**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 13 or his representative with written information regarding the facility bed hold policy when he was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R13's Electronic Medical Record (EMR) documented R13 had a diagnosis of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections (UTI-an infection in any part of the urinary system) reaction due to having an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag), and sepsis (life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). R13's Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident required substantial to maximal staff assistance with toileting and personal hygiene. R13's Care Plan, revised 05/13/24, documented R13 had an indwelling urinary catheter, was at risk for a UTI, and instructed staff to be sure R13 kept his catheter tubing and drainage bag below his bladder so urine didn't back up into his bladder. The care plan instructed staff to let the nurse know if R13 had pain around his catheter, noticed R13's urine was dark, red, or had very little urine output when draining it, and if the urine was cloudy or if it looked like there were things floating in the urine. The care plan instructed staff if R13 had urine in his brief to assess his catheter to ensure it was not kinked, occluded (to close up or block off), or the drainage bag was too full. The Progress Note, dated 05/06/24 at 10:39 PM, documented R13 was admitted to the hospital. A review of R13's clinical record lacked evidence the resident or representative was provided the bed hold policy when he was transferred to the hospital. On 06/18/24 at 11:54 AM, observation revealed R13 sat in a wheelchair at the dining room table with clear urine in his urinary catheter tubing and the covered catheter bag was hooked underneath the seat of his wheelchair. On 06/24/24 at 11:25 AM, Administrative Staff A verified the resident had not been provided the bed hold policy when he was transferred to the hospital on [DATE]. Administrative Staff A stated the residents are provided the bed hold policy on admission. The facility's Bed-Hold Policy, revised 11/28/17, documented that a written notice, which specifies the duration of the bed-hold policy, would be provided at the time of transfer of a resident for hospitalization or therapeutic leave. The facility failed to provide R13 or his representative with written information regarding the facility bed hold policy when he was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to assess Resident (R) 10's ability to smoke safely. This placed R10 at risk for injury during smoking. Findings included: - R10's Electronic Medical Record (EMR) included diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), right femur (thigh-bone) fracture with routine healing, dementia (a progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and personal history of nicotine and alcohol dependence. The admission Minimum Data Set (MDS), dated [DATE], documented R10 had refused to answer cognition questions and staff assessed R10 as modified independence with cognitive abilities. R10 had verbal behaviors directed toward others which occurred four to six days of the observation period which significantly interfered with the resident's care and put others at significant risk of physical injury. R10 rejected evaluation or care one to three days of the observation period. R10 required substantial assistance with upper body dressing and personal hygiene and was dependent for lower body dressing and toileting, sit to lying, and chair/bed transfers. The MDS further documented R10 had no current tobacco use and received an antidepressant (class of medications used to treat mood disorders), hypnotic (medication used to induce sleep), anticoagulant (medication used to prevent blood clotting), opioid (medications used to treat pain) and antiplatelet (medication used to stop blood cells from sticking together). The Behavioral Symptoms Care Area Assessment (CAA), dated 05/07/24, documented R10 had many behaviors during the observation period which included verbal outbursts, rejection of care, often yelling and cursing, and becoming agitated and upset about smoking rules. The CAA further documented R10 was provided reminders of smoking rules and policy. R10's Care Plan, dated 05/10/24, documented that R10's smoking supplies were kept locked in the nurses' station. The plan directed staff to notify R10's family members when needing more cigarettes. R10 was able to smoke safely with the supervision of a staff member at smoke breaks but needed assistance to and from the smoke breaks. The care plan further documented R10 became upset at times about the smoke breaks and rules. R10's EMR recorded a Smoking Assessment dated 12/09/19 from a previous admission. The EMR lacked a current admission Smoking Assessment. The Progress Note dated 04/30/24 at 02:06 AM documented R10 had been yelling out throughout the shift, leaving inappropriate, threatening, voicemails on family member's phones. R10 was angry with staff about not being able to smoke at undesignated times. Staff provided R10 with a copy of the smoking rules. The note further documented that at 07:00 PM, R10 refused to come in after one cigar and staff stayed outside with R10 for 70 minutes on the smoking patio. On 06/20/24 at 01:33 PM, observation revealed R10 in the dining room and reported to the activity staff person that he and other residents wondered who was going to bring the smoking supplies. R10 also reported the residents were on time for the smoke break and staff was not there and available for the smoke time. On 06/20/24 at 01:35 PM, observation revealed facility staff brought smoking materials for residents and assisted residents outside to smoke. The staff remains outside with residents during the smoke time. On 06/20/24 at 01:53 PM, observation revealed R10 was assisted through the threshold of the patio door. R10 commented What are you looking at? though no one else was present. He then began to wheel himself through the dining room and another resident began to push his wheelchair toward his room when he remarked We are probably breaking the rules somehow. On 06/24/24 at 10:10 AM, Licensed Nurse (LN) G reported R10 was compliant with the smoking routine although they will push the time longer than the set limit. LN G reported staff had to remind him of the time frames, and staff were present during smoking time. LN G reported a smoking assessment was done on admission and changes in the resident's condition. On 06/24/24 at 10:17 AM, Administrative Nurse D reported initially the nursing staff marked no for resident smoking and that the facility had not completed a smoking assessment for the safety of the resident. The facility's Smoking policy, dated 11/28/17, documented that if a resident chooses to smoke, the facility will offer the resident the opportunity to do so in a safe environment within the guidelines. Residents who express a desire to smoke will have a Smoking Assessment completed. If the resident's smoking assessment indicates he/she is unable to smoke independently, the facility will implement a supervised smoking program. The Smoking Assessment is completed quarterly and with any significant change in the resident condition. If the assessment indicates the resident is no longer able to safely smoke independently, the supervised smoking procedures will be followed. A resident has the right to state a formal complaint or request a smoking re-assessment at any time, should they feel their smoking rights have been violated. The facility failed to evaluate R10's ability to safely smoke with R10's recent admission to the facility. This placed R10 at risk for injury during smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R188's Electronic Medical Record (EMR) documented R188 had a diagnosis of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R188's Quarterly Minimum Data Assessment (MDS), dated [DATE], documented R188 had a Brief Interview of Mental Status (BIMS) of 13, which indicated intact cognition. The MDS documented R188 was dependent on staff with most activities of daily living (ADLS). The MDS documented R188 had not received an antianxiety (class of medications that calm and relax people) medication during the observation period. R188's Care Plan, revised 04/09/24, documented R188 received medications that had black box warnings and instructed staff to watch R188 for the indicated reactions and notify the physician right away if they see any of them. The care plan instructed staff to leave R188 alone to either watch television (TV) or write when she became angry or agitated. The Physician Order, dated 06/14/24 at 02:34 PM, instructed staff to administer Ativan, 0.5 milligrams (mg), every four hours as needed (PRN) anxiety. The order lacked an end date for the medication. On 06/20/24 at 08:57 AM, observation revealed R188 rested quietly in bed with eyes open with oxygen on per nasal cannula at two liters. On 06/24/24 at 10:51 AM, Administrative Nurse D verified that R188's physician order for PRN Ativan lacked a stop date and stated it should have a 14-day stop date from when it was ordered. The facility's Psychoactive Medications Policy, revised 11/28/17, PRN antianxiety, antidepressant, hypnotic, and sedative time limitation 14 days order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. The facility failed to obtain a stop date on R188's PRN Ativan. This placed the resident at risk for unnecessary medications and related complications. The facility had a census of 35 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to obtain a stop date from the physician for the continued use of Ativan (antianxiety medication) as needed (PRN) for two residents, Resident (R)30 and R188. This placed the residents at risk for complications related to psychotropic (alters mood or thought) medications and unnecessary medications. Findings included: - R30's Electronic Medical Record documented diagnoses of a generalized anxiety disorder (excessive, ongoing anxiety and worry that can interfere with daily activities), convulsions (involuntary series of contractions of a group of muscles), sleep apnea (a disorder of sleep characterized by periods without respirations), obsessive-compulsive disorder (OCD- anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R30 was independent for eating and dependent on staff for all other activities of daily living (ADLs) including mobility. The MDS documented R30 received antianxiety (a class of medications that calm and relax people) medications. R30's Care Plan, dated 05/16/24, stated information regarding the medications R30 received with black box warnings (BBW- highest safety-related warning that medications can be assigned by the Food and Drug Administration) was located in the medication administration record. The care plan stated R30 often became anxious which resulted in fast-talking, restlessness, wiggling around, worried about pain, and other things. R30 had PRN Ativan if needed. The plan directed staff to administer this if needed. The plan documented R30 sometimes would press the call light repeatedly without realizing she was it when she felt anxious. She did this at times even when a staff member or her husband was right next to her. The care plan directed staff to watch for any side effects R30 may have due to the antianxiety medications such as sedation, drowsiness, or dizziness. The plan documented that sometimes instead of alerting staff that she was feeling anxious or upset, she called her husband on her cell phone and talked to him about it. Usually, he called the facility to alert staff of R30's feelings. When R30 feels anxious about her oxygen or breathing, checking her oxygen will help reassure her and calm her down. The Physician Order, dated 06/10/24, directed staff to administer Ativan, 0.5 milligrams (mg) three times daily PRN for anxiety. The order documented it was to be indefinite (no specific stop date). On 06/20/24 at 11:30 AM, observation revealed R30 in bed, awake, and Certified Medication Aide (CMA) M administered medications to her. R30 took the pills whole with water. On 06/24/24 at 1045 AM, Administrative Nurse D verified staff should have obtained a stop date for the use of PRN Ativan. The facility's Psychoactive Medication policy, dated 11/28/2017, stated PRN antianxiety, antidepressant, hypnotic, and sedative medications would be limited to 14 days unless the attending physician or prescribing practitioner believed it appropriate to extend the order. The attending physician or prescribing practitioner must document the rationale for the extended time period in the medical record and indicate a specific duration. The facility failed to obtain a stop date from the physician for the use of Ativan PRN for R30, placing the resident at risk for complications related to unnecessary psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F655 [NAME] The facility had a census of 39 residents. The sample included three residents reviewed for quality of care. Based on record review and interview, the facility failed to develop a baseline care plan for Resident (R) 1, which addressed his immediate health needs including his below the knee amputation (surgical removal of a body part), surgical incision, and daily dressing changes. This placed the resident at risk for inappropriate care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of acquired absence of right leg below knee, acute kidney failure (the kidneys suddenly cannot filter waste from the blood), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and hypertension (high blood pressure). The Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R1 had moderately impaired cognition and required substantial to maximum assistance for upper and lower dressing, toileting, sit to stand, chair to bed, putting footwear on and off, and bathing. The MDS further documented R1 had no upper functional impairment, had lower functional impairment on one side, and had a surgical wound. The Baseline Care Plan, dated 10/19/23, documented R1 was alert, required assistance of two staff for transfers, toileting, and one staff for personal hygiene, dressing, bathing, and mobility. The care plan further documented R1 was alert and had no pain. The baseline care plan lacked mention of R1's amputation and/or the presence of a surgical incision and related treatments. R1's hospital Discharge Summary, dated 10/19/23, directed staff to keep the wound clean and dry, and continue with daily dressing changes, 4 x 4 gauze (an absorbent dressing for wounds), Kerlix (stretchy gauze bandage) and an ace wrap (provides moderate support to weak, sore muscles and joints) until seen at his follow-up appointment. The Nurse's Notes, dated 10/19/23 at 06:30 PM, documented R1's right knee skin was clean, dry and intact with sutures placed. R1 had a surgical incision, sutures were present, and the resident was on anticoagulants (blood thinner). The Nurse's Notes, dated 10/23/23 at 04:00 PM, documented R1's family member inquired about R1's dressing change to his incision and stated the surgeon requested a picture of the incision for review. The nurse's note further documented staff reviewed the Discharge Summary for dressing change orders, then removed the soiled dressing which had a moderate amount of dried blood. The note documented R1 had purplish discoloration surrounding the incision and had no odor or warmth to the incision. The dressing was changed as ordered, and staff reapplied the brace. The Treatment Administration Record, dated October 2023 lacked evidence staff provided R1's dressing changes until 10/23/23 (4 days after admission). R1 was discharged from the facility on 10/27/23. On 11/14/23 at 03:10 PM, Licensed Nurse (LN) G stated the nurse completed new admission paperwork and inputs all the orders from the physician into the computer and the following shift reviewed the admission packet to ensure no orders were missed. On 11/16/23 at 10:30 AM, Administrative Nurse D stated the baseline care plan should address his surgical wound and treatments. The facility's Care Plan policy, dated 11/28/17, documented the charge nurse was responsible for creating a baseline care plan within 48 hours after admission to be individualized to address the residents specific needs. The facility failed to develop a baseline care plan for R1, who had a new below the knee amputation and required daily dressing changes. This placed R1 at risk for inappropriate care and services due to uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 39 residents. The sample included three residents reviewed for quality of care. Based on record review and interview, the facility failed to ensure Resident (R) 1 received wound care as ordered for four days after a below the knee amputation (surgical removal of a body part). This placed the resident at risk for infection and decline. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of acquired absence of right leg below knee, acute kidney failure (the kidneys suddenly cannot filter waste from the blood), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and hypertension (high blood pressure). The Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R1 had moderately impaired cognition and required substantial to maximum assistance for upper and lower dressing, toileting, sit to stand, chair to bed, putting footwear on and off, and bathing. The MDS further documented R1 had no upper functional impairment, had lower functional impairment on one side, and had a surgical wound. The Baseline Care Plan, dated 10/19/23, documented R1 was alert, required assistance of two staff for transfers, toileting, and one staff for personal hygiene, dressing, bathing, and mobility. The care plan further documented R1 was alert and had no pain. The baseline care plan lacked mention of R1's amputation and/or the presence of a surgical incision and related treatment. R1's hospital Discharge Summary, dated 10/19/23, directed staff to keep the wound clean and dry, and continue with daily dressing changes, 4 x 4 gauze (an absorbent dressing for wounds), Kerlix (stretchy gauze bandage) and an ace wrap (provides moderate support to weak, sore muscles and joints) until seen at his follow-up appointment. The Nurse's Notes, dated 10/19/23 at 06:30 PM, documented R1's right knee skin was clean, dry and intact with sutures placed. R1 had a surgical incision, sutures were present and the resident was on anticoagulants (blood thinner). The Nurse's Notes, dated 10/23/23 at 04:00 PM, documented R1's family member inquired about R1's dressing change to his incision and stated the surgeon requested a picture of the incision for review. The nurse's note further documented staff reviewed the Discharge Summary for dressing change orders, then removed the soiled dressing which had a moderate amount of dried blood. The note documented R1 had purplish discoloration surrounding the incision, and had no odor or warmth to the incision. The dressing was changed as ordered, and staff reapplied the brace. The Treatment Administration Record, dated October 2023 lacked evidence staff provided R1's dressing changes until 10/23/23 (4 days after admission). R1 was discharged from the facility on 10/27/23. On 11/14/23 at 03:10 PM, Licensed Nurse (LN) G stated the nurse completed new admission paperwork and inputs all the orders from the physician into the computer and the following shift reviewed the admission packet to ensure no orders were missed. On 11/14/23 at 03:45 PM, Administrative Nurse D stated the dressing change order was missed upon admission and when the family member told the facility, the dressing change was immediately done and placed on the treatment record. Administrative Nurse D further stated education was provided to all the nurses and she expected each nurse to read the admission paperwork thoroughly, so orders were correct and not missed. Upon request a policy for dressing change, following physician orders, was not provided by the facility. The facility failed to ensure R1's dressing change to his surgical wound was changed daily as physician ordered. This placed the resident at risk for infection and decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 39 residents. The sample included three residents, with two reviewed for footcare. Based on observation, record review, and interview, the facility failed to provide footcare to two sampled resident, Resident (R) 2 and R3, who had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and required foot care from a licensed nurse. This placed the residents at risk for complications including poor hygiene, discomfort, and injuries. Findings included: - The Electronic Medical Record (EMR) for R2 recorded diagnoses of diabetes mellitus type 2, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), end stage renal disease (kidneys are damaged and cannot filter blood the way they should), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition and required some assistance with self-care, dependent upon staff for toileting, substantial to maximum assistance with showers, lower body dressing, putting on footwear, and partial or moderate assistance with upper body dressing assistance. R2's Care Plan, dated 11/13/23 directed staff to assess her skin for any impairment during bathing, dressing, toileting. The plan directed staff to have a licensed nurse provide nailcare. On 11/14/23 at 11:30 AM, during wound care, R2 stated she had two sore toes, and she was prone to ingrown nails. Upon request, Licensed Nurse (LN) G removed R2's socks and looked at her feet. Observation revealed R2's toe nails were very thick, brown in color, and were grown over the tips of her toes. On 11/14/23 at 11:30 AM, LN G stated she would have R2 take a whirlpool bath the next day so that R2's toes could soak, and then she would provide R2 toenail care. LN G further stated she would have the podiatrist check R2's toenails on his next visit. On 11/14/23 at 03:34 PM, Administrative Nurse D stated she would make sure R2 was seen the next time the podiatrist came. Administrative Nurse D said she expected a LN to provide toenail care between the podiatrist visits. The facility's Foot Care policy, dated 04/27/18, documented foot care would be provided to residents to ensure they receive proper treatment and care to maintain mobility and good foot health. The facility failed to provide foot care to R2, who had overgrown toenails on both feet, This placed the resident at risk for complications and injury. - The Electronic Medical Record (EMR) for R3 documented diagnoses of diabetes mellitus type 2, candidiasis of nails (yeast infection which caused nails to separate from the finger or toes), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 was cognitively intact, and dependent upon staff for toileting, showers, putting on footwear, and substantial to maximum assistance or personal hygiene. R3's Care Plan, dated 08/24/23, initiated on 06/14/19, directed staff to help keep her fingernails and toenails short as she had trouble trimming them herself, and the care of the nails was to be done by a nurse. On 11/14/23 at 10:30 AM, observation revealed R3's feet were very dry with large flakes of skin coming off of the top and bottoms of her feet. R3's toenails were thick, brown, and grown over the tops of her toes. R3 asked Licensed Nurse (LN) H to put lotion on her feet for her. On 11/14/23 at 10:30 AM, LN H stated R3 received nailcare from the podiatrist that came to the facility, so staff did not do any nail care for her. LN H was unsure when the last time the podiatrist had been to the facility or when he was coming back. On 11/14/23 at 03:45 PM, Administrative Nurse D stated the podiatrist was at the facility the beginning of October but further stated she expected the nurse to provide toenail care between podiatry visits. The facility's Foot Care policy, dated 04/27/18, documented foot care would be provided to residents to ensure they receive proper treatment and care to maintain mobility and good foot health. The facility failed to provide foot care to R3, who had overgrown toenails on both feet, This placed the resident at risk for complications and injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R20's Electronic Medical Record (EMR), recorded diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), low back pain, overactive bladder, chronic kidney disease, peripheral vascular disease (abnormal condition affecting the blood vessels) and behavioral disturbance. The Quarterly Minimum Data Sheet (MDS), dated [DATE], documented R20 had moderately impaired cognition, required limited assistance of one person for activities of daily living, and physical help of one staff for bathing. R20 had occasional incontinence of urine and bowel, was not steady but able to stabilize without staff assistance. The Urinary Incontinence Care Area Assessment, dated 09/26/22, documented R20 was occasionally incontinent of urine per voiding diary, required limited assistance with toileting and toileting hygiene, and wore incontinent products to help clothing and promote dignity. R20 had been open toilet with cueing and the facility planned for incontinence with the start of toileting program of cueing to toilet at 06:00 AM, after meals, midafternoon and at bedtime to help promote continence. The Progress Note, dated 03/22/23 at 04:16 PM, documented R20 had not walked to the dining room for meals. R20 sat in her walker/wheelchair at the opening to her room and yelled for help. R20 reported she could not walk, but with staff encouragement she did walk to the dining room. On 04/03/23 at 08:03 AM observation revealed R20 walked into the dining room escorted by a Certified Medication Aide (CMA) R. R20's pants, on her buttocks area, were visibly wet. R20's pants sagged with wetness/weight of an incontinent brief. Survey team member brought the wet pants to CMA R's attention. CMA R instructed the hospitality aide to take R20 to the bathroom. The hospitality aide informed CMA R she could not take R20. Licensed Nurse (LN) H identified the name of R20 to the surveyor, and the survey told LN H R20 pants were wet, LN H looked at R20's pants and did not direct staff to provide assistance with the incontinence. Staff then sat R20 in a dining room chair for breakfast. R20 had uncombed oily hair. On 04/03/23 at 12:11 PM observation revealed staff pushed R20 while she sat on the seat of her walker. R20 had uncombed, oily hair. Staff encouraged and assisted R20 into a dining chair with a gait belt. As R20 stood, a round, wet circle was visible on the back of her pants and her incontinent product sagged between her legs. Staff preceded to sit R20 in the chair to eat her breakfast. On 04/03/23 at 01:06 PM observation revealed R20 made it to her room, from the dining room, and called for help as staff were bringing other residents to their rooms. Staff inquired what R20 needed and R20 told them she wanted to go upstairs. Staff then assisted R20 back to the dining room in her walker chair and placed her in front of her plate. On 04/03/23 at 01:29 PM Administrative Nurse D assisted R20 to stand and R20 continued to have a wet spot on the back of her pants. Staff assisted R20 to her room in a wheelchair. Staff assisted R20 to her recliner. Surveyor alerted staff R20 had wet pants and a filled, sagging brief. Staff looked at each other and asked each other if they saw the wetness. Staff then assisted resident to the bathroom and assisted to change R20's pants and brief, before returning R20's recliner. R20's hair remained uncombed and oily in appearance. On 04/03/23 at 01:32 PM Certified Nurse Aide (CNA) O stated R20 had a toileting routine. The routine was to toilet R20 when she got up in the morning, after breakfast, before lunch, the middle of the afternoon, then R20 would sleep until supper time. CNA O was unsure of the toileting schedule for the other shifts. On 04/03/23 at 01:29 PM CMA S stated R20 took usually toileted independently. CMA S stated R20 usually wore pullup undergarments. CMA S stated she was unsure when R20 had changed incontinent undergarment to tabbed briefs from pull ups. On 04/04/23 at 03:00 PM, Administrative Nurse D stated R20 should be assisted with her toileting needs. She verified R20 should not have wet clothing in public spaces and should have clean and combed hair, for the resident's dignity. Administrative Nurse D stated she expected the staff to provide ADL cares including combing hair and other grooming needs and she also expected staff to provide bathing for all resident as directed by their care plan and preferences. The facility's Activities of Daily Living policy, dated 04/27/18, documented residents will be given the appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living. The facility will provide care and services based on the comprehensive assessment of the resident and consistent with his/her needs or choices for the following activities of daily living. Residents who are unable to carry out activities of daily living and are dependent on staff will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to provide a dignified experience for R20 which placed the resident at risk of impaired dignity and decreased psychosocial wellbeing. The facility had a census of 40 residents. The sample included 14 residents, with two reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect for two sampled residents, Resident (R) 33, who was unnecessarily exposed from the waist down, and R20, who was taken to the dining room with soiled pants. This placed the resident's at risk for undignified care and services. - The Electronic Medical Record for R33 documented diagnoses of type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), hyperlipidemia (condition of elevated blood lipid levels), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), urinary retention (a lack of ability to urinate and empty the bladder). R33's admission Minimum Data Set (MDS), dated [DATE], documented R33 had intact cognition and required extensive assistance of one staff for transfers, dressing, toileting, and personal hygiene. The MDS further documented R33 required the use of an indwelling Foley catheter (tube used for draining urine from the bladder and having an inflatable part at the bladder end that allows the tube to be kept in place for variable time periods), was always incontinent of bowel, and had a urinary tract infection (an infection in any part of the urinary system) in the last 30 days. The Quarterly MDS, dated 03/02/23, documented R33 had intact cognition and required extensive assistance of two staff for transfers, toileting, and extensive assistance of one staff for bed mobility. The MDS further documented R33 had an indwelling Foley catheter and was frequently incontinent of bowel. The Urinary Catheter Care Plan, dated 03/16/23, initiated on 2/13/22, directed staff to ensure catheter care was performed every shift and as needed, if staff notice R33's urine turning darker in color, encourage good fluid intake. The plan directed if she was experiencing burning, cloudy or foul odor from the urine, let her physician know right away, and replace her catheter as ordered by the physician. Monitor urine output each shift, if staff notice a low urine output, sediment in her urine, abnormal urine color, notify the physician. The update dated 03/16/23 further directed staff to apply a urinary catheter leg drainage bag to R33's catheter when she was out of her bed or up ambulating. On 04/04/23 at 08:15 AM, observation revealed R33 laid in bed. Certified Nurse Aide (CNA) O and CNA P applied gloves and pulled down the resident's incontinence brief and pants. CNA O took R33's catheter bag, still full of urine, and guided the bag up the inside of the right pant leg and out the top of R33's pants. Further observation revealed CNA O and CNA P stood there as R33 was exposed from the waist down and discussed who would complete the catheter care and who would drain the catheter bag. Continued observation revealed CNA P took an incontinence wipe, performed incontinence care, and ran out of wipes before she could do catheter care. CNA P opened R33's nightstand drawer with soiled hands and was unable to find gloves. CNA O looked for more incontinence wipes in R33's dresser drawer and stated Well, I guess we need to stock these rooms and took R33's roommates' s incontinence wipes. Observation revealed R33 continued to be exposed from the waist down as the CNAs looked for incontinence wipes. CNA P took an incontinence wipe and wiped around the catheter tubing at the insertion site but did not cleanse the catheter tubing. With the same soiled gloves, CNA P and CNA O pulled up R33's incontinence brief and pants. Further observation revealed CNA O sat a container on the floor to drain the catheter bag, and spilled urine on the floor. CNA O stated, how did it get spilled onto the floor? CNA O failed to cleanse the port of the catheter tubing before clamping the tubing, took the catheter bag and down the top of R33's pants, down the inside of the right pant leg and held onto it as he assisted R33 into her recliner and asked her where she wanted him to place the catheter bag. R33 instructed CNA O to put the catheter bag in the dignity bag and lay it on top on her trash can. On 04/04/23 at 12:20 PM, CNA P verified they had not covered R33 up when looking for extra gloves. On 04/05/23 at 11:56 AM, Administrative Nurse D stated staff should not leave residents exposed if they are not providing cares. Upon request, a policy for dignity was not provided by the facility. The facility failed to promote care in a manner to maintain and enhance dignity and respect for R33, who was exposed from the waist down without cares being given. This placed the resident risk for undignified care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to notify Resident (R) 29's physician of his decline in respiratory status and extremely high blood pressures, which placed R20 at risk for delayed treatment. Findings included: - R29's Electronic Medical Record (EMR) recorded diagnoses of degenerative (progressively worsening) disease of nervous system, essential hypertension (elevated blood pressure), memory deficit following cerebral infarction (stroke), personal history of COVID-19 (a very contagious respiratory virus capable of progressing to severe symptoms and in some cases death), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), morbid obesity, adult obstructive sleep apnea (absence of breathing), and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had intact cognition, was independent with set up assistance for activities of daily living (ADL). R29 was continent of urine and bowel and was steady at all times with transitions and walking. R29 received an antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions) routinely. The Continuous Positive Airway