**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to update the electronic clinical record to reflect resident code status per signed advanced directive for two of five sampled residents, R38 and R45. The Advanced Directives forms were signed for CPR, however, the electronic record revealed DNR. The findings include: 1. Review of the facility policy Advance Directive Standard of Practice reviewed 10/2020, revealed it was the resident's right to formulate an Advance Directive. The facility would determine if the resident had executed an Advance Directive on admission to the facility and copies would be in the resident's medical record and scanned into the electronic medical record (EMR). If the resident was determined to not have decision making capabilities, the facility would approach the legal representative or health care proxy for the resident in regards to Advance Directives. Review of the facility policy Resident Rights Under Federal Law not dated, revealed the facility would protect and promote the rights of each resident. Residents had the right to create Advance Directives in accordance with state law. Review of the clinical record for Resident (R) 38 revealed the facility admitted the resident on [DATE] and re-admitted the resident on [DATE]. The resident's diagnoses included Congestive Heart Failure (CHF) and Mild Neurocognitive Disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) of 11 out of 15. Review of R38's Cardiopulmonary Resuscitation Consent (CPR) form dated [DATE] revealed the resident and his/her POA both signed to choose CPR be performed in the event of cardiac arrest. Review of the care plan, dated [DATE], for R38's Advance Directive revealed on [DATE] the resident was a Full Code status and the resident had a Power of Attorney (POA). The care plan also revealed on [DATE] the resident was Do Not Resuscitate (DNR) upon return from the hospital. An intervention included the resident would have his/her health care wishes/ advance directives honored. Review of R38's Advance Directives Order Form dated [DATE] revealed a physician order for DNR. In interview on [DATE] at 3:14 PM, Licensed Practical Nurse (LPN) 5 stated the nurse completing a resident admission obtained the resident's code status. She stated the purpose of the Advance Directive was to know if the resident wanted CPR in case his/her heart stopped. The LPN stated if there was a question on a resident's status, staff would look in the electronic health record as she did not have access to the signed paper copy. She further stated she was unsure how the discrepancy with R38's Advance Directive occurred. She stated if the computer was different from the signed form, there was the potential for staff to do what they are not supposed to do. In interview on [DATE] at 9:20 AM, the Admissions Director (AD) stated she completed the admission packet for the resident, however if the resident entered the facility after 5:00 PM the nurse on duty would complete the resident's code status. She stated she was only involved for a resident re-admission if the resident's code status changed. The AD stated she did not recall R38's code status on return from the hospital, however she stated the hospital mentioned comfort measures with the family and palliative car services saw the resident in the hospital. She further stated the purpose of the Advance Directive was in case the resident's heart stopped, the facility knew what the resident's wishes were. She also stated the nurse would refer to the directive in the computer which came from the physician's order entered into the system. She further stated if the resident's heart stopped, staff would follow the order for DNR. The AD stated staff would not perform CPR on R38 and he/she could pass away. In interview on [DATE] at 1:10 PM, the Unit Manager (UM) stated she began employment at the facility on [DATE]. She stated when a resident returned from the hospital as a new admission, the resident's code status was reviewed and changed if needed. The UM stated code status was reviewed by the Interdisciplinary Team (IDT). She stated the nurse did not have access to the paperwork and the computer record was the resource for staff to know a resident's code status. The UM stated if there was a discrepancy between the computer record and the paperwork, staff would not perform CPR as the computer said DNR. On [DATE] at 1:54 PM interview with the Director of Nursing (DON) revealed a resident's Advance Directive was not completed when he/she returned from the hospital. She stated residents with a DNR status were reviewed in the IDT clincical meeting. The DON stated she did not recall reviewing R38's code status upon return from the hospital. She stated if there was a discrepancy between the computer and the paperwork, the resident's wishes would not be followed and CPR would not be provided. In interview on [DATE] at 3:37 PM, the administrator stated the facility audited resident admissions for the Advance Directive when a resident returned to the facility. She stated no one at the facility identified R38's code status did not match what was in the computer. She stated the purpose of the Advance Directive was to make a resident's wishes and choice if he/she wanted CPR or progress a natural course. The Administrator stated if there was a discrepancy the resident's wishes may not be followed and would not receive CPR. 2. Review of the facility policy Advance Directive Standard of Practice reviewed 10/2020, revealed the resident had the right to formulate an Advance Directive. The facility determined if the resident had an Advance Directive upon admission to the facility and copies would be in the resident's medical record and scanned into the electronic medical record (EMR). If the facility determined the resident did no have decision making capabilities, the the legal representative or health care proxy for the residentwas approached in regards to Advance Directives. Review of the facility policy Resident Rights Under Federal Law not dated, revealed the facility protected and promoted the rights of each resident. Residents had the right to create Advance Directives in accordance with state law. Review of the clinical record for Resident (R) 45 revealed the facility admitted the resident on [DATE] and re-admitted the resident on [DATE]. The resident's diagnoses included Congestive Heart Failure (CHF) and Left Ventricular Failure. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) of 10 out of 15. Cardiopulmonary Resuscitation (CPR) Consent form signed on [DATE] revealed R45 chose CPR in the event of cardiac arrest. Review of the Advance Directioves Order From dated [DATE] revealed the physician order for Do Not Resuscitate (DNR). Review of R45's care plan dated [DATE] for Advance Directives revealed the resident had a DNR status with an onset date of [DATE]. In interview, on [DATE] at 8:42 AM, R45 stated he/she wanted to be let go if found unresponsive and did not want chest compressions. The resident stated yesterday the facility also asked him/her. In interview on [DATE] at 3:14 PM, Licensed Practical Nurse (LPN) 5 stated the resident's code status was completed by the nurse completing the resident admission. She stated the purpose of the Advance Directive was to know if the resident wanted CPR in case his/her heart stopped. The LPN stated staff looked in the electronic health record as she did not have access to the signed paper copy. She stated if the computer was different from the signed form, there was the potential for staff to do what they are not supposed to do. In interview on [DATE] at 9:20 AM, the Admissions Director (AD) stated she completed the admission packet for the resident, unless the resident entered the facility after 5:00 PM and the nurse on duty would complete the resident's code status. She stated she was only involved for a resident re-admission if the resident's code status changed. The AD stated R45's code status was follwed by what was in the computer from the physician order. She further stated the purpose of the Advance Directive was in case the resident's heart stopped, the facility knew what the resident's wishes were. She also stated the nurse would refer to the directive in the computer which came from the physician's order entered into the system. She further stated if the resident's heart stopped, staff would follow the order for DNR and would not perform CPR on R45 who could pass away. In interview on [DATE] at 1:10 PM, the Unit Manager (UM) stated the resident's code status was reviewed and changed if needed when a resident returned from the hospital as a new admission. The UM stated code status was reviewed by the Interdisciplinary Team (IDT). She stated the nurse did not have access to the paperwork and the computer record was the resource for staff to know a resident's code status. The UM stated R45 returned to the facility this month and would not receive CPRas the computer noted DNR and staff would not have the paperwork. On [DATE] at 1:54 PM interview with the Director of Nursing (DON) revealed the Advance Directive for a resident was not completed upon return from the hospital. She stated residents with a DNR status were reviewed in the IDT clincical meeting. The DON stated if there was a discrepancy between the computer and the paperwork, the resident's wishes would not be followed and CPR would not be provided. In interview on [DATE] at 3:37 PM, the administrator stated the facility audited resident admissions for the Advance Directive when a resident returned to the facility. She stated She was sure R45's code status was discussed and reviewed. The Administrator stated the purpose of the Advance Directive was to make a resident's wishes and choice if he/she wanted CPR or progress a natural course. The Administrator stated if there was a discrepancy the resident's wishes may not be followed and would not receive CPR.

Based on observation, interview, and facility policy review, the facility failed to ensure the resident(s) right to be free from abuse and neglect for one of one sampled resident. (R9) R9 stated staff left the room while providing her a shower, which made her feel scared. R9 was a quadriplegic and unable to call for help. The findings include: Review of a facility policy titled, Abuse Prohibition Standard of Practice, dated 11/2016 and revised 07/2022, revealed the facility would prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property and to ensure reporting and investigating of alleged violations in accordance with Federal and State laws. Review of a facility policy titled, Safety and Supervision Standard of Practice, dated 07/2020 and revised 02/2021, revealed the facility strived to make the environment as free from accident hazards as possible and resident safety and supervision were facility-wide priorities. Review of a facesheet revealed the facility admitted R9 on 11/04/2016 with diagnoses to include: lymphedema, not elsewhere classified, morbid obesity (severe) due to excess calories, and Multiple sclerosis. Review of the resident's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/04/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of a 15 out of 15, indicating the resident was cognitively intact. Review of a grievance form dated 07/16/2024 at 3:00 PM, revealed R9 stated she was being given a shower by CNA14. R9 stated she asked CNA14 twice to raise her arm and wash under it. CNA 13 replied with I am, threw down the hose and stated she was done and going to get another aide, leaving R9 in the room naked, soaked and unattended to. Section II documented action taken was education was provided to staff, as well as coaching and counseling. The State Survey Agency (SSA) Surveyor was unable to interview the nurse whom provided the education as she was out of the facility on medical leave. During an interview on 08/26/2024 at 8:37 AM with R9, she stated on 07/16/2024, CNA14 was helping her with a shower in the shower room and kept reaching across her body covering her face. R9 stated she was claustrophobic and kept telling the staff member to stop. R9 stated the staff member became angry, throwing the shower nozzle to the floor and walking out of the shower room , leaving her on the shower table alone with the water still running. R9 stated she began to yell for help but nobody could hear her and she felt scared. R9 stated she felt like she laid there forever however it was about fifteen minutes in reality. R9 further stated two other staff members entered the room and stated CNA14 told them R9 kicked CNA14 out of the shower room. During an interview on 08/28/2024 at 5:43 PM with Certified Nursing Assistant (CNA) #14, she stated she was giving R9 a shower and R9 kept complaining that she wasn't doing it correctly and to get out and find someone else. CNA14 stated she did leave the room to find another staff member to take over and left R9 laying on the shower table. CNA14 stated she should have stopped the shower, cover R9 with a sheet and pull the cord to alert other staff she needed assistance. CNA14 stated R9 could have fell off of the table and it was not appropriate to have left the resident alone. CNA14 stated she had only been employed at the facility a few weeks at the time and was reeducated by a nurse. During an interview on 08/29/2024 at 2:37 PM with the Director of Nursing (DON), she stated a resident should never be left alone in the shower room. The DON stated CNA14 should have used the pull cord in the shower room and waited until someone could relieve her before leaving the room. The DON stated CNA14 was reeducated immediately. During an interview on 08/29/2024 at 3:39 PM with the Administrator she stated, the facility does not want staff to leave anyone unattended in the shower room. The Administrator stated R9 was unable to call for help and it was a safety concern. The Administrator further stated CNA14 should have used the emergency pull cord or stuck her head out of the door and yelled for someone to come help her.

