to equipment testing and storage of kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 05/17/23 at 07:42 AM an observation revealed plates and bowls stored on top of a cart were not covered or inverted. On 05/17/23 at 07:43 AM an observation revealed plates and bowls stored in a metal bin under a table. The dishes were stored below waist level and the side of the bin was open leaving the plates and bowls exposed. The plates and bowls were uncovered and not inverted. On 05/17/23 at 07:45 AM review of the Dish Machine and Temperature Log for April 2023 revealed a lack of evidence that dishwasher temperatures were monitored for 79 out of 90 scheduled times. Review of the Dish Machine and Temperature Log for May 2023 revealed a lack of evidence that dishwasher temperatures were monitored for 17 out of 51 scheduled times. On 05/17/23 at 07:59 AM a stack of bowls on a storage shelf were uncovered and not inverted. On 05/18/23 at 07:33 AM plates and bowls continued to be stored in a metal bin under a table, not inverted or covered. 05/22/23 at 11:33 AM plates and bowls continued to be stored face up in metal bin under a table. The side of the bin remained opened exposing the dishes. The plates and bowls were not covered. On 05/22/23 at 11:33 AM Dietary BB stated that dishes were stored face up, not inverted, and stored on a cart that went out to serve meals. He stated that excess dishes were then stored in the metal bin under the table. He stated that the metal bin was supposed to be closed and that it was not normally left open. Dietary BB further stated that the expectation was for kitchen staff, on each shift, to assess and document temperatures on the Dish Machine and Temperature Log when dishes were cleaned after each meal. The facility's policy Dishwashing Machine Use revised March 2010 documented the operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. The facility failed to maintain sanitary dietary standards related to equipment testing and storage of kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns.

The facility census totaled 32 residents. Based on observation, interview, and record review the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the 32 residents who reside in the facility. Findings included: The facility failed to ensure a surety bond was in place to protect resident's trust accounts. This deficient practice placed 30 residents at risk for complication related to monetary issues. (Refer to F570) The facility failed to ensure Resident (R)7 remained free from neglect when facility staff failed to provide the necessary number of qualified staff members along with the required medical equipment to provide appropriate assistive cares for R7. (Refer to F600) The facility failed to provide written notification of the reason and location for the transfer to the hospital for R16 or her representative. This deficient practice placed R11 at risk of delayed care. (Refer to F623) The facility failed to ensure staff provided and documented consistent bathing cares for Resident (R) 29, R7, R11, and R30 who required extensive assistance from staff with bathing. This deficient practice had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial wellbeing. (Refer to F677) The facility failed to provide physician ordered pressure reducing heel protectors for R10 when in bed who had an unstageable pressure related injury to her right heel. This deficient practice placed R10 at increased risk of worsening or further pressure related injuries. (Refer to F686) The facility failed to identify R12 wheelchair positioning, which had the potential to place her at risk of loss of independence, dignity, and social wellbeing. (Refer to F688) The facility failed to ensure adequate staffing and equipment to provide safe repositioning for R7 during meal services. The deficient practice resulted in a serious injury for R7 evidenced by a painful, humerus fracture. The deficient practice further created the likelihood for severely impaired psychosocial well-being including fear. (Refer to F689) The facility failed to implement an individualized toileting plan to prevent R7's decline in bowel and bladder incontinence. This deficient practice placed the residents at risk for complications related to incontinence. (Refer to F690) The facility failed to provide appropriate hand hygiene during peri-care for R11 who has a history of sepsis and UTI's. This deficient practice placed R11 at risk of further infection, catheter related complication along with alteration in her dignity, well-being. (Refer to F690) The facility failed prevent weight loss for R19 and provide consistent support during meals services. This deficient practice placed R19 at risk for altered hydration and nutrition. (Refer to F692) The facility failed to ensure that recommendation made during the CP's monthly MRR were addressed and follow-up on by the physician and nursing staff. The facility