Pressure [CPAP -respiratory therapy in which air is pumped into the lungs through the nose and mouth]/Oxygen Care Plan initiated on 05/11/22, documented R29 would keep oxygen saturation level above 90 percent (%), and directed staff to check oxygen saturation levels according to the doctor's orders or anytime R29 became short of breath or complained of feeling as if he could not catch his breath. R29's EMR included Special Instruction on admission which directed staff to notify the physician if systolic blood pressure (SBP-maximum blood pressure during a contraction of the heart) of greater that 160 or less than 90, the diastolic blood pressure (DBP-measurement during pause before next heartbeat) greater than 100 or less than 60, resting pulse greater than 100 or less than 50, respirations greater than 28 or less than 10, and oxygen saturation less than 90%. The Physician Order Sheet (POS), dated 03/08/23, directed staff to administer: Diovan (medication used to treat high blood pressure and heart failure) 320 milligrams (mg) by mouth one time a day for hypertension. Norvasc (medication used to treat high blood pressure and chest pain) 10 mg by mouth daily at bedtime. Zebeta (medication used to treat high blood pressure) 10 mg by one time a day for hypertension; hold the medication and contact the physician for pulse less than 50. Review of the March 2023 EMR revealed the following blood pressure results above physician ordered parameters: 03/06/23 blood pressure of 162/95 millimeters (mm) of Mercury (Hg) 03/20/23 blood pressure of 179/95 mmHg 03/21/23 blood pressure of 179/90 mm/Hg 03/22/23 blood pressure of 160/109 mm/Hg 03/23/23 blood pressure of 191/100 mm/Hg 03/27/23 blood pressure of 175/96 mm/Hg 03/29/23 blood pressure of 165/105 mm/Hg Review of the April 2023 EMR revealed the following blood pressure results above physician ordered parameters: 04/01/23 blood pressure of 167/90 mm/Hg 04/03/23 blood pressure of 215/136 mm/Hg The Progress Note dated 04/04/23 at 10:05 AM recorded R29 had shortness of breath and grunting respirations. R29 reported he felt poorly, had trouble breathing, and was having problems catching his breath. R29 had a blood pressure reading of 151/96 mm/Hg, oxygen saturation of 68%, a temperature of 98.0 Fahrenheit (F) and a pulse of 68. Staff called the physician and reported the vital signs, and the facility received a call back from the physician's office to send R29 to the hospital immediately per emergency medical services (EMS). On 04/03/23 at 08:15 AM observation revealed R29 walked through the dining room, slowly, with deep growling/grunting respirations and a moist cough. R29 ate only cereal for breakfast. On 04/03/23 at 12:30 PM observation revealed R29 walked through the dining room with a slower gait and continued with growling/grunting respirations and a moist cough. R29 did not eat well again, took only a few bites, and left the table with a slow and slightly unsteady gait. On 04/04/23 at 08:17 AM observation revealed R29 sat in the dining room, with a breakfast plate in front of him. R29 had obvious respiratory difficulties as evidenced by growling/grunting respirations, cough, and nasal congestion. On 04/04/23 at 08:19 AM Licensed Nurse (LN) H stated that R29's blood pressure sometimes ran high, and she had not notified the physician of the out of parameter readings. LN H reported R29 had been tested for COVID-19 and result had been negative but did not know date of last test. On 04/04/23 at 04:08 PM, Administrative Nurse D reported R29 admitted to the hospital, and was positive for COVID 19. Administrative Nurse D reported facility staff initiated COVID-19 testing for all the residents. On 04/05/23 at 08:19 AM, LN I reported there were no positive COVID-19 residents. LN I confirmed R29 was admitted to the hospital and was treated for COVID-19. On 04/05/23 at 10:30 AM, Administrative Nurse D stated R29's elevated blood pressures should have been reported to the physician, and verified the record lack physician notifications. Administrative Nurse D stated the medical record also lacked documentation of oxygen administration when the resident had respiratory distress and had an oxygen saturation of 68%. Administrative Nurse D stated oxygen should have been administered. The facility's Clinician Notification policy, dated 11/28/17, documented that notification of physicians and other clinicians will be done on a timely basis. The resident's physician and/or other pertinent clinicians will be notified of a significant change in the resident's physical, mental, or psychosocial status (that is deterioration in health mental or psychosocial status in either life-threatening conditions or clinical complications). A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Decision making regarding notification parameters for clinical signs and symptoms will be based on physician orders and physician specific parameters and Interact Acute Change in Condition File Cards and Care Plans. The facility's Clinician Notification policy, dated 11/28/17, documented that notification of physicians and other clinicians will be done on a timely basis. The resident's physician and/or other pertinent clinicians will be notified of a significant change in the resident's physical, mental, or psychosocial status (that is deterioration in health mental or psychosocial status in either life-threatening conditions or clinical complications). A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Decision making regarding notification parameters for clinical signs and symptoms will be based on physician orders and physician specific parameters and Interact Acute Change in Condition File Cards and Care Plans. The facility failed to ensure staff notified R29's physician for R29's significantly high blood pressure, which were out of parameter, and R29's respiratory distress which placed R29 at increased risk for physical complication, adverse outcomes, and delayed treatment.

The facility had a census of 40 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide the estimated cost and resident or representative's choice for continued skilled services for the three reviewed residents on the Advanced Beneficiary Notice the (ABN), CMS form 10055. (Resident (R) 31, R38, and R93). This placed the residents at risk for uninformed decisions regarding skilled services. Findings included: - The Medicare ABN form informed the beneficiaries that Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included an option for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment of services. (3) I do not want the listed services. The facility lacked documentation staff provided R31 (or their representative) the estimated cost or choice of option 1, 2, or 3 on the ABN form 10055 when the resident's skilled services ended 02/02/23. The facility lacked documentation staff provided R38 (or their representative) the estimated cost or choice of option 1,2 or 3 on the ABN form 10055 when the resident's skilled services ended 11/11/22. The facility lacked documentation staff provided R93 (or his representative) the estimated cost or choice of option 1,2, or 3 on the ABN form 10055 when the resident's skilled services ended 02/07/23. On 04/04/23 at 02:45 PM, Administrative Staff A verified the facility had not provided the information in the above findings on their ABN form 10055. On 04/04/23 at 3:00PM, Administrative Nurse D stated social service designee was responsible for providing the information to the residents or their representatives listed above on their ABN form 10055. Upon request the facility failed to provide a policy regarding beneficiaries. The facility failed to provide R31, R38, and R93 with the cost estimate for further services and choice for continued services on the ABN form 10055. This placed the residents at risk for uninformed decisions regarding skilled services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 29, who had elevated blood pressure and treatment with antihypertensive (medications used to treat high blood pressure) medications. This placed R29 at risk for complications related to complications related to uncommunicated or unmet care needs. Findings included: - R29's Electronic Medical Record (EMR) recorded diagnoses of degenerative (progressively worsening) disease of nervous system, essential hypertension (elevated blood pressure), memory deficit following cerebral infarction (stroke), personal history of COVID-19 (a very contagious respiratory virus capable of progressing to severe symptoms and in some cases death), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), morbid obesity, adult obstructive sleep apnea (absence of breathing), and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had intact cognition, was independent with set up assistance for activities of daily living. R29 was continent of urine and bowel and was steady at all times with transitions and walking. R29 received an antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions) routinely. R29's Care Plan lacked a hypertension problem goals, and treatment interventions. The Physician Order Sheet (POS), dated 03/08/23, directed staff to administer: Diovan (medication used to treat high blood pressure and heart failure) 320 milligrams (mg) by mouth one time a day for hypertension. Norvasc (medication used to treat high blood pressure and chest pain) 10 mg by mouth daily at bedtime. Zebeta (medication used to treat high blood pressure) 10 mg by one time a day for hypertension; hold the medication and contact the physician for pulse less than 50. R29's EMR included Special Instruction on admission which directed staff to notify the physician if systolic blood pressure (SBP-maximum blood pressure during a contraction of the heart) of greater that 160 or less than 90, the diastolic blood pressure (DBP-measurement during pause before next heartbeat) greater than 100 or less than 60, resting pulse greater than 100 or less than 50, respirations greater than 28 or less than 10, and oxygen saturation less than 90 percent (%). Review of the March 2023 EMR revealed the following blood pressure results above physician ordered parameters: 03/06/23 blood pressure of 162/95 millimeters (mm) of Mercury (Hg) 03/20/23 blood pressure of 179/95 mmHg 03/21/23 blood pressure of 179/90 mm/Hg 03/22/23 blood pressure of 160/109 mm/Hg 03/23/23 blood pressure of 191/100 mm/Hg 03/27/23 blood pressure of 175/96 mm/Hg 03/29/23 blood pressure of 165/105 mm/Hg Review of the April 2023 EMR revealed the following blood pressure results above physician ordered parameters: 04/01/23 blood pressure of 167/90 mm/Hg 04/03/23 blood pressure of 215/136 mm/Hg On 04/03/23 at 12:30 PM observation revealed R29 walked through the dining room with a slower gait and continued with growling/grunting respirations and a moist cough. R29 did not eat well again, took only a few bites, and left the table with a slow and slightly unsteady gait. On 04/04/23 at 08:17 AM observation revealed R29 sat in the dining room, with a breakfast plate in front of him. R29 had obvious respiratory difficulties as evidenced by growling/grunting respirations, cough, and nasal congestion. On 04/05/23 at 10:30 AM, Administrative Nurse D stated R29's elevated blood pressures should have been called/reported the physician. Administrative Nurse D verified the care plan lacked a hypertension problem with goals and interventions. The facility's Care Plan policy, dated 11/28/17, documented a care plan will be developed for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs and are consistent with the resident's desires and preferences. The comprehensive care plan will be developed after completion of the MDS and CAA s with the input from the care planning team, the resident and the resident's family and/or representative. The facility failed to develop a comprehensive care plan related to elevated blood pressure and treatment of antihypertensive medication which placed the resident at risk for complications related to uncommunicated or unmet care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R2's Electronic Medical Record (EMR) recorded diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), mild intellectual disabilities (a diverse group of severe, chronic conditions due to mental and/or physical impairment. Individuals with developmental disabilities have problems with major life activities such as language, mobility, learning, self-help and independent living), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and chronic kidney disease. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R2 had severe cognitive impairment, rejected evaluation or care behavior which occurred one to three days during the look back period and behaviors worsened. R2 felt it was somewhat important to choose between a tub bath, shower, bed bath, or sponge bath. The MDS further documented R2 required extensive to total assistance of one to two staff for activities of daily living and bathing. Received hospice care. The Activity of Living Care Area Assessment (CAA), dated 03/17/23, documented R2's baseline for activities of daily living, and staff to help anticipate needs such as hygiene and toileting. The CAA further documented there was no anticipation on improvement and R2 had recently admitted on hospice services. The Activity of Daily Living Care Plan, dated 03/23/23, documented R2 needed extensive assistance with bathing, preferred showers to be offered twice a week during the day on Thursday and Sunday. R2 often refused bathing and needed kind reminders of the importance of bathing. The care plan further directed staff if R2 refused a shower to offer her a bed bath. The care plan also included R2 facial hair tended to grow quickly and thick and should be shaved daily. Bathing Task record review revealed bathing provided to R2 on: 01/06/23 01/15/23 (8 days) 02/03/23 (18 days) 02/26/23 (22 days) 03/04/23 (5 days provided by hospice staff) 03/20/23 (15 days provided by hospice staff) 03/23/23 03/24/23 (provided by hospice staff) 03/30/23 (5 days) 04/03/23 (provided by hospice staff) The facility was unable to provide evidence of refusal sheets. On 04/03/23 at 07:52 AM observation revealed R2 sat in the dining room in a wheelchair. R2's hair was unclean and she had thick; dark-colored facial hair around her mouth and down under her chin. On 04/03/23 at 10:21 AM observation revealed R2 in her room with a hospice aide getting ready to bath the resident. On 04/03/23 at 11:48 AM R2 was brought to the dining room by facility staff. R2 no longer had dark facial hair. R2 had damp hair and requested a blanket due to being cold with damp hair. Staff provided R2 with a blanket. On 04/04/23 at 09:10 AM CNA Q reported the CNAs checked at the beginning of their shift who was scheduled for baths that day. CNA Q reported if a resident refused a bath the CNA's were to ask the resident twice, then fill out a refusal sheet and gave it to the nurses, and the nurses were to document in the resident's chart why the resident refused. 