The facility failed to ensure performance evaluations were completed for two of two sampled CNAs. The facility did not provide evaluations for CNAs employed over one year and trained based on those evaluation results. The findings include: Review of the personnel files for Certified Nurse Aide (CNA) 10 and CNA 13 revealed they did not have annual performace evaluations completed. The facility hired CNA 10 on 05/12/2017, the last performance evaluation completed was signed on 08/28/2018. The facility hired CNA 13 on 12/10/2015, and the last completed evaluation was signed 04/06/2021. In interview on 08/29/2024 at 9:57 AM, the Human Resource (HR) and Payroll Manager stated she worked at the facility 5 yeas and began as the HR Manager in December 2023. She stated employee performance evaluations were completed once a year based on their anniversary date. The HR Manager stated she places the completed evaluation into the employee's file, which she was responsible to maintain. She also stated the facility used a computer program to enter the employee hire date and the computer auto-populated when an evaluation was due. She stated when this occurred, she had to dismiss the autopopulated alert as it did not automatically go away. She stated when an employee's evaluation was due, she informed the Administrator. The HR Manager further stated the computer program did not flag if an evaluation was overdue. She stated she was unsure the reason CNA 10 and CNA 13 did not have their evluations completed. In interview on 08/29/2024 at 1:54 PM, the Director of Nursing (DON) stated she began employment at the facility in April 2024, and as the DON about 2 weeks ago. She stated the purpose of the employee performance evaluation was to ensure the employee did his/her job appropriately and provided good resident care. The DON stated the CNA evaluations were completed by the HR Manager. She further stated she completed the nurses evaluations, and the nurses were responsible to supervised the CNAs. The DON stated she was unsure if the nurses provided input into the CNA evaluations. She also stated she wanted to know if a CNA evaluation was not compelted, as she oversees the clinical department. The DON stated if the evaluation was not completed the facility was not able to follow up on theemployee's job performance. On 08/29/2024 at 3:37 PM, interview with the Administrator revealed she started employement at the facility at the end of June 2024. She stated she was not aware how far back employee performance evaluations were not completed until the survey. The Administrator stated she or the DON were responsible to complete the CNA evaluations. She stated the HR Manager received notifications from a computer program when evaluations were due. She further stated she asked the HR Manager to inform her when she (the HR Manager) sees them. The Administrator stated if the evaluations were not completed, employees had less information of what they did that was, good or where they needed to improve or areas to work on.

The facility failed to ensure daily nursing staffing was posted in the facility for two of five days during the survey. The last posted daily staffing 08/27/24. The findings include: Observation of the posted staffing on 08/29/2024 at 3:16 PM revealed the last posted date was 08/27/2024. In interview on 08/29/2024 at 3:24 PM, the Director of Nursing (DON) stated the Staff Scheduler/Certified Nurse Aide (CNA) 6 was responsible to post staffing in the morning during the week. The DON stated she did not check on this morning to see if the daily staffing was posted. She further stated the purpose of posting staffing information was so everyone knew the facility had adequate staffing to provide patient care. The DON stated if the information was not posted, the facility would have a hard time proving the staffing for the day. She also stated if the Scheduler was out during the week, she, the DON, would post the information. In interview on 08/29/2024 at 3:28 PM, the Staff Scheduler/CNA 6 stated she was responsible to post the daily staffing sheets and she did not post the sheet for this day. She stated when she came to work this day, she knew she would work as a CNA and was worried about resident care. The Scheduler also stated the day before (08/28/2024) the Administrator told her she would find someone to post the staffing for the day. The Scheduler further stated she posted in the morning when she comes in to work, however she worked as a CNA yesterday and this day. She stated the purpose to post daily staffing was to know how many staff to residents ratio. She stated without the posting, it was possible the facility would not have proper staffing available to provide resident care. On 08/29/2024 at 3:37 PM, interview with the Administrator revealed the Scheduler was responsible to post daily staffing. She stated the purpose to post was for transparency so others would know the facility had staff. The Administrator further stated the Scheduler worked as a CNA on 08/28/2024 and 08/29/2024, and the Unit Manager was the backup to post. She also stated the Scheduler worked as a CNA about once per week. The Administrator stated if the staffing was not posted daily, whomever looked for staffing posting would not have the information he/she was looking for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (Resident (R) 203) of 21 sampled residents was free from a significant medication error. R203 was sent to the hospital for pain control after not receiving her routinely ordered controlled pain medication for over two days after admission. The findings include: Review of a facility policy titled, Medication Administration Standard of Practice, dated 10/2020, revealed medications would be administered in a safe and timely manner, and as prescribed. 1. Observation on 08/26/2024 at 2:06 PM revealed R203 ambulating on Heritage Hall in her wheelchair. The resident was yelling out for help to use the bedpan and stating she was in pain. Interview at this time with R203 revealed she was admitted to the facility on the night of 08/23/2024. R203 stated she had taken Oxycodone (a controlled opioid medication used to treat moderate to severe pain) and Lyrica (medication used for nerve and muscle pain) for at least four years prior to admission. However, she continued, she had not received her scheduled pain medication since admission because the facility staff told her the physician had not sent in a prescription and they had not received her medication. R203 stated she had requested to be transferred to the emergency room for pain control. Additional observation on 08/26/2024 at 2:17 PM revealed three Emergency Management personnel transporting R203 to the hospital via ambulance. The resident was evaluated and treated in the emergency room but was not admitted , to the hospital, and returned to the facility around 3:00 AM on 08/27/2024. Review of a face sheet revealed the facility admitted R203 on 08/23/2024 with diagnoses including chronic migraine without aura, a displaced trimalleolar fracture of the left lower leg, chronic pain, muscle wasting and atrophy, and