failed to provide documentation of the physician responses and nursing follow up recommendations for R5, R9, R12, R29, and R30. This places these residents at risk for unnecessary medication administration and adverse side effects. (Refer to F756) The facility failed maintain physician ordered laboratory test results for R10 and R12 had been signed and scanned into the clinical record. This deficient practice could result in unnecessary tests and delayed treatment. (Refer to F779) The facility failed to ensure the director of food and nutrition services was a certified dietary manager. This deficient practice placed all residents at risk for unmet dietary and nutritional needs. (Refer to F801) The facility failed to maintain sanitary dietary standards related to equipment testing and storage of kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. (Refer to F812) The facility failed to ensure all staffing data entered in the PBJ system was auditable and able to be verified through either payroll, invoices, and/or tied back to a contract. The facility failed to ensure accurate data was submitted including the hours paid for all required licensed staff (agency), including hours the DON served as the charge nurse. (Refer to F851) The facility failed to ensure the Quality Assurance Performance Improvement (QAPI) team meet quarterly with the required personnel in attendance. This deficient practice placed 32 residents at risk for ineffective care. (Refer to F868) The facility failed to ensure nursing staff cleaned/sanitized shared equipment after each use. The facility failed to ensure nursing staff placed a protective barrier down when using a glucometer (a medical device used to measure the approximate concentration of glucose in the blood). The facility failed to use appropriate hand hygiene while providing care to residents. These deficient practices placed the residents at risk for increased infection and transmission of communicable disease. (Refer to F880) The facility failed to proactively apply the principles of antibiotic stewardship by failing to track and trend antibiotics for the residents of the facility from January 2022 through April 2023. The facility failed to ensure antibiotics administered were in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance. (Refer to F881) The facility failed to ensure that sampled Resident (R) 29 and R30 that had consented to receive the influenza and pneumococcal vaccine were administered the vaccinations. This deficient practice placed these residents at risk for acquiring, transmitting, or experiencing complications from influenza and pneumococcal disease. (Refer to F883) The facility failed to identify and develop corrective action plans for potential quality deficiencies through the QAPI plan to correct identified quality issues. This deficient practice placed the residents at risk for ineffective care. (Refer to F867) The facility failed to ensure the QAPI team meet quarterly with the required personnel in attendance. This deficient practice placed 32 residents at risk for ineffective care. (Refer to F868) A review of the facility's Quality Assurance Performance Improvement (QAPI) team meeting sign-in sheet indicated a QAPI meetings were held 02/08/22, 03/08/22, 04/12/22, 07/27/22, and 10/26/22. The facility was unable to provide documentation showing meetings held after October 2022. The review indicated no quality measures, concerns, monitoring, performance improvement plans (PIPs), or QAPI guidance/education occurred after 10/26/22. On 05/22/23 at 04:10PM Administrative Staff A reported that she was not aware she was supposed to be running the QAPI program at the facility. She reported the facility will have its first QAPI meeting on 05/24/23 since October 2022. She stated that going forward the facility will meet monthly and quarterly to identify facility concerns and create Performance Improvement Plans (PIP). She stated the QAPI committee will monitor identified concerns and implemented interventions. A review of the facility's Quality Assurance Performance Improvement (QAPI) policy dated 11/08/22 indicated the facility will provide an ongoing and comprehensive program dealing wit the full range of services provided. The QAPI process will address issues within clinical care, quality of life, resident choice, care transitions, services provided by the facility. The policy indicated that QAPI leadership was responsible for ensuring the staff training was completed to meet and sustain goals developed by the QAPI team. The policy noted that QAPI will provide quality measures to falls, pain management, medications, behaviors, weight loss, and increased needs for assistance with activities of daily living. The policy stated that that QAPI team will monitor the effectiveness of the interventions. The facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the 26 residents who reside in the facility.