04/04/23 03:00 PM Administrative Nurse D stated the bathing should be completed as the resident's preference, if the resident refuses the staff are to be approaching the resident another time and then the charge nurse is to fill out a refusal form, she has instructed staff to bring the refusal forms to her Monday thru Friday so she may address what the issue is with bath refusals. The facility failed to ensure R2 had baths per resident preference. This placed R2 at risk for complications related to poor hygiene. The facility had a census of 40 residents. The sample included 14 residents, with nine reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for four sampled residents, Resident (R)17, R38, and R2. This placed the residents at risk for complications related to poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R17 documented diagnoses of hypertension (high blood pressure), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition and required limited assistance of one staff for personal hygiene, bed mobility, transfers, and supervision with one staff for locomotion. The MDS further documented R17 required extensive assistance for bathing. The ADL Care Plan, dated 02/16/23, documented R17 preferred to bathe twice per week, was scheduled for Wednesday and Saturday evening, preferred to use the shower chair for bathing, and required partial assistance with bathing tasks. The care plan further documented R17 needed assistance to wash her legs, back, and perineal area. The February and March 2023 Bathing Report, documented R17 was scheduled for Wednesday and Saturday, and documented R17 had not received a bath or shower during the following days: 02/01/23 - 02/17/23 (17 days) 02/19/23 - 03/06/23 (16 days) 03/08/23 - 03/26/23 (19 days) The EMR documented R17 refused a bath or shower on 03/11/23, 03/22/23, and 03/25/23. On 04/03/23/ at 07:35 AM, observation revealed R17 sat on the edge of her bed. Her hair was greasy and disheveled. On 04/04/23 at 01:30 PM, observation revealed R17 with greasy, disheveled hair; her sweatshirt had dried stains on it. On 04/05/23 at 12:15 PM, observation revealed R17 with greasy, disheveled hair. On 04/04/23 at 09:10 AM, Certified Nurse Aide (CNA) Q stated at the beginning of the shift, staff checked the computer to see which residents were scheduled for bathing. CNA Q stated if the resident refused, the aides asked the resident twice and if the resident continued to refuse, the aides gave a refusal sheet for the nurse to document on and document the refusal. On 04/04/23 at 12:02 PM, Licensed Nurse (LN) H stated R17 did refuse her baths and staff were to have the resident sign a refusal sheet. On 04/05/23 at 12:00 PM, Administrative Nurse D stated staff asked the residents if they want their bath or shower and if the residents refused, staff filled out a refusal sheet. The facility's Bath and Shower policy, dated 11/28/17, documented the facility ensures the residents' baths and showers are performed and documented as scheduled according to resident preference to maintain each resident's hygiene and dignity. The charge nurse was to add the resident's name to the bath/shower schedule on the day's resident prefers, indicating the resident's preference of a shower or bath and on the shift that accommodates the time the resident prefers. The person that gives the resident his/her bath is to document the date, day of the week, type of bath and/or hair care given, and signature on the touchscreen which ensures documentation is included in the resident's electronic medical record. The Director of Nursing or designated personnel would review the Bathing Report to ensure each resident was receiving bath/showers and hair care as required. The facility failed to provide R17 consistent bathing services as care planned, placing her at risk for complications related to poor hygiene. - The Electronic Medical Record (EMR) for R38 documented diagnoses of delusional disorder (a type of mental health condition which a person cannot tell what is real from imagined), depression (a mental disorder characterized by persistently depressed mood or loss of interest in activities), and hypertension (high blood pressure). The 5-day Medicare Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting and limited assistance of one staff for personal hygiene. The MDS further documented R38 required extensive assistance of one staff for bathing. R38's Quarterly MDS, dated 03/09/23, documented R38 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting and limited assistance of one staff for personal hygiene. The MDS further documented R38 required extensive assistance of one staff for bathing. The ADL Care Plan, dated 03/23/23, documented, R38 liked to bathe two to three times a week on Monday, Wednesday, and Friday in the evening. R38 preferred to use the shower chair for bathing and required partial assistance with bathing tasks. The care plans further documented R38 needed assistance to wash her legs, back, and perineal area. The January 2023 Bathing Record documented R38 was scheduled for Monday, Wednesday, and Friday, and documented R38 had not received a bath or shower during the following days: 01/14 - 01/29 (16 days) The February and March 2023 Bathing Record documented R38 was scheduled for Monday, Wednesday, and Friday, documented R38 had not received a bath or shower during the following days: 02/01/23 - 02/24/23 (24 days) 02/28/23 - 03/07/23 (8 days) 03/09/23 - 03/19/23 (11 days) 03/23/23 - 03/31/23 (9 days) The EMR documented R38 refused a shower on 02/24/23 and 03/10/23. On 04/03/23 at 9:30 AM, observation revealed R38 sat at the dining table. Her hair was messy, and appeared greasy. On 04/04/23 at 08:00 AM, observation revealed R38's hair remained disheveled and greasy. On 04/04/23 at 09:10 AM, Certified Nurse Aide (CNA) Q stated at the beginning of the shift, staff checked the computer to see which residents were scheduled for bathing. CNA Q stated if the resident refused, the aides asked the resident twice and if the resident continued to refuse, the aides gave a refusal sheet for the nurse to document on and document the refusal. On 04/04/23 at 12:02 PM, Licensed Nurse (LN) H stated R38 did refuse her baths and staff were to have the resident sign a refusal sheet. On 04/05/23 at 12:00 PM, Administrative Nurse D stated staff asked the residents if they want their bath or shower and if the residents refused, staff filled out a refusal sheet.The facility's Bath and Shower policy, dated 11/28/17, documented the facility ensures the residents' baths and showers are performed and documented as scheduled according to resident preference to maintain each resident's hygiene and dignity. The charge nurse was to add the resident's name to the bath/shower schedule on the day's resident prefers, indicating the resident's preference of a shower or bath and on the shift that accommodates the time the resident prefers. The person that gives the resident his/her bath is to document the date, day of the week, type of bath and/or hair care given, and signature on the touchscreen which ensures documentation is included in the resident's electronic medical record. The Director of Nursing or designated personnel would review the Bathing Report to ensure each resident was receiving bath/showers and hair care as required. The facility failed to provide R38 consistent bathing services as care planned, placing her at risk for complications related to poor hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 40 residents. The sample included 14 residents with one resident reviewed for quality of care. Based on observation, interview, and record review, the facility failed to ensure staff provided assessment, ongoing monitoring, and physician involvement for Resident (R)29 who had elevated blood pressures out of physician ordered parameters and failed to identify the potential signs and symptoms of respiratory virus and provide appropriate follow up and screening. As a result, R29 was sent emergently to the acute hospital in distress, with a low oxygen saturation. This placed R29 at increased risk for physical complications, adverse outcomes, and delayed treatment. Findings included: - R29's Electronic Medical Record (EMR) recorded diagnoses of degenerative (progressively worsening) disease of nervous system, essential hypertension (elevated blood pressure), memory deficit following cerebral infarction (stroke), personal history of COVID-19 (a very contagious respiratory virus capable of progressing to severe symptoms and in some cases death), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), morbid obesity, adult obstructive sleep apnea (absence of breathing), and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had intact cognition, was independent with set up assistance for activities of daily living (ADL). R29 was continent of urine and bowel and was steady at all times with transitions and walking. R29 received an antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions) routinely. The Continuous Positive Airway Pressure [CPAP -respiratory therapy in which air is pumped into the lungs through the nose and mouth]/Oxygen Care Plan initiated on 05/11/22, documented R29 would keep oxygen saturation level above 90 percent (%), and directed staff to check oxygen saturation levels according to the doctor's orders or anytime R29 became short of breath or complained of feeling as if he could not catch his breath. R29's EMR included Special Instruction on admission which directed staff to notify the physician if systolic blood pressure (SBP-maximum blood pressure during a contraction of the heart) of greater that 160 or less than 90, the diastolic blood pressure (DBP-measurement during pause before next heartbeat) greater than 100 or less than 60, resting pulse greater than 100 or less than 50, respirations greater than 28 or less than 10, and oxygen saturation less than 90%. The Physician Order Sheet (POS), dated 03/08/23, directed staff to administer: Diovan (medication used to treat high blood pressure and heart failure) 320 milligrams (mg) by mouth one time a day for hypertension. Norvasc (medication used to treat high blood pressure and chest pain) 10 mg by mouth daily at bedtime. Zebeta (medication used to treat high blood pressure) 10 mg by one time a day for hypertension; hold the medication and contact the physician for pulse less than 50. Review of the March 2023 EMR revealed the following blood pressure results above physician ordered parameters: 03/06/23 blood pressure of 162/95 millimeters (mm) of Mercury (Hg) 03/20/23 blood pressure of 179/95 mmHg 03/21/23 blood pressure of 179/90 mm/Hg 03/22/23 blood pressure of 160/109 mm/Hg 03/23/23 blood pressure of 191/100 mm/Hg 03/27/23 blood pressure of 175/96 mm/Hg 03/29/23 blood pressure of 165/105 mm/Hg Review of the April 2023 EMR revealed the following blood pressure results above physician ordered parameters: 04/01/23 blood pressure of 167/90 mm/Hg 04/03/23 blood pressure of 215/136 mm/Hg The Progress Note dated 04/04/23 at 10:05 AM recorded R29 had shortness of breath and grunting respirations. R29 reported he felt poorly, had trouble breathing, and was having problems catching his breath. R29 had a blood pressure reading of 151/96 mm/Hg, oxygen saturation of 68%, a temperature of 98.0 Fahrenheit (F) and a pulse of 68. Staff called the physician and reported the vital signs, and the facility received a call back from the physician's office to send R29 to the hospital immediately per emergency medical services (EMS). R29's EMR lacked evidence staff obtained an order and applied supplemental oxygen for R29's low oxygen saturation level of 68%. On 04/03/23 at 08:15 AM observation revealed R29 walked through the dining room, slowly, with deep growling/grunting respirations and a moist cough. R29 ate only cereal for breakfast. On 04/03/23 at 12:30 PM observation revealed R29 walked through the dining room with a slower gait and continued with growling/grunting respirations and a moist cough. R29 did not eat well again, took only a few bites, and left the table with a slow and slightly unsteady gait. On 04/04/23 at 08:17 AM observation revealed R29 sat in the dining room, with a breakfast plate in front of him. R29 had obvious respiratory difficulties as evidenced by growling/grunting respirations, cough, and nasal congestion. On 04/04/23 at 08:19 AM Licensed Nurse (LN) H stated that R29's blood pressure sometimes ran high, and she had not notified the physician of the out of parameter readings. LN H reported R29 had been tested for COVID-19 and result had been negative but did not know date of last test. On 04/04/23 at 04:08 PM, Administrative Nurse D reported R29 admitted to the hospital, and was positive for COVID 19. Administrative Nurse D reported facility staff initiated COVID-19 testing for all the residents. On 04/05/23 at 08:19 AM, LN I reported there were no positive COVID-19 residents. LN I confirmed R29 was admitted to the hospital and was treated for COVID-19. On 04/05/23 at 10:30 AM, Administrative Nurse D stated R29's elevated blood pressures should have been reported to the physician, and verified the record lack physician notifications. Administrative Nurse D stated the medical record also lacked documentation of oxygen administration when the resident had respiratory distress and had an oxygen saturation of 68%. Administrative Nurse D stated oxygen should have been administered. The facility's Clinician Notification policy, dated 11/28/17, documented that notification of physicians and other clinicians will be done on a timely basis. The resident's physician and/or other pertinent clinicians will be notified of a significant change in the resident's physical, mental, or psychosocial status (that is deterioration in health mental or psychosocial status in either life-threatening conditions or clinical complications). A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Decision making regarding notification parameters for clinical signs and symptoms will be based on physician orders and physician specific parameters and Interact Acute Change in Condition File Cards and Care Plans. The facility failed to ensure staff provided assessment, ongoing monitoring and physician involvement for R29 who had significantly high blood pressure, which were out of parameters set forth by the facility, lacked documentation of continued elevated blood pressures and assessment of R29's respiratory distress as evident by grunting/growling, moist cough until survey team member inquired on R29's condition. This placed R29 at increased risk for physical complication, adverse outcomes, and delayed treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 40 residents. The sample included 14 residents with two residents sampled for bowel and bladder and catheter (tube inserted into the bladder to drain urine). Based on observation, interview, and record review, the facility failed to provide assistance with Resident (R)20 for toileting and incontinence care, and failed to ensure R33, who had a history of urinary tract infection (UTI) received proper catheter cleansing technique. These deficient practices placed R20 and R33 at risk of complications and increased infections. Finding included: - R20's Electronic Medical Record (EMR), recorded diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), low back pain, overactive bladder, chronic kidney disease, peripheral vascular disease (abnormal condition affecting the blood vessels) and behavioral disturbance. The Quarterly Minimum Data Sheet (MDS), dated [DATE], documented R20 had moderately impaired cognition, required limited assistance of one person for activities of daily living, and physical help of one staff for bathing. R20 had occasional incontinence of urine and bowel, was not steady but able to stabilize without staff assistance. The Urinary Incontinence Care Area Assessment, dated 09/26/22, documented R20 was occasionally incontinent of urine per voiding diary, required limited assistance with toileting and toileting hygiene, and wore incontinent products to help clothing and promote dignity. R20 had been open toilet with cueing and the facility planned for incontinence with the start of toileting program of cueing to toilet at 06:00 AM, after meals, midafternoon and at bedtime to help promote continence. The Bowel and Bladder Care Plan dated 01/23/23, documented R20 was usually continent of bowels and occasionally incontinent of bladder; R20 could perform toileting with partial assistance and cueing. The care plan directed staff R20 required wore incontinence product to protect clothing and promote dignity. The care plan directed staff to cue R20 to the bathroom within an hour of 06:00 AM, after meals, prior and after dinner, before going to bed, and as needed episodes. The Progress Note, dated 03/22/23 at 04:16 PM, documented R20 had not walked to the dining room for meals. R20 sat in her walker/wheelchair at the opening to her room and yelled for help. R20 reported she could not walk, but with staff encouragement she did walk to the dining room. On 04/03/23 at 08:03 AM observation revealed R20 walked into the dining room escorted by a Certified Medication Aide (CMA) R. R20's pants, on her buttocks area, were visibly wet. R20's pants sagged with wetness/weight of an incontinent brief. Survey team member brought the wet pants to CMA R's attention. CMA R instructed the hospitality aide to take R20 to the bathroom. The hospitality aide informed CMA R she could not take R20. Licensed Nurse (LN) H identified the R20 to the surveyor, and the survey told LN H R20 pants were wet, LN H looked at R20's pants and did not direct staff to provide assistance with the incontinence. Staff then sat R20 in a dining room chair for breakfast. R20 had uncombed oily hair. On 04/03/23 at 12:11 PM observation revealed staff pushed R20 while she sat on the seat of her walker. R20 had uncombed, oily hair. Staff encouraged and assisted R20 into a dining chair with a gait belt. As R20 stood, a round, wet circle was visible on the back of her pants and her incontinent product sagged between her legs. Staff proceded to sit R20 in the chair to eat her breakfast. On 04/03/23 at 01:06 PM observation revealed R20 made it to her room, from the dining room, and called for help as staff were bringing other residents to their rooms. Staff inquired what R20 needed and R20 told them she wanted to go upstairs. Staff then assisted R20 back to the dining room in her walker chair and placed her in front of her plate. On 04/03/23 at 01:29 PM Administrative Nurse D assisted R20 to stand and R20 continued to have a wet spot on the back of her pants. Staff assisted R20 to her room in a wheelchair. Staff assisted R20 to her recliner. Surveyor alerted staff she had wet pants and a filled, sagging, staff looked at each other and asked each other if they saw the wetness. Staff then assisted resident to the bathroom and assisted to change R20's pants and brief, before returning R20's recliner. On 04/03/23 at 01:32 PM Certified Nurse Aide (CNA) O stated R20 had a toileting routine. The routine was to toilet R20 when she got up in the morning, after breakfast, before lunch, the middle of the afternoon, then R20 would sleep until supper time. CNA O was unsure of the toileting schedule for the other shifts. On 04/03/23 at 01:29 PM CMA S stated R20 took usually toileted independently. CMA S stated R20 usually wore pullup undergarments. CMA S stated she was unsure when R20 had changed incontinent undergarment to tabbed briefs from pull ups. On 04/04/23 at 03:00 PM, Administrative Nurse D stated R20 should be assisted with her toileting needs. She verified R20 should not have wet clothing in public spaces and should have clean and combed hair, for the resident's dignity. Administrative Nurse D stated she expected the staff to provide ADL cares including combing hair and other grooming needs