rheumatoid arthritis. Review of the resident's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14/15, which indicated the resident was cognitively intact. Review of physician orders for R203 revealed routine orders for Lyrica (Pregabalin) 100mg (milligrams) one capsule twice a day and Oxycodone 10mg tablet one tablet every eight hours with a start date of 08/23/2024. In addition, the resident had orders for Tylenol 325 mg, two tablets as needed (PRN) for pain, as well as Tylenol 650 mg rectally PRN for pain. Although the resident was admitted on [DATE], review of the 08/01/2024 - 08/27/2024 Medication Administration Record (MAR) revealed the first dose of Lyrica 100 mg was not documented as given until 08/24/2024 at 7:00 PM (one day after admission). Per the MAR, the resident did not receive the first dose of Oxycodone 10mg tablet until 08/24/2024 at 11:00 PM (over a day after admission) Review of the MAR revealed these medications were documented as being administered by Licensed Practical Nurse (LPN) 8. During an interview with LPN8 on 08/28/2024 at 7:10 PM, he stated he did not administer Oxycodone or Lyrica on 08/24/2024 and if the MAR reflected that, it must have been a documentation error. Further interview with LPN8 revealed that he did not administer the medications because they had not yet arrived at the facility. Although the MAR documented that the medications were given on 08/24/2024, review of a packing slip confirmed the facility did not receive R203's Oxycodone 10mg tablets and Pregabalin 100mg capsules until 08/26/2024. The Oxycodone and Pregablin were not administered until 08/27/2024 at 7:00 AM, after the resident returned from the hospital. Further review of the 08/01 - 08/27/2024 MAR revealed that the PRN Tylenol was not administered during the two+ days from admission on [DATE], till hospital transfer on 08/26/2024, and review of the resident's Progress Notes revealed no evidence of pain. Review of an inventory list from the facility's emergency Cubex supply (E-kit) revealed the facility had six Oxycodone-Acetaminophen 10/325mg tablets in stock/available for use. However, review of the transaction log, dated 08/23/2023 through 08/27/2024, revealed staff failed to remove the medication from the Cubex and administer the ordered Oxycodone to R203. During an interview on 08/27/2024 at 9:30 AM, Registered Nurse (RN) 1 stated she was an agency nurse. RN1 stated LPN5 was responsible for admitting R203. Although there was a physician's prescription on 08/23/2024 for the Oxycodone and Lyrica. LPN5 did not obtain the needed hard copy to order the pain medications from the pharmacy. RN1 stated she called the medical director on 08/24/2024 to request a prescription be sent to the pharmacy and the physician replied with Thank you. RN1 stated she did not work on 08/25/2024 and when she returned on 08/26/2024, R203's pain medication was still not stocked in the medication cart. RN1 stated she called the medical director again and he instructed her to notify his office and it would be taken care of. RN1 stated she did call the medical director's office to request the prescriptions be sent to the pharmacy. Although there was no evidence in the clinical record that the resident experienced pain on 08/23 - 08/25/2024, RN1 stated that on 08/26/2024, R203 began to complain of increased pain and asked to be sent to the hospital for an evaluation. RN1 stated typically the resident would admit with their pain medication with them or a written prescription. RN1 stated if the resident did not have a prescription, the admitting nurse was responsible to obtain the prescription and fax the prescription to the pharmacy. RN1 stated the pharmacy usually delivers the medication on the same day they receive the prescription. RN1 further stated if the resident had not received their medication, a nurse could pull medication from the Cubex; however, she did not know if this had been done for R203. RN1 confirmed that the facility ultimately did receive R203's medication during the time she was in the emergency room on [DATE]. During an interview on 08/29/2024 at 3:02 PM with LPN5, she stated she worked through an agency and had worked regularly at the facility since 03/2024. LPN5 stated she was responsible for R203's admission on [DATE]. LPN5 stated R203 did not have a hard copy of the prescriptions for Oxycodone or Lyrica, and it was her error, adding she should have asked someone what to do. LPN5 further stated she placed R203's admission papers in the tray for the administration team to review and assumed they would order R203's medications. LPN5 stated she misunderstood the process and should have asked someone since she did not know, and she should have called the medical director or ensured the sending facility had actually sent a prescription with the resident. LPN5 stated the normal process would be to obtain a hard copy of the prescriptions and fax it to the pharmacy, but she was tired and had several admissions that day. During an interview with LPN8 on 08/28/2024 at 7:10 PM, LPN8 stated he had worked on 08/24/2024 and R203's medications had not been received, so he called the pharmacy and was made aware they had not received a prescription. LPN8 stated he assumed the admitting nurse had not faxed the prescription, so he called the medical director. LPN8 stated the medical director replied with Thank you, and he did not hear anything back the remainder of the evening. He stated on 08/25/2024 when he reported to work, R203 still did not have her medications so he again called the medical director, who responded with Thanks, I'll take care of it LPN8 stated the admitting nurse should have ensured a hard copy of the resident's prescriptions had been faxed to the pharmacy so the resident would have had her medication. An attempt to conduct a telephone interview with the medical director (MD) on 08/28/2024 at 7:30 PM was unsuccessful and the MD did not return the telephone call. During an interview on 08/29/2024 at 2:37 PM with the Director of Nursing (DON), she stated she was not made aware until 08/27/2024 that R203 had not received her scheduled pain medications. The DON stated the admitting nurse was responsible for obtaining all orders for the resident. The DON stated on 08/27/2024, they learned that the physician had initially sent R203's prescription to an incorrect pharmacy. The DON stated that once R203 complained of increasing and uncontrolled pain on 08/26/2024, it was necessary to send the resident to the emergency room. The DON stated she expected nursing staff to obtain orders and send the prescription to the pharmacy during the admission process. The DON further stated she expected to be notified immediately so a decision could be made in a timelier manner and the resident could receive their prescribed medications. During an interview with the Administrator on 08/29/2024 at 3:39 PM, she stated she expected medications to arrive from the pharmacy in a timely manner and staff should ensure they had received the appropriate orders. The Administrator stated there should have been better communication with the