The facility identified a census of 32 residents. Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to develop corrective actions plans and monitor them to correct identified quality deficiencies prior to survey. This deficient practice placed the residents at risk for ineffective care. Findings Included: The facility failed to ensure a surety bond was in place to protect resident's trust accounts. This deficient practice placed 30 residents at risk for complication related to monetary issues. (Refer to F570) The facility failed to ensure Resident (R)7 remained free from neglect when facility staff failed to provide the necessary number of qualified staff members along with the required medical equipment to provide appropriate assistive cares for R7. (Refer to F600) The facility failed to provide written notification of the reason and location for the transfer to the hospital for R16 or her representative. This deficient practice placed R11 at risk of delayed care. (Refer to F623) The facility failed to ensure staff provided and documented consistent bathing cares for R29, R7, R11, and R30 who required extensive assistance from staff with bathing. This deficient practice had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial wellbeing. (Refer to F677) The facility failed to provide physician ordered pressure reducing heel protectors for R10 when in bed who had an unstageable pressure related injury to her right heel. This deficient practice placed R10 at increased risk of worsening or further pressure related injuries. (Refer to F686) The facility failed to identify R12 wheelchair positioning, which had the potential to place her at risk of loss of independence, dignity, and social wellbeing. (Refer to F688) The facility failed to ensure adequate staffing and equipment to provide safe repositioning for R7 during meal services. The deficient practice resulted in a serious injury for R7 evidenced by a painful, humerus fracture. The deficient practice further created the likelihood for severely impaired psychosocial well-being including fear. (Refer to F689) The facility failed to implement an individualized toileting plan to prevent R7's decline in bowel and bladder incontinence. This deficient practice placed the residents at risk for complications related to incontinence. (Refer to F690) The facility failed to provide appropriate hand hygiene during peri-care for R11 who has a history of sepsis and UTI's. This deficient practice placed R11 at risk of further infection, catheter related complication along with alteration in her dignity, well-being. (Refer to F690) The facility failed prevent weight loss for R19 and provide consistent support during meals services. This deficient practice placed R19 at risk for altered hydration and nutrition. (Refer to F692) The facility failed to ensure that recommendation made during the CP's monthly MRR were addressed and follow-up on by the physician and nursing staff. The facility failed to provide documentation of the physician responses and nursing follow up recommendations for R5, R9, R12, R29, and R30. This places these residents at risk for unnecessary medicaotion administration and adverse side effects. (Refer to F756) The facility failed to ensure the director of food and nutrition services was a certified dietary manager. This deficient practice placed all residents at risk for unmet dietary and nutritional needs. (Refer to F801) The facility failed to maintain sanitary dietary standards related to equipment testing and storage of kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. (Refer to F812) The facility failed to ensure the Quality Assurance Performance Improvement (QAPI) team meet quarterly with the required personnel in attendance. This deficient practice placed 32 residents at risk for ineffective care. (Refer to F868) The facility failed to ensure nursing staff cleaned/sanitized shared equipment after each use. The facility failed to ensure nursing staff placed a protective barrier down when using a glucometer (a medical device used to measure the approximate concentration of glucose in the blood). The facility failed to use appropriate hand hygiene while providing care to residents. These deficient practices placed the residents at risk for increased infection and transmission of communicable disease. (Refer to F880) The facility failed to proactively apply the principles of antibiotic stewardship by failing to track and trend antibiotics for the residents of the facility from January 2022 through April 2023. The facility failed to ensure antibiotics administered were in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance. (Refer to F881) The facility failed to ensure that R29 and R30, who had consented to receive the influenza and pneumococcal vaccine were administered the vaccinations. This deficient practice placed these residents at risk for acquiring, transmitting, or experiencing complications from influenza and pneumococcal disease. (Refer to F883) On 05/22/23 at 04:10PM Administrative Staff A reported that she was not aware she was supposed to be running the QAPI program at the facility. She reported the facility will have its first QAPI meeting on 05/24/23 since October 2022. She stated that going forward the facility will meet monthly and quarterly to identify facility concerns and create Performance Improvement Plans (PIP). She stated the QAPI committee will monitor identified concerns and implemented interventions. A review of the facility's Quality Assurance Performance Improvement (QAPI) policy dated 11/08/22 indicated the facility will provide an ongoing and comprehensive program dealing with the full range of services provided. The QAPI process will address issues within clinical care, quality of life, resident choice, care transitions, services provided by the facility. The policy indicated that QAPI leadership was responsible for ensuring the staff training was completed to meet and sustain goals developed by the QAPI team. The policy noted that QAPI will provide quality measures to falls, pain management, medications, behaviors, weight loss, and increased needs for assistance with activities of daily living. The policy stated that that QAPI team will monitor the effectiveness of the interventions. The facility failed to identify and develop corrective action plans for potential quality deficiencies through the QAPI plan to correct identified quality issues. This deficient practice placed the residents at risk for ineffective care.