and she also expected staff to provide bathing for all resident as directed by their care plan and preferences. The facility's Activities of Daily Living policy, dated 04/27/18, documented residents will be given the appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living. The facility will provide care and services based on the comprehensive assessment of the resident and consistent with his/her needs or choices for the following activities of daily living. Residents who are unable to carry out activities of daily living and are dependent on staff will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility failed to provide R20 with assistance with her toileting and urine incontinence which placed the resident at risk for skin damage, infection and dignity concerns. - The Electronic Medical Record for R33 documented diagnoses of type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), hyperlipidemia (condition of elevated blood lipid levels), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), urinary retention (a lack of ability to urinate and empty the bladder). R33's admission Minimum Data Set (MDS), dated [DATE], documented R33 had intact cognition and required extensive assistance of one staff for transfers, dressing, toileting, and personal hygiene. The MDS further documented R33 required the use of an indwelling Foley catheter (tube used for draining urine from the bladder and having an inflatable part at the bladder end that allows the tube to be kept in place for variable time periods), was always incontinent of bowel, and had a urinary tract infection (an infection in any part of the urinary system) in the last 30 days. The Quarterly MDS, dated 03/02/23, documented R33 had intact cognition and required extensive assistance of two staff for transfers, toileting, and extensive assistance of one staff for bed mobility. The MDS further documented R33 had an indwelling Foley catheter and was frequently incontinent of bowel. The Urinary Cather Care Plan, dated 03/16/23, initiated on 2/13/22, directed staff to ensure catheter care was performed every shift and as needed, if staff notice R33's urine turning darker in color, encourage good fluid intake. The plan directed if she was experiencing burning, cloudy or foul odor from the urine, let her physician know right away, and replace her catheter as ordered by the physician. Monitor urine output each shift, if staff notice a low urine output, sediment in her urine, abnormal urine color, notify the physician. The update dated 03/16/23 further directed staff to apply a urinary catheter leg drainage bag to her catheter when she was out of her bed or up ambulating. The Physician Order, dated 11/15/22, directed staff to administer cranberry plus probiotic (promotes a healthy urinary tract), one tablet, by mouth, in the morning, for a supplement. The Physician Order, dated 12/02/22, directed staff to insert a 16 French x 30 (cc) cubic centimeters Foley catheter monthly and document urine output every shift for the diagnosis of urinary retention. The Physician Order, dated 01/14/23, directed staff to administer Macrobid (an antibiotic to treat and prevent urinary tract infections), 100 milligrams (mg), by mouth, twice a day, for 10 days for a diagnosis of urinary tract infections (uti). The Nurse's Note, dated 01/13/23 at 07:44 AM, documented R33's catheter was patent and draining, urine was clear and noted sediment, yellow in color. The Nurse's Note, dated 01/13/23 at 11:49 AM, documented staff collected a urinalysis (examination of urine) from R33. The Urinalysis Report, dated 01/13/23, documented R33 had increased protein, and blood in her urine. On 04/04/23 at 08:15 AM, observation revealed R33 laid in bed. Certified Nurse Aide (CNA) O and CNA P applied gloves and pulled down the resident's incontinence brief and pants. CNA O took R33's catheter bag, still full of urine, and guided the bag up the inside of the right pant leg and out the top of R33's pants. Further observation revealed CNA O and CNA P stood there as R33 was exposed from the waist down and discussed who would complete the catheter care and who would drain the catheter bag. Continued observation revealed CNA P took an incontinence wipe, performed incontinence care, and ran out of wipes before she could do catheter care. CNA P opened R33's nightstand drawer with soiled hands and was unable to find gloves. CNA O looked for more incontinence wipes in R33's dresser drawer and stated Well, I guess we need to stock these rooms and took R33's roommates' s incontinence wipes. Observation revealed R33 continued to be exposed from the waist down as the CNAs looked for incontinence wipes. CNA P took an incontinence wipe and wiped around the catheter tubing at the insertion site but did not cleanse the catheter tubing. With the same soiled gloves, CNA P and CNA O pulled up R33's incontinence brief and pants. Further observation revealed CNA O sat a container on the floor to drain the catheter bag, and spilled urine on the floor. CNA O stated, how did it get spilled onto the floor? CNA O failed to cleanse the port of the catheter tubing before clamping the tubing, took the catheter bag and down the top of R33's pants, down the inside of the right pant leg and held onto it as he assisted R33 into her recliner and asked her where she wanted him to place the catheter bag. R33 instructed CNA O to put the catheter bag in the dignity bag and lay it on top on her trash can. On 04/04/23 at 12:20 PM, CNA P stated she knew she had not changed her gloves after incontinence care because she forgot and verified they had not covered R33 up when looking for extra gloves. On 04/05/23 at 11:56 AM, Administrative Nurse D stated staff should not leave residents exposed if they are not providing cares. Administrative Nurse D said the CNA should have removed her soiled gloves before touching other surfaces or the resident. The facility, Urinary Catheter Care undated competency checklist, directed staff to with a clean cloth between the thumb and forefinger of the dominant hand, clean the catheter at point of insertion into urethra using a pen roll to cleanse the entire circumference of the catheter. With the non-dominant hand, hold the catheter in place as the dominant hand cleanses the extension of the catheter tubing. Fold the cloth and repeat cleansing at least twice, continuing if any soilage observed after second wipe. The facility failed to provide appropriate catheter care for R33, who had a history of UTIs. This placed the resident at risk for infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to replace Resident (R) 4's bilevel positive airway pressure (BiPaP -a machine that normalizes breathing by delivering pressurized air) mask, placing R4 at risk for respiratory infection. Findings included: - The Electronic Medical Record (EMR) for R4 documented diagnosis of chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dependence on other enabling machines and devices, dependence on supplemental oxygen, and obstructive sleep apnea (intermittent airflow blockage during sleep). R4's Annual Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition and required extensive assistance of one staff for bed mobility, dressing, toileting, and personal hygiene. The MDS further documented R4 received oxygen and required non-invasive mechanical ventilator. R4's BiPaP/Oxygen Care Plan, dated 02/23/23, documented R4 has a pulmonologist (a doctor who specialized diagnosing and treating diseases of the lungs) for the management of her BiPaP and oxygen, administer breathing treatments as ordered, check R4's oxygen saturation (a measure of how much oxygen the blood carried as a percentage of the maximum it could carry) according to the physician orders. The Physician Order, dated 06/20/19, documented R4 chose to wear her BiPaP at all times. it directed to check skin integrity under the mask every shift and ensure proper fit every shift. The Physician Order, dated 08/23/20, directed staff to change the BiPaP tubing weekly on Sundays. The order was discontinued on 09/13/20. The Treatment Administration Record for March 2023 lacked documentation to direct staff when to change or clean R4's BiPaP mask or tubing. On 04/02/23 at 08:55 AM, observation revealed R4 was in her room in bed with a visibly soiled BiPaP mask on her face. The bottom straps for the mask were also visibly soiled. On 04/04/23 at 12:12 PM, observation revealed R4 was in her room in bed with the visibly soiled BiPaP mask as well as the bottom straps to the mask, on her face. On 04/04/23 at 01:15 PM, R4 stated the mask should be changed every three months and should have a date on the mask. R4 stated she did not remember when staff had changed it last. On 04/04/23 at 01:25 PM, Licensed Nurse (LN) H stated staff change R4's mask monthly but was unsure where they documented that information. LN H stated the mask can be changed at any time for a new mask. On 04/0/23 at 03:00 PM, Administrative Nurse D stated the mask was changed every three months due to cost Administrative Nurse D stated R4 cannot get a new mask whenever she needs it but staff can take the mask off and clean it when needed. Administrative Nurse D further stated she was unaware there was not documentation of when to change and clean the mask and tubing. The facility's CPAP and BiPaP Use policy, dated 11/28/17, directed staff to check the seal of the mask to the face to ensure no air leaked, if so adjust the mask or remove and reseal. The policy further documented, clean the mask seal with soap and water, empty and clean the humidifier weekly with soap and water. The facility failed to ensure R4's BiPaP mask and tubing had been changed or cleaned, placing the resident at risk for infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to ensure the nurse possessed the skills and knowledge necessary to recognize and act upon Resident (R) 29's respiratory distress and elevated blood pressure. This placed R29 at risk for delayed treatment of medical concerns. Findings included: - R29's Electronic Medical Record (EMR) recorded diagnoses of degenerative (progressively worsening) disease of nervous system, essential hypertension (elevated blood pressure), memory deficit following cerebral infarction (stroke), personal history of COVID-19 (a very contagious respiratory virus capable of progressing to severe symptoms and in some cases death), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), morbid obesity, adult obstructive sleep apnea (absence of breathing), and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had intact cognition, was independent with set up assistance for activities of daily living (ADL). R29 was continent of urine and bowel and was steady at all times with transitions and walking. R29 received an antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions) routinely. The Continuous Positive Airway Pressure [CPAP -respiratory therapy in which air is pumped into the lungs through the nose and mouth]/Oxygen Care Plan initiated on 05/11/22, documented R29 would keep oxygen saturation level above 90 percent (%), and directed staff to check oxygen saturation levels according to the doctor's orders or anytime R29 became short of breath or complained of feeling as if he could not catch his breath. R29's EMR included Special Instruction on admission which directed staff to notify the physician if systolic blood pressure (SBP-maximum blood pressure during a contraction of the heart) of greater that 160 or less than 90, the diastolic blood pressure (DBP-measurement during pause before next heartbeat) greater than 100 or less than 60, resting pulse greater than 100 or less than 50, respirations greater than 28 or less than 10, and oxygen saturation less than 90%. The Physician Order Sheet (POS), dated 03/08/23, directed staff to administer: Diovan (medication used to treat high blood pressure and heart failure) 320 milligrams (mg) by mouth one time a day for hypertension. Norvasc (medication used to treat high blood pressure and chest pain) 10 mg by mouth daily at bedtime. Zebeta (medication used to treat high blood pressure) 10 mg by one time a day for hypertension; hold the medication and contact the physician for pulse less than 50. Review of the March 2023 EMR revealed the following blood pressure results above physician ordered parameters: 03/06/23 blood pressure of 162/95 millimeters (mm) of Mercury (Hg) 03/20/23 blood pressure of 179/95 mmHg 03/21/23 blood pressure of 179/90 mm/Hg 03/22/23 blood pressure of 160/109 mm/Hg 03/23/23 blood pressure of 191/100 mm/Hg 03/27/23 blood pressure of 175/96 mm/Hg 03/29/23 blood pressure of 165/105 mm/Hg Review of the April 2023 EMR revealed the following blood pressure results above physician ordered parameters: 04/01/23 blood pressure of 167/90 mm/Hg 04/03/23 blood pressure of 215/136 mm/Hg The Progress Note dated 04/04/23 at 10:05 AM recorded R29 had shortness of breath and grunting respirations. R29 reported he felt poorly, had trouble breathing, and was having problems catching his breath. R29 had a blood pressure reading of 151/96 mm/Hg, oxygen saturation of 68%, a temperature of 98.0 Fahrenheit (F) and a pulse of 68. Staff called the physician and reported the vital signs, and the facility received a call back from the physician's office to send R29 to the hospital immediately per emergency medical services (EMS). R29's EMR lacked evidence staff obtained an order and applied supplemental oxygen for R29's low oxygen saturation level of 68%. On 04/03/23 at 08:15 AM observation revealed R29 walked through the dining room, slowly, with deep growling/grunting respirations and a moist cough. R29 ate only cereal for breakfast. On 04/03/23 at 12:30 PM observation revealed R29 walked through the dining room with a slower gait and continued with growling/grunting respirations and a moist cough. R29 did not eat well again, took only a few bites, and left the table with a slow and slightly unsteady gait. On 04/04/23 at 08:17 AM observation revealed R29 sat in the dining room, with a breakfast plate in front of him. R29 had obvious respiratory difficulties as evidenced by growling/grunting respirations, cough, and nasal congestion. On 04/04/23 at 08:19 AM Licensed Nurse (LN) H stated that R29's blood pressure sometimes ran high, and she had not notified the physician of the out of parameter readings. LN H reported R29 had been tested for COVID-19 and result had been negative but did not know date of last test. On 04/04/23 at 04:08 PM, Administrative Nurse D reported R29 admitted to the hospital, and was positive for COVID 19. Administrative Nurse D reported facility staff initiated COVID-19 testing for all the residents. On 04/05/23 at 08:19 AM, LN I reported there were no positive COVID-19 residents. LN I confirmed R29 was admitted to the hospital and was treated for COVID-19. On 04/05/23 at 10:30 AM, Administrative Nurse D stated R29's elevated blood pressures should have been reported to the physician, and verified the record lack physician notifications. Administrative Nurse D stated the medical record also lacked documentation of oxygen administration when the resident had respiratory distress and had an oxygen saturation of 68%. Administrative Nurse D stated oxygen should have been administered. The facility's Competencies policy, dated 11/28/17, documented competency validation will be completed for all nurses and nurse aides prior to independent care assignments for newly hired staff and annually thereafter. The follow-up for noncompliance with completion was the responsibility of the department head for the employee or the administrator. The facility failed to ensure staff possessed the appropriate skilsl and knowledge necessary in order to provide assessment, ongoing monitoring, and physician involvement for R29 who had significantly high blood pressure, which were out of parameter set forth by the facility, and failure to identify R29's respiratory distress which placed R29 at increased risk for physical complication, adverse outcomes, and delayed treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 40 residents. The sample included 14 residents, with six reviewed for behaviors. Based on observation, record review, and interview the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for one sampled resident, Resident (R) 4, who had behaviors of refusing showers and personal hygiene assistance. This placed the resident at risk for poor hygiene, infection and increased behaviors. Findings included: - The Electronic Medical Record (EMR) for R4 recorded diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition and was dependent upon two staff for bathing and required extensive assistance of one staff for bed mobility, dressing, toileting, and personal hygiene. The MDS further documented R4 did not have any behaviors, and had no skin issues. The Annual MDS, dated 02/03/23, documented R4 had intact cognition and required extensive assistance of one staff for transfers, dressing, toileting, personal hygiene, and bathing. The MDS further documented R4 did not have any behaviors, had moisture associated skin damage, and received ointment other than to her feet. The Anxiety Care Plan, dated 03/13/23, initiated on 06/14/19, directed staff to conduct 1:1 visits with R4 as needed to help identify specific thoughts/ideas that cause anxiety or depression. The plan directed staff to encourage R4 to get out of bed more and get involved with activities and reassure R4 