staff, physician, and pharmacy to ensure R203's medications were received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to protect resident dignity related to a catheter bag cover for four of four sampled residents. Observation of R7, R8, R14, and R11 during survey revealed the catheter urine bag did not have a privacy cover and contained liquid. Observation of R7 included lunch time in the dining room with other residents present. R11 and R14 expressed they would prefer to have their catheter covered. R8 was vulnerable and catheter without dignity bag was visible from the doorway. The findings include: Review of the facility policy Resident Rights Under Federal Law not dated, revealed the facility would protect and promote the rights of each resident. The policy included the resident had a right to a dignified existance. Review of the facility policy Resident Rights Under Kentucky Law not dated, revealed residents were treated with recognition of his/her dignity and included privacy in treatment and in care for his/her personal needs. Review of the clinical record for Resident (R) 7 revealed the facility re-admitted the resident on 09/10/2023. Resident diagnoses included Obstructive and Reflex Uropathy, and Other Specified Disorders of Kidney and Ureter. Review of the resident's Minimum Data Set (MDS) dated [DATE] revealed the facility assessed R7 as cognitively intact with a Brief Interview of Mental Status (BIMS) of 15. The MDS also identified the resident had an indwelling catheter. Review of the resident care plan for impaired bladder elimination, dated 06/09/2020, revealed the resident had a suprapubic catheter. An intervention included use of a dignity cover for the catheter drainage bag, dated 06/09/2020. Observation on 08/26/2024 at 12:40 PM, revealed R7 in the dining room eating his/her meal independently. The resident's catheter bag was on his/her left side of the wheelchair (w/c). The drainage bag was visible with liquid. Other residents were also in the dining room. In Interview on 08/27/2024 at 10:01 AM, R7 stated his/her (urine) drainage bag was changed the previous night and the bag was then covered. R7 stated he/she wanted the bag covered. The resident stated he/she liked having the bag covered and felt different without the cover on the bag. In interview on 08/28/2024 at 2:29 PM, Certified Nurse Aide (CNA) 6/ Staff Scheduler stated R7 had a urinary catheter when she began employment at the facility on 04/24/2024. She stated catheter drainage bags were to have a privacy bag over it. She also stated the privacy covers were in the supply room behind the nurse's station. The CNA stated the purpose of the cover for the resident's dignity. CNA 6 also stated the bags should not be seen or noticeable and she would report to the nurse if a cover was missing. On 08/28/2024 at 2:42 PM interview with CNA 5 revealed she took R7 his/her meal tray in the dining room. She stated catheter bags were supposed to be covered for a resident's dignity and privacy. She also stated it could be embarassing for the resident and hurt his/her feelings if the bag was not covered. CNA 5 stated she was unaware of R7's bag uncovered. In interview on 08/28/2024 at 3:14 PM, Licensed Practical Nurse (LPN) 5 stated she did not see R7's catheter bag without a cover. She stated the purpose of the cover was for the resident's dignity. She further stated without the cover the bag was easy to spill when knocked and could burst easier. Interview on 08/29/2024 at 1:10 PM, with the Unit Manager (UM) revealed catheter bags were expected to have a privacy bag for the resident's dignity. She stated the purpose of the cover was so others would not know there was urine in the bag. She stated she checked residents urine bags had covered. The UM also stated resident's should not come out of their rooms without the cover on the bag. She further stated it was not good for other residents in the dining room to see R7's bag during the meal time. In interview on 08/29/2024 at 1:54 PM, the Director of Nursing (DON) stated she expected urinary catheter bags were covered. She stated the purpose of the cover was for the resident's dignity and for those around the resident. She also stated the cover helped residents feel comfortable. The DON stated every resident should have a dignity cover on the drainage bag. The DON stated she was unaware R7 did not have a cover on the bag. She further stated if the resident did not have a cover, the resident did not have his/her dignity. In interview on 08/29/2024 at 3:37 PM, the Administrator stated she was an LPN and was in her position as Administrator since June 2024. She stated the catheter unire bag should be covered to uphold the resident's dignity. She also stated she expected the nursing staff watched for covers in place. The Administrator stated the purpose of the cover was for the resident's dignity and to make the best situation they can for the resident. She stated if the cover was missing, the resident could feel insecure which could impact his/her dignity. Review of facility's policy titled, Resident Rights Standard of Practice, dated 04/2024, revealed the purpose was to ensure each resident is treated with respect and dignity, and care for in a manner that promotes maintenance or enhancement of his/her quality of life. Further review revealed the resident has the right to be treated with respect and dignity. The facility did not have a policy specific to catheter care. 1. Review of R8's, admission Face Sheet, revealed the facility admitted the resident on 01/09/2015 with diagnoses including Alzheimer's disease, aphasia and dysphagia following a stroke, and congestive heart failure (CHF). Review of R8's, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident was severely cognitively impaired. Observation on 08/25/2024 at 11:27 revealed R8 in bed A with the door open. Further observation revealed R8's catheter drainage bag was visible from the hallway and was without a dignity cover. Additional observation on 08/27/2024 at 8:40 AM revealed R8's catheter drainage bag still without a dignity cover. 2. Review of R14's, admission Face Sheet, revealed the facility admitted the resident on 10/12/2023 with diagnoses including Parkinson's disease, quadriplegia, and type 2 diabetes. Review of R14's, MDS with an ARD of 08/10/2024, revealed the resident had a BIMS score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Observation on 8/25/2024 at 10:51 AM revealed a catheter drainage bag secured to the right side of the bed with no dignity cover in place. In an interview with R14 on 8/25/2024 at 10:51 AM, he stated he was unsure why his catheter bag was not covered, and no one had ever asked. He further stated he wished to have a dignity cover, so the urine was not visible. 