The facility census totaled 32 residents. Based on observation, interview, and record review the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) team meet quarterly with the required personnel in attendance. This deficient practice placed all the residents at risk for ineffective care. Findings Included: - A review of the facility's Quality Assurance Performance Improvement (QAPI) team meeting sign-in sheet indicated a QAPI meetings were held 02/08/22, 03/08/22, 04/12/22, 07/27/22, and 10/26/22. The facility was unable to provide documentation showing meetings held after October 2022. The review indicated no quality measures, concerns, monitoring, performance improvement plans (PIPs), or QAPI guidance/education occurred after 10/26/22. On 05/22/23 at 04:10PM Administrative Staff A reported that she was not aware she was supposed to be running the QAPI program at the facility. She reported the facility will have a QAPI meeting on 05/24/23. She stated that going forward the facility will meet monthly and quarterly to identify facility concerns and create Performance Improvement Plans (PIP). She stated the QAPI committee will monitor identified concerns and implement interventions. A review of the facility's Quality Assurance Performance Improvement (QAPI) policy dated 11/08/22 indicated the facility will provide an ongoing and comprehensive program dealing wit the full range of services provided. The QAPI process will address issues within clinical care, quality of life, resident choice, care transitions, services provided by the facility. The policy indicated that QAPI leadership was responsible for ensuring the staff training was completed to meet and sustain goals developed by the QAPI team. The policy noted that QAPI will provide quality measures to falls, pain management, medications, behaviors, weight loss, and increased needs for assistance with activities of daily living. The policy stated that that QAPI team will monitor the effectiveness of the interventions. The facility failed to ensure the QAPI team met quarterly with the required personnel in attendance. This deficient practice placed all 32 residents at risk for ineffective care.

The facility identified a census of 32 residents. The sample included 17 residents. Based on interview and record review, the facility failed to ensure the principles of antibiotic stewardship were followed to ensure antibiotics were used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance in an ongoing, proactive manner when the facility Infection Preventionist (IP) failed to document and maintain an accurate antibiotic stewardship log monthly. This placed the residents who resided in the facility at risk for unnecessary side effects of antibiotics and antibiotic resistance. Findings included: - Review of the facilities Infection Control Tracking Log for tracking and trending infections from January 2022 through May 2023, revealed lack of Infection Control Logs for May 2022 was missing. The November 2022 and December 2022, January 2023, February 2023, March 2023, April 2023 logs lacked any infection/antibiotic tracking. The Infection Control logs reviewed had incomplete data for analysis of adherence with an evidenced-based surveillance criterion to define infections and effectiveness of the facility's antibiotic stewardship program. The logs revealed incomplete documentation of culture results of organism identification for monitoring trends in infections. On 05/23/23 at 03:26 PM Administrative Nurse E was unavailable for interview. On 05/22/23 at 03:45 PM Administrative Nurse D stated once the IP was caught up, she would have more time to track infection surveillance . The Infection Prevention and Control Program policy updated 10/01/22 documented: The elements of infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Culture reports, sensitivity data, and antibiotic usage reviews were included in surveillance activities. Medical criteria and standardized definitions of infection was used to help recognize and manage infections. Antibiotic usage was evaluated, and practitioners were provided feedback on reviews. Data gathered during surveillance was used to oversee infections and spot trends. The facility failed to proactively apply the principles of antibiotic stewardship by failing to track and trend antibiotics for the residents of the facility from January 2022 through April 2023. The facility failed to ensure antibiotics administered were in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance.