during periods of distress/anxiousness. The Activities of Daily Living (ADLs) Care Plan, dated 03/13/23, initiated on 06/14/19, documented R4 liked her hair in a braid and required staff assistance after every shower she took. The plan directed staff to encourage R4 to reposition in bed to allow air to flow freely to her backside decreasing the risk for moisture damage; help R4 keep her fingernails and toenails short. The plan directed to offer R4 a whirlpool or shower first before giving her a bed bath; R4 preferred to take a bed bath due to her anxiety of going into the shower room. The update, dated 08/20/19, documented R4 preferred to bathe around 10:00 AM on Monday, Wednesday, and Friday and would often refuse. The care plan documented R4 had been educated on the importance of proper bathing, however, continue to educate and encourage if she refused. The January 2023 Bathing Report documented R4 refused a bath, shower, or bed bath 12 times with education provided to the resident. The February 2023 Bathing Report, documented R4 refused a bath, shower, or bed bath 9 times with education provided to the resident. The March 2023 Bathing Report, documented R4 refused a bath, shower, or bed bath 11 times with education provided to the resident. The Physician Order, dated 02/07/23, directed Social Service and Nursing staff to assess strategies for a bathing routine as R4 told the physician she thinks she refused her baths while she was asleep and would like bath refusals in writing signed by R4. The Nurse's Note, dated 03/20/23 at 12:51 PM, documented R4 refused her bath due to being anxious and sick to her stomach. The note further documented R4 was offered medication to help with her nausea, R4 refused and stated she does not ever want a bath. Staff reeducated R4 on skin care and hygiene, with the risk of infections, and R4 stated she did not care if she got any infection or sores and did not want to be out of her bed for any reason. The noted documented R4 was offered a bed bath and she refused. The Nurse's Note, dated 03/22/23 at 11:10 AM, documented R4 flatly refused to take a shower and stated she was afraid she would fall. The note further documented R4 was told that people normally perspire, get sweaty, develop body odor and yeast when they don't shower. R4 stated she doesn't care and refused to bathe at all. On 04/02/23 at 08:55 AM, observation revealed R4, in bed. Her hair was braided, but was greasy and disheveled. Further observation revealed R4's toenails were long, some were grown above the tip of her toes. On 04/04/23 at 09:10 AM, Certified Nurse Aide (CNA) Q stated at the beginning of the shift, staff checked the computer to see which residents were scheduled for bathing. CNA Q stated if the resident refused, the aides asked the resident twice and if the resident continued to refuse, the aides gave a refusal sheet for the nurse to document on and document the refusal. On 04/04/23 at 01:25 PM, Licensed Nurse H stated R4 refused her baths for months; staff educated her and it does not make a difference. On 04/04/23 at 03:00 PM, Administrative Nurse D stated they have tried and tried to get R4 to take a bath, shower, or bed bath and stated R4 refused to sign the refusal sheets. Administrative Nurse D further stated, they try different staff to encourage her and it works a couple times, then she will refuse. Administrative Nurse D stated she did sit down hard on the shower chair, but that was a couple years ago and she still won't go to the shower. R4 used to have an anxiety pill they would give her prior to her shower but she would refuse to take it and she no longer has it. Administrative Nurse D stated Social Service staff should be involved with her and should talk with her about her anxiety and did not know if there was documentation of the resident refusing behavioral health care services or if it was offered. The facility's Behavioral Health policy, dated 11/28/17, documented, residents would receive the necessary behavioral health care and services to attain or maintain the highest practicable physicial, mental, and psychosocial well-being. The policy further documented the facility would ensure the services were person-centered and reflect the resident's goals for care while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. The facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being for R4 who refused bathing and hygiene related to her behavioral health needs and concerns. This placed the resident at risk for poor hygiene, infection and increased behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one sampled resident, Resident (R) 4, who had behaviors of refusing showers and personal hygiene assistance. This placed the residnet at risk for impaired quality of life. Findings included: - The Electronic Medical Record (EMR) for R4 recorded diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition and was dependent upon two staff for bathing and required extensive assistance of one staff for bed mobility, dressing, toileting, and personal hygiene. The MDS further documented R4 did not have any behaviors, and had no skin issues. The Annual MDS, dated 02/03/23, documented R4 had intact cognition and required extensive assistance of one staff for transfers, dressing, toileting, personal hygiene, and bathing. The MDS further documented R4 did not have any behaviors, had moisture associated skin damage, and received ointment other than to her feet. The Anxiety Care Plan, dated 03/13/23, initiated on 06/14/19, directed staff to conduct 1:1 visits with R4 as needed to help identify specific thoughts/ideas that cause anxiety or depression. The plan directed staff to encourage R4 to get out of bed more and get involved with activities and reassure R4 during periods of distress/anxiousness. The Activities of Daily Living (ADLs) Care Plan, dated 03/13/23, initiated on 06/14/19, documented R4 liked her hair in a braid and required staff assistance after every shower she took. The plan directed staff to encourage R4 to reposition in bed to allow air to flow freely to her backside decreasing the risk for moisture damage; help R4 keep her fingernails and toenails short. The plan directed to offer R4 a whirlpool or shower first before giving her a bed bath; R4 preferred to take a bed bath due to her anxiety of going into the shower room. The update, dated 08/20/19, documented R4 preferred to bathe around 10:00 AM on Monday, Wednesday, and Friday and would often refuse. The care plan documented R4 had been educated on the importance of proper bathing, however, continue to educate and encourage if she refused. The January 2023 Bathing Report documented R4 refused a bath, shower, or bed bath 12 times with education provided to the resident. The February 2023 Bathing Report, documented R4 refused a bath, shower, or bed bath 9 times with education provided to the resident. The March 2023 Bathing Report, documented R4 refused a bath, shower, or bed bath 11 times with education provided to the resident. The Physician Order, dated 02/07/23, directed Social Service and Nursing staff to assess strategies for a bathing routine as R4 told the physician she thinks she refused her baths while she was asleep and would like bath refusals in writing signed by R4. The Nurse's Note, dated 03/20/23 at 12:51 PM, documented R4 refused her bath due to being anxious and sick to her stomach. The note further documented R4 was offered medication to help with her nausea, R4 refused and stated she does not ever want a bath. Staff reeducated R4 on skin care and hygiene, with the risk of infections, and R4 stated she did not care if she got any infection or sores and did not want to be out of her bed for any reason. The noted documented R4 was offered a bed bath and she refused. The Nurse's Note, dated 03/22/23 at 11:10 AM, documented R4 flatly refused to take a shower and stated she was afraid she would fall. The note further documented R4 was told that people normally perspire, get sweaty, develop body odor and yeast when they don't shower. R4 stated she doesn't care and refused to bathe at all. R4's clinical record lacked evidence of social service support provided to the resident. On 04/02/23 at 08:55 AM, observation revealed R4, in bed. Her hair was braided, but was greasy and disheveled. Further observation revealed R4's toenails were long, some were grown above the tip of her toes. On 04/04/23 at 09:10 AM, Certified Nurse Aide (CNA) Q stated at the beginning of the shift, staff checked the computer to see which residents were scheduled for bathing. CNA Q stated if the resident refused, the aides asked the resident twice and if the resident continued to refuse, the aides gave a refusal sheet for the nurse to document on and document the refusal. On 04/04/23 at 01:25 PM, Licensed Nurse H stated, R4 refused her baths for months; staff educated her and it does not make a difference. On 04/04/23 at 03:00 PM, Administrative Nurse D stated Social Service staff should be involved with her and should talk with her about her anxiety and did not know if there was documentation of the resident refusing behavioral health care services or if it was offered. The facility's Social Services Designee policy, dated 06/07/22, documented the social services designee assist in implementing and directing social service programs and assure that the residents physical, mental, emotional and social needs are met and maintained on an individual basis. The duties and responsibilities include, record and maintain regular social service progress notes indicating response to the treatment plan and/or adjustment to institutional life, make routine visits to residents and perform services as necessary, maintain contact with the resident's family, and involve them with non-medical progress reports as necessary, and assist in interpreting social, psychological and emotional needs of the resident/family to the medical staff, attending physician, and other resident care team members. The facility failed to identify provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of R4, who had behaviors of refusing showers and personal hygiene assistance. This placed the residnet at risk for impaired quality of life.

The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview the facility staff failed to assess and record temperatures in the medication refrigerators in the medication room. This placed the residents, who received medications from the refrigerators, at risk for receiving less potent or unintended effects from the medications. Findings included: - On 03/30/23 at 09:27 AM, observation in the medication room revealed a lack of evidence that staff assessed and maintained adequate refrigerator temperatures. On 03/30/23 at 09:27 AM, Licensed Nurse (LN) J stated staff checked the temperature daily but did not document the reading. On 04/04/23 at 12:53 PM, Administrative Nurse D verified staff had not been recording the two refrigerator temperatures in the medication room and stated staff should be recording the temperatures. The facility's Storage of Medications and Biologicals Policy, revised 01/21, documented medications requiring refrigeration or temperatures between 36 degrees Fahrenheit (F) and 46 degrees are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless other wise directed on the label. The facility failed to ensure staff assessed and recorded the two refrigerator temperatures in the medication room. This placed the residents, who received medications from the refrigerators, at risk for receiving less potent or unintended effects from the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 40 residents. The sample included 14 residents in which two were reviewed for Hospice (specialized care to people who are near the end of life) services, Resident (R)1 and R30. Based on observation, record review, and interview, the facility failed to ensure communication and collaboration with the Hospice provider placing the residents at risk for uncommunicated and unmet end of life care needs. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with late onset, dementia (progressive mental disorder characterized by failing memory, confusion) with severe mood disturbance, chronic kidney disease, and personal history of malignant neoplasm (cancer) of the breast. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had severe cognitive impairment, had verbal behaviors directed toward others which occurred on to three days of the look back period, required extensive assistance of one to two staff for activities of daily living. The MDS further documented R1 had pain, received routine pain medication and had hospice services. The Hospice Care Plan, dated 03/13/23, documented to coordinate R1's care with the hospice staff to assure all needs were being met. The hospice will consult with facility staff regarding needs being met, pain management, medication management, consulting doctors for new orders, supply healthcare supplies, communication with family, assist in nursing/bathing and companionship. The Progress Note, dated 03/06/23 at 10:51AM, documented the social service designee spoke with family about hospice service due to the resident's decline. Family called to inform the facility they would like to set up hospice services and chose a preferred hospice provider. R1's clinical record including the Hospice binder lacked nursing and other discipline notes related to R1's cares and needs. On 04/04/23 at 09:18 AM, observation revealed R1 sat in the dining room, and called out for help several times though no staff responded to her. On 04/04/23 at 09:14 AM Licensed Nurse (LN) H reported the hospice staff gave the facility staff verbal report and discussed the resident's condition with the staff that was working. LN H stated the hospice staff had not been leaving a paper visit sheet of the visits. On 04/04/23 at 09:17 AM Administrative Nurse D stated hospice was to document their visit and hospice should fax or e-mail the visit note to the facility. Administrative Nurse D stated she had expected the notes to be sent no later than 24 hours. On 04/04/23 at 11:55 AM Consultant GG stated the hospice office would send all the paperwork that was required in the chart and reported there must have been a miscommunication because the visit logs should be in the resident's chart. The facility's Hospice/End of Life policy, dated 11/28/17, documented hospice/end of life services will be provided according to resident's needs and preferences. Social Services will coordinate with hospice. A significant change in status assessment will be initiated and the plan of care will be updated to reflect coordination of care and services with hospice. The facility failed ensure communication and collaboration with Hospice, placing the resident at risk for unmet end of life care needs. - The Electronic Medical Record (EMR) documented R30 had diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety, mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and mood disorder category of mental health problems, feelings of sadness, helplessness, and guilt). R30's Significant Change Minimum Data Set (MDS), dated [DATE], documented R30 had severely impaired cognition and required extensive assistance of one staff for toileting, personal hygiene, bathing, and independent with bed mobility and transfers. The MDS further documented R30 received hospice services. The Hospice Care Plan, dated 03/13/23, directed staff to coordinate care with the hospice staff to ensure all my needs are being met, inform her family of her condition and if she would like to see them, respect R30's advance directives, and provide her with mediations and other measures to maintain her comfort as hospice will provide medications. Review of R30's clinical record lacked documentation a hospice care plan of coordination of care between hospice and the facility, nursing and other discipline visit notes, and hospice admission documentation. On 04/03/23 at 08:56 AM, observation revealed R30 lying on her bed with eyes closed. On 04/04/23 at 09:14 AM, Licensed Nurse (LN) H stated hospice gives a verbal report to staff on the resident's condition and did not think a paper copy was left at the facility. On 04/04/23 at 09:17 AM, Administrative Nurse D stated hospice document when they visit the resident and expected the hospice documents to be in the resident's chart within 24 hours of the visit. On 04/04/23 at 11:55 AM, Consultant GG stated there was a miscommunication and the documents were being provided to the facility and was aware the care plan, logs and visits should be in the resident's chart. The facility Hospice/End of Life policy, dated 11/28/17, documented Hospice/End of Life services would be provided according to resident's needs and preferences. Social Services would meet with the resident, family, and/or resident representative to discuss options for end of lice services including hospice. Upon decision to elect hospice services, the physician would be contacted to obtain orders, and social services would coordinate with hospice. A significant change in status assessment would be initiated and the plan of care would be updated to reflect coordination of care and services with hospice. The facility failed to coordinate care between themselves and hospice services, documentation of hospice visits, and admission documentation for R30, who received hospice services. This placed the resident at risk for inappropriate end of life care.