3. Review of R11's MDS with an ARD of 10/19/2023, revealed the facility admitted the resident on 01/16/2020 with diagnoses including non-traumatic spinal cord dysfunction, neurogenic bladder (a condition where normal bladder function is disrupted due to nerve damage), dementia, and CHF. Review of R11's, MDS with an ARD of 07/05/2024, revealed the resident had a BIMS score of nine out of 15, which indicated the resident was moderately cognitively impaired. Observation of R11's catheter drainage bag on 08/28/2024 at 9:31 AM, revealed the absence of a dignity cover. In an interview with R11 on 08/28/2024, she stated she wished they would put something over her catheter bag because she did not like the bag visible to people. In an interview with Certified Nursing Assistant (CNA) 5 on 08/28/2024 at 9:14 PM, she stated all residents with catheters should have a dignity bag, but they did not. She further stated she was not exactly sure why but thought maybe it was because they did not have enough at the facility. In an interview with CNA 8 on 08/28/2024 at 3:17, she stated some of the residents had dignity covers over their catheter drainage bags and some did not, but she was unsure why. In an interview with the central supply clerk on 08/28/2024 at 3:29 PM, she stated the facility had an ample supply of catheter dignity bags. Observations on 08/28/2024 at 3:29 PM in supply closet behind the nurse's station revealed one opened box that contained one dignity bag and two unopened boxes of 20. In an interview with CNA10 on 08/28/2024 at 9:55 AM, she stated all catheter drainage bags should be covered with a dignity bag to protect residents' privacy. In an interview with Licensed Practical Nurse (LPN) 5 on 08/29/2024 at 10:24 AM, she stated every resident with a catheter should have a dignity cover over the drainage bag. She further stated, Nobody wants you looking at their urine. In an interview with the Unit Manager (UM) on 08/29/2024 at 10:48 AM, she stated all residents with catheters should have a dignity cover over their catheter drainage bag for privacy and respect. In an interview on 08/29/2024 at 2:28 PM with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), she stated every resident with a catheter should have a dignity cover over the drainage bag. She further stated it was important for the bag to be covered because it protected the resident's privacy. In an interview with the Director of Nursing (DON) on 08/29/2024 at 3:03 PM, she stated it was her expectation any resident with a catheter had dignity cover in place over the drainage bag. In an interview with the Administrator on 08/29/2024 at 3:55 PM, she stated it was her expectation nursing ensured all residents with a catheter had a dignity cover over the drainage bag. She further stated no one wanted a catheter and they should make the situation the best scenario possible. The Administrator stated failure to provide a dignity cover resulted in potential impact to a resident's dignity and feelings of insecurity.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming and personal hygiene for ten (Resident (R) 9, R14, R25, R26, R35, R39, R40, R42, R108, and R254) of 21 sampled residents. Residents did not receive regularly scheduled showers and/or baths, and grooming/hygiene, including nail care, as needed. The findings include: Review of a facility policy, titled Activities of Daily Living (ADLs), dated 10/2020, revealed the facility would work to provide care and services to residents that were person-centered, and honor and support each resident's preferences, choices, values, and beliefs. The policy stated the facility protocol would be to provide the resident the appropriate care and services to maintain or improve his/her ability to carry out the ADLs. The facility would provide care and services for the following ADLs: hygiene (bathing, dressing, grooming, oral care) and any resident who was unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. However, the facility did not include specifics related to the provision of these services. 1. Review of R9's admission Face Sheet revealed the facility admitted the resident on 11/04/2016 with diagnoses including multiple sclerosis (MS), morbid obesity, and type 2 diabetes. Review of R9's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. Per the MDS, the resident was dependent on staff for bathing and had no refusals of care. Review of the resident's care plan revealed the resident required two-person assistance with the use of a mechanical lift. Review of the resident's shower/bath schedule revealed the resident was supposed to receive a shower twice a week. Per the shower sheet, each day was to be documented that either a bath was given, a shower was given, the activity did not occur, or the resident refused care. Review of R9's shower sheets from 11/01/2023 through 01/31/2024 revealed no documented showers, baths, or refusals between 11/12/2023 and 11/20/2023; between 12/04/2023 and 12/10/2024; between 12/15/2023 and 12/22/2023; between 12/24/2023 and 01/05/2024; or between 01/07/2024 and 01/21/2024. During an interview with R9 on 08/26/24 at 08:37 AM, she stated her showers were often not provided on her shower day because of staffing issues. She further stated it was very depressing when she did not receive a shower. During an interview with Certified Nursing Assistant (CNA) 3 on 08/27/24 at 07:49 PM, she stated R9 required two people for her care and preferred her shower during the day. CNA3 stated R9's showers were not always provided on her scheduled shower day because there were not enough people to help on the floor. 2. Review of R14's admission Face Sheet revealed the facility admitted the resident on 10/12/2023 with diagnoses including Parkinson's disease, quadriplegia, and type 2 diabetes. Review of R14's MDS, with an ARD of 08/10/2024, revealed the resident had a BIMS score of 12/15, which indicated the resident was moderately cognitively impaired. Per the MDS, the resident was dependent on staff for Activities of Daily Living (ADLs) and did not refuse case. Review of R14's care plan, with a date of 10/12/2023, revealed the resident would be provided ADL assistance per assessment. The resident's shower schedule was twice weekly. Review of R14's shower sheets from 05/26/2024 through 08/24/2024 revealed documentation of partial or total bed baths, but no showers. Further review revealed no documentation of any bath hygiene between 06/21/2024 through 06/30/2024; 07/23/2024 through 07/31/2024; or 08/07/2024 through 08/13/2024. Observation on 08/26/24 at 9:39 AM revealed R14's fingernails were approximately one to one and a half inches long; were yellowed in color; and dirt was observed underneath all ten fingernails. During an interview with R14 on 08/26/2024 at 9:39 AM, he stated he was not sure the last time his nails were trimmed. He further stated he liked to have his nails trimmed and clean. Further interview with R14 revealed that yesterday (08/25/2024) was the first time in about six months he was offered a bath. 3. Review of R26's admission Face Sheet revealed the facility admitted the resident on 04/05/2024 with diagnoses including legal blindless, right below the knee amputation (BKA), and type 2 diabetes. Review of R26's MDS, with an ARD of 07/04/2024, revealed the resident had a BIMS score of 14/15, which indicated the resident was cognitively intact. Per the MDS, the resident required assistance with bathing/showering, and did not refuse care. Review