The facility identified a census of 31 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to protect Resident (R) 1 from having his personal privacy violated when on 02/12/23 at approximately 08:00 PM, Dietary Staff (DS) BB took a picture of R1 sitting in his wheelchair with R1's gluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineum) showing above his pants and showed the picture to other residents. Certified Medication Aide (CMA) R brought another resident out of her room to view R1's stated of undress and then CMA M laughed at the situation. Certified Nurses Aide (CNA) M, witnessed the events above and failed to report the personal privacy violation that occurred to R1. This deficient practice placed R1 at risk for degradation and embarrassment. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of spastic hemiplegia (paralysis of one side of the body) of the left non-dominant side, epilepsy (brain disorder characterized by repeated seizures), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated 02/14/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of fifteen which indicated R1 had intact cognition. The MDS further documented R1 required extensive assistance of one to two staff for bed mobility, transfer, toilet use, personal hygiene, dressing, and bathing. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 05/31/22, documented R1 had a diagnosis of spastic hemiplegia effecting his left side and a personal history of malignant (cancerous) neoplasm (tumor) of the brain. The CAA documented R1 required assistance with his ADL's related to his left sided hemiplegia. The Self-Care Deficit Care Plan, dated 08/31/22, documented R1 had a self-care deficit related to hemiplegia with the goal of maintain his current level of function. The care plan directed staff R1 required extensive staff assistance with dressing, bathing, bed mobility, and toilet use and to encourage R1 to fully participate with each interaction as able. The Facility Incident Report, dated 02/20/23, documented on 02/12/23 at approximately 09:00 PM, R2 and R3 were watching the Super Bowl on TV with Dietary Worker BB. Administrative Nurse D, who was functioning as the overnight nurse, approached the table the three were sitting at and asked when R2 and R3 would like their pills and blood sugars taken so as not to disturb the game. R2 told Dietary Worker BB to show Administrative Nurse D the picture. Dietary Worker BB said, no I don't think so. R2 and the R3 encouraged Dietary Worker BB to show the Administrative Nurse D the picture on dietary worker BB's phone. Dietary Worker BB stated, She's too professional, I don't think it is a good idea and she won't think it is funny. Administrative Nurse D told Dietary Worker BB she needed to see the picture. The picture that Administrative Nurse D saw on Dietary Worker BB's phone was the back of R1 sitting in his wheelchair with his gluteal cleft showing above his pants. Administrative Nurse D went to check on R1 to make sure that his clothing was in place and the way it was supposed to be and then reported the incident to Administrative Staff A. Upon investigation, R4 stated that he saw R3 take a picture of R1's compromised state of undress and shared it with Dietary Worker BB. R4 also stated CMA R was aware of R1's compromised stated of undress and went into R5's room and asked her if she wanted to see something funny and brought R5 out in her wheelchair to observe R1's compromised state of undress. CMA R was laughing and stated, Don't you think it's a little drafty in here? R2 was uncooperative and hostile during the investigation and said, I didn't take any picture and I didn't see any picture, and refused to provide a witness statement. R3 was uncooperative and hostile during the investigation and said, I have the resident right to take whatever picture I want in this place, and refused to provide a witness statement. Dietary Worker BB stated R2 asked him to take a picture of R1's state of undress because R2 couldn not as he only had a flip phone. Dietary Worker BB said, So I did. Dietary Worker BB further stated, When I first saw him [R1] I told a staff member that he needed help. I deleted that picture from my phone. I did that training on abuse and I learned what I did was wrong, and I feel bad. CNA M stated that she did not see a picture being taken, but she did see CMA R bring R5 out of her room in her wheelchair and put her directly behind R1 and was laughing and stated, Don't you think it's a little drafty in here? CMA R denied any participation in the event during her interview. Dietary Worker BB, CMA R, and CNA M were all terminated from employment at the facility. On 03/01/23 at 01:30 PM, observations revealed R1 sat in his wheelchair watching TV. R1 was dressed appropriately in a t-shirt and sweat pants. On 03/01/23 at 10:30 AM, R4 stated that he knew of the incident when the picture of R1 had been taken and he had deleted that picture from his phone. When asked if the Dietary Staff BB had sent him the picture of R1, R4 refused to answer. On 03/01/23 at 11:00 AM, R3 denied any knowledge of the incident and refused to answer questions. On 03/01/23 at 11:30 PM, R5 stated that she knew a picture had been taken of R1 and stated she had been taken out to see R1's state of undress and laughed at him. On 03/01/23 at 01:30 PM, R1 stated he felt bad knowing that someone had taken a picture of him like that because it wasn't right. R1 stated that he felt safe at the facility and received good care at the facility and was glad the person who took the picture of him no longer worked at the facility. On 03/01/23 at 02:00 PM, Administrative Nurse D stated the situation never should have happened because the staff had been trained on Abuse, Neglect, and Exploitation and reporting of incidents. Administrative Nurse D stated that the former employees' actions were against the facility policy and procedure and said employees had been terminated from employment at the facility. The Abuse Prevention, Identification, Investigation and Reporting Policy, revised 02/06/23, documented all residents have the right to be free from abuse, neglect, misappropriation of resident policy, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that result in personal degradation including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (cameras, smart phones, or other electronic devices) to take, keep or distribute photographs and/or recordings on social media or multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility failed to prevent R1's personal privacy from being violated. This deficient practice placed R1 at risk for degradation and embarrassment.