The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to make good faith efforts to identify multiple issues of concern for the 40 residents, who resided in the facility. This placed the residents at risk for decreased quality of care. Findings included: - Based on observation, record review, and interview, the facility failed to provide Resident (R) 30 and R20 care in a manner to maintain and enhance dignity and respect. Refer to F550. Based on observation, record review, and interview, the facility failed to notify R29's physician of a change of condition. Refer to F580. Based on record review, and interview, the facility failed to place estimated cost on the Medicare Beneficiary Notices for three residents. Refer to F582. Based on observation, record review, and interview, the facility failed to address hypertension (elevated blood pressure) medication in the comprehensive care plan for R29. Refer to F656. Based on observation, record review, and interview, the facility failed to provide routine bathing for R17, R38, and R2. Refer to F677. Based on observation, record review, and interview, the facility failed to provide quality of care for R29 who had a condition change. Refer to F684. Based on observation, record review, and interview, the facility failed to provide incontinent care for R20 and proper urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care for R33. Refer to F690. Based on observation, record review, and interview, the facility failed to provide clean and sanitary respiratory equipment for R4. Refer to F695. Based on record review, and interview, the facility failed to provide competent nursing staff for R29 who had elevated blood pressure and respiratory distress. Refer to F726. Based on observation, record review, and interview, the facility failed to provided physician ordered mental health support for R4. Refer to F740. Based on observation, record review, and observation, the facility failed to provide medically related social service support for R4. Refer to F745 Based on observation, record review, and interview, the facility failed to document medication room refrigerator temperatures. Refer to F761. Based on observation, record review, and interview, the facility failed to obtain hospice (special care to people who are near the end of life) documentation for coordination of care for R1 and R30. Based on observation, record review, and interview, the facility failed to conduct waterborne pathogen test, isolate R26 who had been exposed to COVID (a highly infectious respiratory disease) positive roommate and provide proper urinary catheter care for R33. Refer to F880. On 04/05/23 at 12:45 PM, Administrative Staff A reported she collected data from the interdisciplinary team and other sources of information for the quality assessment and assurance program that meets on a monthly basis to formulate plans of improvement. The facility's QAPI Plan, dated 06/21/22, documented the QAPI program will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice, and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action. We utilize the best available evidence (e.g. data, national benchmarks, published best practices, clinical guidelines) to define and measure our goals. The facility failed to identify multiple issues of concern for the 40 residents who reside in the facility placing the residents at risk for lack of quality care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - On 04/05/23 at 10:00 AM observation revealed R26's room, which he shared with COVID positive R29, lacked personal protective equipment and signage on the door for isolation precautions and a variety of staff entering and exiting the room. On 04/04/23 at 04:08 PM, Administrative Nurse D reported R29 admitted to the hospital, and was positive for COVID 19. Administrative Nurse D reported facility staff initiated COVID-19 testing for all the residents On 04/05/23 at 08:19 AM, LN I reported the facility had no positive COVID residents. LN I confirmed R29 had been admitted to the hospital and was being treated for COVID. On 04/05/23 at 10:30 AM Administrative Nurse D stated R26 did not come out of his room, but staff went in and out of the room. Administrative Nurse D verified R26 should be isolated due to exposure to R29's symptomatic COVID condition and subsequent positive test. The facility's COVID 19 Isolation policy, dated 10/06/22, documented isolation precautions will be utilized when there is a COVID-19 risk. Residents determined to be at risk for COVID-19 will be placed on droplet isolation. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. The facility will post a notice at the door indicating the resident is on droplet isolation. Employees caring for residents on droplet precautions are to wear a gown, gloves, N-95 face mask, and googles/face shield. The facility failed to isolate R26 after exposure to his symptomatic, COVID positive room mate which increased the risk for internal transmission of COVID. - The Electronic Medical Record for R33 documented diagnoses of type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), hyperlipidemia (condition of elevated blood lipid levels), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), urinary retention (a lack of ability to urinate and empty the bladder). R33's admission Minimum Data Set (MDS), dated [DATE], documented R33 had intact cognition and required extensive assistance of one staff for transfers, dressing, toileting, and personal hygiene. The MDS further documented R33 required the use of an indwelling Foley catheter (tube used for draining urine from the bladder and having an inflatable part at the bladder end that allows the tube to be kept in place for variable time periods), was always incontinent of bowel, and had a urinary tract infection (an infection in any part of the urinary system) in the last 30 days. The Quarterly MDS, dated 03/02/23, documented R33 had intact cognition and required extensive assistance of two staff for transfers, toileting, and extensive assistance of one staff for bed mobility. The MDS further documented R33 had an indwelling Foley catheter and was frequently incontinent of bowel. The Urinary Catheter Care Plan, dated 03/16/23, initiated on 2/13/22, directed staff to ensure catheter care was performed every shift and as needed, if staff notice R33's urine turning darker in color, encourage good fluid intake. The plan directed if she was experiencing burning, cloudy or foul odor from the urine, let her physician know right away, and replace her catheter as ordered by the physician. Monitor urine output each shift, if staff notice a low urine output, sediment in her urine, abnormal urine color, notify the physician. The update dated 03/16/23 further directed staff to apply a urinary catheter leg drainage bag to her catheter when she was out of her bed or up ambulating. The Physician Order, dated 11/15/22, directed staff to administer cranberry plus probiotic (promotes a healthy urinary tract), one tablet, by mouth, in the morning, for a supplement. The Physician Order, dated 12/02/22, directed staff to insert a 16 French x 30 (cc) cubic centimeters Foley catheter monthly and document urine output every shift for the diagnosis of urinary retention. The Physician Order, dated 01/14/23, directed staff to administer Macrobid (an antibiotic to treat and prevent urinary tract infections), 100 milligrams (mg), by mouth, twice a day, for 10 days for a diagnosis of urinary tract infections (uti). The Nurse's Note, dated 01/13/23 at 07:44 AM, documented R33's catheter was patent and draining, urine was clear and noted sediment, yellow in color. The Nurse's Note, dated 01/13/23 at 11:49 AM, documented staff collected a urinalysis (examination of urine) from R33. The Urinalysis Report, dated 01/13/23, documented R33 had increased protein, and blood in her urine. On 04/04/23 at 08:15 AM, observation revealed R33 laid in bed. Certified Nurse Aide (CNA) O and CNA P applied gloves and pulled down the resident's incontinence brief and pants. CNA O took R33's catheter bag, still full of urine, and guided the bag up the inside of the right pant leg and out the top of R33's pants. Further observation revealed CNA O and CNA P stood there as R33 was exposed from the waist down and discussed who would complete the catheter care and who would drain the catheter bag. Continued observation revealed CNA P took an incontinence wipe, performed incontinence care, and ran out of wipes before she could do catheter care. CNA P opened R33's nightstand drawer with soiled hands and was unable to find gloves. CNA O looked for more incontinence wipes in R33's dresser drawer and stated Well, I guess we need to stock these rooms and took R33's roommates' s incontinence wipes. Observation revealed R33 continued to be exposed from the waist down as the CNAs looked for incontinence wipes. CNA P took an incontinence wipe and wiped around the catheter tubing at the insertion site but did not cleanse the catheter tubing. With the same soiled gloves, CNA P and CNA O pulled up R33's incontinence brief and pants. Further observation revealed CNA O sat a container on the floor to drain the catheter bag, and spilled urine on the floor. CNA O stated, how did it get spilled onto the floor? CNA O failed to cleanse the port of the catheter tubing before clamping the tubing, took the catheter bag and down the top of R33's pants, down the inside of the right pant leg and held onto it as he assisted R33 into her recliner and asked her where she wanted him to place the catheter bag. R33 instructed CNA O to put the catheter bag in the dignity bag and lay it on top on her trash can. On 04/04/23 at 12:20 PM, CNA P stated she knew she had not changed her gloves after incontinence care because she forgot and verified they had not covered R33 up when looking for extra gloves. On 04/05/23 at 11:56 AM, Administrative Nurse D stated staff should not leave residents exposed if they are not providing cares. Administrative Nurse D said the CNA should have removed her soiled gloves before touching other surfaces or the resident. Upon request, a policy for hand hygiene was not provided by the facility. The facility failed perform appropriate hand hygiene when providing incontinence care for R33. This placed the resident at risk for infections. The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable disease and infections when the facility failed to develop a water management plan to minimize the risk for development of Legionella (type of bacteria that can cause serious lung infections) or other waterborne pathogens (agents that cause disease or infection) from entering the facility water system. The facility staff further failed to assess and document washing machine temperatures. Staff failed to isolate Resident (R) 36 after exposure to his roommate's symptomatic COVID (highly contagious, potentially fatal respiratory infection). Staff failed to perform appropriate hand hygiene when providing R33's cathter (tube inserted into the bladder to drain urine) cares. These deficient practices placed all residents at increased risk for developing an infection. Findings included: - On 04/04/23 at 08:39 AM, observation of the laundry room revealed a lack of evidence staff assessed and documented the washing machine temperatures. On 04/04/23 at 08:39 AM, Laundry Staff (LS) V stated he checked the washing machine temperature every morning but did not document it. On 04/04/23 at 11:09 AM, Maintenance Staff (MS) U stated he checked the washing machine temperature daily but did not document it. MS U stated he was unaware he needed to document them. On 04/04/23 at 12:42 PM, when asked to see the facility's water management plan, MS U was unaware of a plan and stated the facility did not have one. On 04/04/23 at 02:09 PM, Administrative Staff A stated the facility had a plan but had not been following it. The facility's Legionella Policy, revised 04/27/18, documented the facility would conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. The policy stated annual testing would be completed at least once a year and with any new construction, equipment changes, changes in treatment products(disinfectants), change in water usage, changes in water usage or one or more cases of disease thought to be associated with the system. The facility failed to develop a water management plan for detecting Legionella and other waterborne pathogens in the water system and failed to monitor and record washing machine temperatures. This placed the 40 residents at risk for developing an infection.

The facility had a census of 40 residents. The sample included 14 residents. Based on interview and record review the facility failed to provide an Infection Preventionist (IP) designated to manage and monitor the facility's Infection Prevention and Control Program (IPCP) for the 40 residents who resided in the facility. This placed the residents at risk for infections and health problems. Findings included: - On 04/04/23 at 10:05 AM, Administrative Nurse D stated she was enrolled in the IP program but had not completed it. Administrative Nurse D said the nurse consultant monitored the IPCP remotely, but the facility had no certified IP to provide oversight and monitor the facility's IPCP at least part-time in the facility. The facility's Infection Preventionist Policy, undated, documented the facility would designate an IP who would be responsible for oversight of the infection IPCP. The IP would have primary professional training in nursing or another related field. This person would work at least part time at the facility and would have completed specialized training in IPCP. The facility failed to provide an IP who held the required certification to manage and monitor the facility's Infection Prevention and Control Program for the 40 residents who reside in the facility. This placed the residents at risk for infections and health problems.

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect, when staff attempted to obtain Resident (R)10's pulse at the dining room table, with 10 other residents in full view of the procedure. Findings included: - On 09/21/21 at 12:05 PM, observation revealed R10 seated in reclining broda (a pressure reducing chair that tilts and reclines) chair, and Certified Nurse Aide (CNA) assisted the resident to eat lunch. Certified Medication Aide (CMA) S approached the resident at the dining room table and attempted to get a pulse reading from her left little finger without success. Continued observation revealed CMA S removed the resident's sock on her left foot and attempted to obtain her pulse reading from the left little toe and was unable to obtain a reading. CMA S explained to the resident she had to give her a medication that required her to get the resident's pulse. On 09/27/21 at 11:00 AM, Administrative Nurse D verified staff should not obtain the residents pulse reading in the dining room and it was a dignity issue. The undated facility's Resident Rights policy, recorded each resident shall have the right to personal privacy and confidentiality of personal and clinical records. Privacy shall be provided during medical and nursing treatment, written and telephone communications, personal cares, visits, meetings of family and resident groups. The facility failed to promote care for R10 in a manner to maintain and enhance dignity and respect.