of the care plan, dated 04/04/2024, revealed the resident would be provide the level of assistance required with ADLs. The resident's shower schedule was twice weekly. a. During interview with R26 on 08/27/24 at 8:36 AM, he stated he had not received a shower last month. Review of R26's shower sheets from 05/27/2024 through 08/24/2024 revealed no documented showers, baths, or refusals between 07/07/2024 and 08/09/2024. During an interview with CNA5 on 08/28/2024 at 9:14 AM, she stated R26 was scheduled for a shower yesterday, but it was missed because she did not have time or help. b. Observation on 08/27/2024 at 8:36 AM revealed R26's fingernails were approximately one to one and a half inches long, yellow in color, brittle, and dirty underneath. During an interview with R26 on 08/27/2024 at 8:36 AM, he stated he wanted to have his nails trimmed and cleaned. He further stated he had a visual impairment and frequently used his hands when he ate finger type foods. During an interview with CNA 10 at 08/29/2024 at 9:55 AM, she stated the CNAs trimmed residents' fingernails unless the resident was a diabetic. If the resident was diabetic, then nursing staff was responsible for nail care. CNA 10 further stated it was important fingernails were kept trimmed and cleaned because of cleanliness, especially when the resident ate. 4. Review of R25's admission Face Sheet revealed the facility admitted the resident on 03/20/2019 with diagnoses including left sided paralysis following a stroke and contracture of left hand and left wrist. Review of R25's MDS, with an ARD of 08/06/2024, revealed the resident had a BIMS score of 14/15, which indicated the resident was cognitively intact. Per the MDS, the resident required assistance with bathing/showering and did not refuse care. The resident's care plan, dated 11/08/2019, noted the resident had a self-care deficit and required assistance with ADLs. Review of R25's shower sheets from 05/26/2024 through 08/25/2024 revealed no documented showers, baths, or refusals between 07/06/2024 and 08/05/2024. Observation on 08/25/24 at 11:47 AM revealed R25's hair was dirty, greasy, and matted to the resident's head. During interview with R25 on 08/25/2024 at 11:47 AM, he expressed concern about the frequency of baths and stated it had been about a month since he received a shower or bath. In an additional interview with R25 on 08/27/2024 at 8:48 AM, he stated he still had not received a shower. He further stated he wanted a bath because he felt dirty. 5. Review of R35's admission Face Sheet revealed the facility admitted the resident on 01/06/2023 with a diagnosis of left sided paralysis following a stroke. Review of R35's MDS, with an ARD of 08/20/2024, revealed the resident had a BIMS score of 15/15, which indicated the resident was cognitively intact. Per the MDS, the resident was dependent on staff for showers/bathing and did not refuse care. The care plan, dated 01/17/2023, noted the resident had a self-care deficit and staff were to provide ADL assistance per the MDS assessment. The resident's shower schedule was twice weekly. Review of R35's shower sheets from 05/26/2024 through 08/25/2024 revealed no documented showers, baths, or refusals between 07/19/2024 and 07/31/2024 or between 08/11/2024 and 08/25/2024. During an interview with R35 on 08/25/2024 at 11:15 AM, she stated her scheduled showers were not always provided. Observation during this interview revealed the resident had dirty, uncombed hair. 6. Review of R40's admission Face Sheet revealed the facility admitted the resident on 08/18/2022 with diagnoses including, acute and chronic respiratory failure, type 2 diabetes, and stroke. Review of R40's MDS, with an ARD of 07/31/2024, revealed the resident had a BIMS score of 15/15, which indicated the resident was cognitively intact. Per the MDS, the resident required assistance with bathing and did not refuse care. The resident's care plan, dated 08/18/2022, noted the resident required assistance with ADLs per their assessment. The resident's shower schedule was twice weekly. Review of R40's shower sheets from 11/01/2023 through 01/31/2024 revealed no documented showers, baths, or refusals between 11/08/2023 and 11/13/2023 or between 01/03/2024 and 01/10/2024. Review of R40's shower sheets from 05/26/2024 through 08/24/2024 revealed no documented shower, bath, or refusals between 07/19/2024 to 07/31/2024 or between 08/11/2024 to 08/25/2024. No observation or interview was conducted as the resident was out to the hospital during the survey. 7. Review of R108's admission Face Sheet revealed the facility admitted the resident on 10/17/2023 with diagnoses including paraplegia and type 2 diabetes. Per this closed record, the resident's discharge date was 05/08/2024. Review of R108's MDS, with an ARD of 04/03/2024, revealed this resident required assistance with bathing. Per the care plan, dated 10/16/2023, the resident had a self-care deficit and ADL assistance was to be provided as required per assessment. Review of R108's shower sheets from 11/01/2023 through 01/31/2024 revealed one documented entry on 12/01/2023 for a shower. 8. Review of R254's admission Face Sheet revealed the facility admitted the resident on 12/04/2023 with diagnoses that included paralysis following a stroke, dementia, and congestive heart failure (CHF). Per this closed record, the resident's discharge date was 01/11/2024. Review of R254's shower sheets from 12/04/2023 through 01/10/2024 revealed no documented showers, baths, or refusals between 12/04/2023 and 12/10/2023. 9. Review of a face sheet revealed the facility admitted R39 on 02/15/2024 with diagnoses including cognitive communication deficit, history of transient ischemic attack (TIA) and cerebral infarction, and unspecified dementia with other behavioral disturbance. Review of a Quarterly MDS, with an ARD of 08/21/2024, revealed the facility assessed R39 to have a BIMS score of 3/15 indicating the resident had severe cognitive impairment. Per the MDS, the resident needed staff assistance with bathing and did not refuse care. Review of R39's shower sheets from 05/27/2024 through 08/28/2024 revealed no documented showers, baths, or refusals from 07/07/2024 through 08/05/2024. 