The facility had a census of 20 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or their representative) the Advance Beneficiary Notice (ABN) for skilled services for Resident (R) 2, R7, and R11. Findings included: - The Medicare Advanced Beneficiary Notice (ABN) informed the beneficiary that Medicare may not pay future skilled therapy services and provided a cost estimate of continued services. The form included option for the beneficiary to (1) receive specified therapy listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I am responsible for payment, but can appeal Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services. (3) I do not want the listed therapy services. The facility lacked documentation R2 had been provided with Center of Medicare (CMS)-10055 form when the resident skilled services ended 05/21/21, which informed the resident (or their representative) the estimated cost of skilled services if an appeal to Medicare was denied, leaving the resident responsible for payment of skilled services. The facility lacked documentation R7 had been provided with CMS-10055 form when the resident skilled services ended 03/30/21, which informed the resident (or their representative) the estimated cost of skilled services if an appeal to Medicare was denied, leaving the resident responsible for payment of skilled services. The facility lacked documentation R11 had been provided with CMS-10055 form when the resident skilled services ended on 03/06/21, which informed the resident (or their representative) the estimated cost of skilled services if an appeal to Medicare was denied, leaving the resident responsible for payment of skilled services. On 09/23/21 at 02:09 PM, Social Service (SS) S verified she was not aware of the CMS-10055 form, therefore had not provided it to R2, R7, and R11 (or their representatives). The facility failed to provide a Beneficiary Notice Requirement policy upon request. The facility failed to provide the resident (or their representative) the CMS-10055 form when discharged from skilled services for R2, R7, and R11, placing the resident's at risk to make uninformed decisions for their skilled services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 20 residents. The sample included 12 residents with two residents reviewed for respiratory services. Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services when they failed to ensure staff stored oxygen delivery devices in a sanitary manner for Resident (R) 7. Findings included: - R7's electronic medical record (EMR) documented a diagnosis of chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status score of four which indicated impaired cognition. R7 required extensive assistance from staff for all activities of daily living and wore oxygen during the look back period. The Care Plan dated 07/14/21 directed staff that episodes of increased confusion could be a sign of low oxygen level. It directed staff to ensure oxygen was in place in R7's nares, and to check oxygen saturation as needed. On 09/22/21 at 10:10 AM, observation revealed R7's oxygen nasal cannula (a thin tube inserted into the nose to deliver supplemental oxygen) loosely wrapped and unbagged on top of the oxygen concentrator. On 09/22/21 at 11:39 AM, observation revealed R7's oxygen tank and tubing with nasal cannula on back of his wheelchair unbagged. Further observation revealed Certified Medication Aide (CMA) N transferred R7 to his wheelchair, removed the concentrator nasal cannula from him and set it in his recliner seat, then placed the unbagged nasal cannula attached to the oxygen tank onto the resident's face. On 09/22/21 at 12:12 PM, observation revealed Certified Nurse Aide (CNA) M removed R7's nasal cannula from him and placed it, without a bag, on the top of the oxygen tank. CMA M then picked up the unbagged nasal cannula off the top of the concentrator and placed it on the resident. On 09/27/21 at 08:36 AM, observation revealed CNA M draped the oxygen tubing and nasal cannula over the back of the oxygen tank without bagging it. On 09/27/21 at 01:23 PM, Administrative Nurse D stated oxygen cannulas are to be stored in a plastic bag when not in use. She verified R7's nasal cannula on his oxygen tank was not bagged. The facility's Respiratory Therapy Prevention of Infection Policy, dated November 2011, documented staff were to keep the oxygen cannula and tubing in a plastic bag when not in use. The policy documented staff were to rinse, dry and store the mouthpiece in a plastic bag, marked with date and resident's name, between uses. The facility failed to store oxygen treatment devices in a sanitary manner for R7 placing the resident at increased risk for respiratory infections.