The facility had a census of 36 residents. The sample included 13 residents, with three unsampled residents 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 for skilled services for Resident (R) 21, R137, and R138 and the Notice of Medicare Non-Coverage for R21 and R138. Findings included: - The Medicare Advance Beneficiary Notice (ABN) informed the beneficiary that Medicare may or may not pay for 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 Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not pay Medicare, I am responsible for payment for services. (3) I do not want the listed therapy services. The Notice of Medicare Non-Coverage (NOMNC) informed the beneficiary when their Medicare covered skilled nursing facility services ended. The CMS 10055 (ABN) form was not provided to R137 or the resident's representative. The facility documented the CMS 10123 and 10055 forms were not provided to R21 and R138 or their representatives. The undated facility's Beneficiary Notices policy, documented the facility would ensure that proper notification of beneficiary rights to resident's when skilled services end per federal guidelines. The Skilled Nursing Facility ABN and NOMNC are communication tools required by CMS to ensure residents and their families are aware of when Medicare services would be discontinued or when Medicare will likely not pay for a service. The facility failed to provide the resident (or their representative) the ABN and NOMNC form when discharged from skilled services for R21, R137, and R138, placing the resident's risk to make uninformed decisions for their skilled services.

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week, as the charge nurse for the 36 residents who resided in the facility. Findings included: - Review of the Registered Nursing Staffing Schedule for June, July, August and September 2021, recorded the facility lacked a Registered Nurse on the following days: September 4th, 5th, 11th, 12th, 18th and 19th August 1st, 7th, 8th, 14th, 15th, 21st, 22nd, 28th, and 29th. July 3rd, 4th, 10th, 11th, 17th, 18th, 24th, and 25th June 5th, 6th, 12th, 13th, 19th, 20th, 26th, and 27th On 09/21/21 at 08:30 AM, observation revealed 36 residents resided in the facility. On 09/27/21 at 11:00 AM, Administrative Staff D verified the facility did not have a Registered Nurse in the building or working as a charge nurse for the above documented dates. Upon request the facility failed to provide a policy regarding daily Registered Nurse coverage. The facility failed to provide a registered charge nurse for the 36 residents who resided in the facility, without utilizing the DON, placing the facility and residents at risk for inadequate nurse guidance and leadership.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 36 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R) 26's insulin (hormone which allowed cells throughout the body to uptake glucose) pen that had expired, and failed to discard the Tuberculin (a protein extracted from tuberculosis {an infectious bacterial disease characterized by the growth of nodules in tissue, especially the lungs} to determine if a person had been exposed to tuberculin) vaccine vial that had expired. Findings included: - On 09/21/21 at 08:40 AM, observation of the medication cart for [NAME] and half of Kitten Hall, revealed R26's Levemir (a long acting insulin that can work for around 24 hours or longer) flex pen with an expiration date of 09/14/21 (6 days). On 09/21/21 at 08:45 AM, observation of the refrigerator in the medication room revealed one 5 milliliter (ml) vial of tuberculin had expired 07/02/2021. On 09/21/21 at 08:50 PM, Licensed Nurse (LN) H verified R26 received insulin daily, and the resident received insulin from the insulin flex pen on 09/20/21. LN H verified the Tuberculin vial was outdated and she would discard and get a new vial. On 09/27/21 at 11:00 AM, Administrative Nurse D stated the nurses were to date the insulin pens/vials when opened, label with the resident's name, and discard expired medications. Upon request the facility failed to provide an Insulin storage policy. The Medication Administration Policy, dated March 2011, documented vials and ampules of injectable medications are used in accordance with the manufactures recommendations or the provider pharmacy's direction for storage, use, and disposable. Vials and ampules that are sent from the provider pharmacy in a box or container with the label on the outside are kept in that box or container. The initials of the first person to use the vial and the date opened are recorded on multi dose vial. Open medication will either be discarded immediately after use or in compliance with the manufacture storage requirements, The facility failed to discard R26's Levemir flex insulin pen and the outdated vial of tuberculin, placing the residents at risk for receiving ineffective medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 36 residents. The sample included 13 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 5. Findings included: - R5's Physician's Order Sheet, dated 08/25/21, revealed diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion ), senile degeneration of the brain, and Adult Failure to Thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals). The admission Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired cognition. The MDS further indicated the resident required extensive one staff assistance with bed mobility, transfers, walking in room, locomotion on and off the unit. The resident received as needed pain medication and had frequent pain. The MDS documented the resident received Hospice services. The Physician's Order, dated 06/09/21, directed the staff to provide hospice services for the resident. Review of the medical records revealed the 06/09/21 initiated hospice assessment, and care plan was not available for the facility staff to reference. Upon the Surveyor's inquiry, Administrative Nurse D requested the hospice nurse provide initial hospice assessment, including the plan of care to the facility. The hospice nurse stated he/she had provided the information to the facility; however, the facility did not have it with the residents scanned in information or at the nurse's station. On 09/23/21 at 01:00 PM, observation revealed the resident lying in bed, eyes closed, with his wife on the fall mat next to him. On 09/27/21 at 11:00 AM, Administrative Nurse D verified hospice completes an assessment on admission to the hospice services, and a care plan according to the resident's care needs. Administrative Nurse D verified she expected the plan of care to be scanned into the resident's chart for facility staff to know what the facility provided, and what services hospice provided. The Hospice policy, dated 06/08/21, documented a written Plan of Care (POC) would be established and maintained. The POC would be completed and updated by the attending physician, medical director, physician designee and the hospice interdisciplinary team. These POC reviews would be documented and the plan will include assessment of the hospice resident's needs and identification of services to be provided. Including management of discomfort and symptom relief. The plan will state in detail the scope and frequency of services needed to meet the hospice patient and caregivers needs. Hospice attends facility care conference and resident's caregiver meetings as deemed necessary. Hospice will be responsible for the professional's management and the coordination of the plan of care. The facility failed to obtain the hospice records, assessment and plan of care for R5, who received hospice services, placing him at risk for inappropriate end of life care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 36 residents. The sample included 13 residents, with seven reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide adequate supervision and assistance to prevent accidents for two of seven sampled residents, Resident (R) 16, who caught her hand in a bed rail, R23, who had to be lowered to the ground while transferred from a sit to stand lift, and failed to ensure the chemicals were inaccessible to the 10 cognitively impaired, independently mobile residents who resided in the facility. Findings included: - R16's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had impaired cognition and required extensive assistance of two staff for transfers, bed mobility, toileting, had unsteady balance, and no functional impairment. The Fall Care Area Assessment (CAA), dated 04/03/21, documented the resident was at risk for falls due to cognition and impaired mobility. The revised Fall Care Plan, dated 09/19/21, originally dated 03/31/21, directed staff to check on the resident frequently when in bed to make sure the resident did not roll out of bed or try to transfer herself from the bed. The Bed Mobility Device Assessment, dated 03/16/21, documented the resident used a bed cane device to enable bed mobility and did not prevent the resident from getting in and out of bed. The assessment further documented the resident used the bed cane to assist the resident to sit on the edge of her bed and staff had no concerns with the use of the cane device. The Nurse's Note, dated 06/06/21 at 07:30 AM, documented the resident was found half way out of bed with her right hand caught in bed rail and her face was on the mattress. The note further stated the nurse aide had moved the resident prior to the nurse entering her room. The note documented the resident had a small bruise on the back of her right hand, no other injuries noted, and the nurse wrapped the rail with a sheet for resident safety. The Nurse's Note lacked documentation of an investigation regarding the resident's hand being caught in the bed rail. On 09/22/21 at 09:33 AM, observation revealed the resident's bed had a scooped mattress (a special mattress with raised sides which may be used as a fall prevention measure), fall mat beside the bed, and no bed rails. On 09/22/21 at 11:30 AM, Certified Nurse Aide (CNA) M stated the resident does not have any bed rails and stated he was unaware of any incidents regarding the resident and bed rails. On 09/23/21 at 11:36 AM, Administrative Nurse D stated the incident was not investigated and stated the cane bed rail was taken off right away. Administrative Nurse D further stated the incident should have been investigated and educated the nursing staff to make sure an incident was filled out and an investigation started. On 09/27/21 at 10:55 AM, Licensed Nurse (LN) G stated when there was a fall or incident, a risk management form was completed for an investigation to begin and stated the resident had not had any bed rails on for a long time. The facility's Occurrences policy, dated 11/28/17, documented the facility would ensure each resident received adequate supervision of assistive devices to reduce the risk of occurrences and all residents would be assessed for fall risk and those determined to be at risk would have interventions implemented. The interventions would be reviewed periodically and would be revised or additional ones added as needed. Any accident or occurrence would be thoroughly investigated to rule out abuse and neglect and determine a root cause. The appropriate interventions would be developed based on the root cause analysis. The facility failed to ensure cognitively impaired R16 received adequate supervision and investigate when the resident's hand was caught in a bed rail, placing the resident at risk for further injury. - R23's Quarterly MDS, dated 08/05/21, documented the resident had impaired cognition and required extensive assistance of two staff for bed mobility, transfers, and did not ambulate. The MDS further documented the resident had unsteady balance, no functional impairment, and had two or more non-injury falls. The Fall CAA, dated 02/04/21, documented the resident had several recent falls and needed assistance with a lift for transfers. The Fall Care Plan, dated 09/02/21, originally dated 06/25/20, directed staff to provide two person transfer assistance with a sit to stand lift (a mobility device used to transfer residents from a seated position to a standing position when unable to do so on their own) due to the resident's inability to stand up straight on her own. The update, dated 09/02/21, directed staff to use two staff assistance for sit to stand lift transfer and if weaker, use a hoyer lift (an assistive device that allows residents to be transferred from one place to another) with two staff assistance. The Fall Risk Assessment, dated 05/06/21 and 09/14/21 documented the resident a high fall risk. The Change in Condition Evaluation Report (CIC) dated 06/24/21 at 04:10 PM, documented the resident was observed lying on the floor with her back on the CNA's legs, the CNA had started to transfer the resident from her wheelchair to bed with the sit to stand lift when she noticed that the resident was sliding out of the sling. The CIC report further documented the CNA got behind the resident and lowered her to the floor. The report documented the resident did not receive any injuries and the CNA was educated on proper use of the sit to stand lift and the use of two staff at all times. The CIC Report, dated 09/02/21 at 9:25 AM, documented the resident was on the floor in the shower room. The nurse entered the shower room and observed the resident seated on her buttocks in front of the tub with the sit to stand in front of her. The CNA reported when she transferred the resident, her arm slipped out of the sling and the CNA lowered her to the floor. The resident was assessed without injury. On 09/22/21 at 10:11 AM, observation revealed the resident seated in her wheelchair with a sling (used with the lift to transfer the resident) underneath her. CNA M and CNA O attached the sling to the hoyer lift and transferred the resident to her bed. On 09/22/21 at 10:11 AM, CNA O stated the resident had a few falls because she tried to be independent, stated she was unsure about any falls while using the sit to stand lift, and stated they used two staff when transferring the resident with the lift. On 09/27/21 at 10:55 AM, LN G stated staff used a lift for the resident to transfer because she tried to get up alone and would fall and stated two staff are to assist the resident with the lift. On 09/27/21 at 02:00 PM, Administrative Nurse D verified the care plan directed staff to use two staff when transferring the resident with the lift and verified there were not two certified staff assisting the resident with a lift transfer when she was lowered to the floor. Administrative Nurse D stated the resident should have be assessed for the hoyer lift. The facility's Mechanical Lift Use policy, dated 11/28/17, documented the facility will utilize both sit to stand and sling lifts for resident transfers in situations where the resident was unable to safely and adequately bear weight and maneuver from one surface to another. The sit to stand lift would be used when a resident was able to bear weight and to hold onto the arm bar of the lift. Once the resident was positioned and secured with the sling, the resident was lifted into position. The sling lift would be used when a resident was unable to bear weight and/or could not hold onto the sling or control body movements. The facility failed to ensure cognitively impaired R23's environment remained as free of accident hazards as possible when staff lowered the resident to the floor twice while using the sit to stand lift to transfer the resident, placing the resident at risk for injury. - On 09/21/21 at 09:00 AM, observation during initial facility tour revealed an unlocked spa door on Kitten Hall across from the nurse's station. Further observation revealed the door contained a keypad needed to open the door, that was unlocked. The spa room contained the following; Two, One-quart bottles of Diversey Virex Tuberculin disinfectant cleaner. One, 32-ounce spray bottle of Clorox Bleach Germicidal Cleaner, One, 8 fluid ounces, bottle of Pet Pro Oxy urine Eliminator One, one-quart bottle of Diversey Crew Heavy Duty toilet bowl cleaner One, one-quart spray bottle of Glance nonammoniated, multi surface glass cleaner All of the item's labels documented keep out of reach of children, Hazardous if swallowed, can cause significant burns to skin and eyes. On 09/21/21 at 09:35 PM, Licensed Nurse (LN) G verified the spa room should have been locked and chemicals were to be stored in a locked secure location. On 09/27/21 at 03:30 PM, Administrative Nurse D verified the spa door was always to remain locked and chemicals needed to be kept behind a locked door. Administrative Nurse D stated the facility had 10 cognitively impaired independently mobile residents. The facility's Storage of Chemicals policy, dated 01/26/21, stated the facility is to ensure that all products are labeled and stored in a manner that eliminates risk of improper use and should be stored in a locked area. The facility failed to store hazardous chemicals in a safe environment, placing 10 cognitively impaired independently mobile residents at risk for injury