The facility had a census of 20 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to perform adequate infection control during wound care for two residents, Resident (R) 7, R14 and toileting for R10. Findings included: - On 09/22/21 at 03:10 PM, observation revealed Administrative Nurse D used hand gel and a paper towel to wipe off R14's bedside table and set a clean cover on the table for her supplies. Administrative Nurse D washed her hands and put on gloves, set out her wound care supplies, and cleaned the scissors with alcohol. Administrative Nurse D used scissors to remove the moderately soiled dressing. R14's left heel had a large black eschar (dead skin) area. Administrative Nurse D cleansed the heel with foaming wound cleanser and gauze several times, removed her soiled gloves, and donned clean gloves without washing her hands. Administrative Nurse D cleaned R14's left toe wounds with wound cleanser and gauze, changed gloves without washing her hands, and applied a wound treatment with a new gauze for each open area. Administrative Nurse D changed gloves without washing her hands, applied wound treatment creams around the heel wound, and applied Silver alginate dressing (highly absorbent wound dressing) on the open area. Silver alginate applied to an absorbent pad on his heel and wrapped the foot with gauze. Administrative Nurse D stated R14's foot and ankle area were leaking body fluids and his skin was wet. On 09/23/21 at 11:28 AM, observation revealed Licensed Nurse (LN) G checked R7's right upper arm, removed a wound dressing from an open area, and cleansed the open area with wound cleanser and gauze. LN G changed gloves without washing her hands, measured the wound and applied a clean dressing. LN G found another dressing on a larger, irregular shaped open area lower on his upper arm, to which she cleansed and applied a clean dressing without removing her soiled gloves. LN G removed her contaminated gloves after checking R7's other arm, handling clothing and supplies. On 09/23/21 at 04:42 PM, observation revealed Administrative Nurse D assisted R10 to the toilet. Administrative Nurse D removed R10's brief, which had a moderate amount of urine, used moist wipes to clean the peri frontal area, then used a new wipe to clean from front to back. Administrative Nurse D placed a clean brief on the resident, pulled up her clothing, and then removed her soiled gloves. On 09/27/21 at 01:40 PM, observation revealed LN G used her scissors to cut R14's left foot bandage and removed it. She set the contaminated scissors on the recliner footrest and used wound cleanser moistened gauze to soften the old dressing. Further observation revealed LN G did not remove her soiled gloves before using more wound cleanser moistened gauze to clean the wound. LN G changed her gloves without washing hands, applied antifungal cream around the wound, changed gloves without washing her hands, and cut the silver alginate dressing to fit the wound with her contaminated scissors. On 09/23/21 at 04:42 PM, Administrative Nurse D verified she should have removed her soiled gloves after peri care and before touching the new brief and clean clothing. On 09/27/21 at 01:45 PM, LN G, verified she had not disinfected her scissors after cutting off the soiled bandage, and had not washed her hands between glove changes. On 09/27/21 at 01:10 PM, Administrative Nurse D verified the staff are to wash their hands after removing soiled gloves during wound care. The facility's Infection Control Policy, dated August 2021, documented hand hygiene should be performed before and after contact with a resident, after contact with body fluids, contaminated surfaces or objects in a resident's room. Hands shall be washed with soap and water after direct or indirect contact with blood or body fluids. The policy documented staff were to change gloves and wash hands before moving from a contaminated body site to a clean site during resident care. The facility failed to perform adequate infection control practices during wound care for R7 and R14, and incontinence care for R10, placing residents at risk for infection.