10. Review of a face sheet revealed the facility admitted R42 on 10/17/2022 with diagnoses including cervical disc disorder with myelopathy, major depressive disorder, and neurogenic bowel. Review of a Quarterly MDS, with an ARD of 07/28/2024, revealed the facility assessed R42 to have a BIMS score of a 15/15 indicating the resident was cognitively intact. Per the MDS, the resident needed staff assistance with bathing and did not refuse care. Review of R42's shower sheets from 05/27/2024 through 08/28/2024 revealed no documented showers, baths, or refusals from 07/04/2024 through 07/12/2024, 07/15/2024 through 07/22/ 2024, and 08/15/2024 through 08/26//2024. During an interview with R42 on 08/29/2024 at 1:10 PM, he stated he did not receive showers regularly. R42 stated he has had to wait several days between showers due to a lack of staff to assist. R42 stated he had waited up to a week in the past. R42 stated he did like to take his showers and it was frustrating to him when he could not receive a shower. R42 further revealed there had been many times that staff wouldn't even ask him if he wanted a shower because they did not have enough help. During an interview with CNA5 on 08/28/2024 at 9:14 AM, she stated that typically, four to five showers were completed on day shift, and she was unsure about night shift. CNA5 stated sometimes they had a shower aide, but lately the facility was short staffed. She further stated when they had one aide per hall and the mechanical lift required two staff, it was hard to get showers completed. CNA5 stated residents had complained to her about missed showers. She further stated residents had missed outside appointments because they told her they felt dirty. During an interview with CNA10 on 08/29/2024 at 9:55 AM, she stated residents were usually showered twice a week; however, some residents had complained to her their showers were missed. During an interview with CNA9 on 08/28/2024 at 1:57 PM, she stated if a shower aide was not scheduled to work, the CNA on the floor was responsible for showers and she found it difficult to give showers on top of her other assigned duties. CNA9 stated she often worked without a shower aide scheduled and they were short staffed. During an interview on 08/29/2024 at 10:24 AM with Licensed Practical Nurse (LPN) 5, she stated residents had complained their showers were not received. She further stated some days they had a shower aide and that helped, but other days there was not enough staff to make certain all showers were completed. During an interview with the Unit Manager (UM) on 08/29/2024 at 10:48 AM, she stated there should not be any reasons showers were not provided unless a resident refused. During an interview with the Director of Nursing (DON) on 08/29/2024 at 2:37 PM, she stated residents have assigned shower days twice a week. The DON stated she expected the facility to be staffed appropriately to be able to provide the care the residents required, and she thought the facility had been. Further interview with the DON, on 08/29/2024 at 3:03 PM, revealed she had no concerns with the overall hygiene of residents. She further stated it was her expectation nurses helped with ADL's if needed. During an interview with the Administrator on 08/29/2024 at 3:39 PM, she stated she was aware there was work to be done, and the facility was working on an action plan related to showers. The Administrator stated she wanted to ensure a shower aide was staffed at least three days a week. She stated showers should not be missed and the CNA working the floor was responsible to ensure the resident received their shower or bath. The Administrator stated their goal was to ensure all scheduled showers were given, adding that there should never be a day a resident did not receive their scheduled shower.

Review of the facility's policy titled, Policies and Practices - Infection Control, revised 10/2018 revealed the objective is to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the facility's undated policy titled, Isolation - Categories of Transmission-Based Precautions revealed staff and visitors will wear gloves (clean, non-sterile) when entering room. Further review revealed staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. The State Survey Agency (SSA) Surveyor requested a respiratory/oxygen policy on 08/27/2024 at 3:16 PM and a catheter care policy on 08/28/2024 at 8:20 AM. The Administrator stated the facility did not have a catheter care policy. The Administrator further stated the facility followed physician orders related to oxygen tubing because they did not have a specific respiratory and/or oxygen policy. 1. Review of R8's, admission Face Sheet, revealed the facility admitted the resident on 01/09/2015 with diagnoses including Alzheimer's disease, aphasia and dysphagia following a stroke, and congestive heart failure (CHF). Review of R8's, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) of 00 out of 15, which indicated the resident was severely cognitively impaired. Review of R8's, Physician Order Form, dated as of 08/29/2024 revealed an order in place for oxygen at two liters. Further review revealed no orders in place related to resident's oxygen tubing. a. Observation on 08/25/2024 at 11:27 revealed R8 in bed A with the door open. Further observation revealed R8's catheter drainage bag was visible from the hallway. An additional observation revealed R8's catheter drainage bag positioned on the floor. During an interview with Certified Nursing Assistant (CNA) 5 on 08/28/2024 at 9:14 AM, she stated a resident's catheter drainage bag should not be placed on the floor because of infection concerns. During an interview with CNA8 at 08/28/2024 at 3:17 PM, she stated she worked at the facility as a CNA since May of this year and received training during orientation related to infection control and prevention. CNA8 stated catheter bags should never be left where they touched the floor because of the risk for infection. During an interview with Housekeeper #1 on 08/29/2024 at 9:45 AM, she stated resident rooms were cleaned daily. Housekeeper #1 stated if she found a resident's catheter bag or oxygen tubing on the floor, she stopped and notified the nurse or the aide. She further stated it was not acceptable to sweep or mop around a catheter bag or oxygen tubing on the floor because it was dirty and increased the chances for infection. During an interview with Licensed Practical Nurse (LPN) 5 on 08/29/2024 at 10:24 AM, she stated if she observed a resident's catheter drainage bag on the floor, she replaced it with a new bag. She further stated catheter drainage bags should not be on the floor because of infection risks. During an interview with the Unit Manager (UM) on 08/29/2024 at 10:48 AM she stated catheter drainage bags should not be on the floor because of contamination risks. The UM stated she performed rounds and room checks every morning. She further stated she had observed catheter drainage bags on the floor when she made rounds and provided immediate education to staff. During an interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) on 08/29/2024 at 2:28 PM, she stated she had been in her role for only two weeks but had started work on a new IP training program for both orientees and current employees. She further stated she planned for more skills checks, yearly check offs and return demonstrations. The ADON/IP stated she currently monitored for compliance with infection control practices through random audits. The ADON/IP stated catheter drainage bags should not be on the floor because of infection control concerns, The ADON/IP stated she had not observed any breaks in infection since she started at the facility. During an interview with the Administrator on 08/29/2024 3:52 PM, she stated catheter drainage bags should not touch the floor because of cleanliness and if positioned incorrectly affected urine flow. She further stated she expected staff to follow the facility's policies and procedures related to infection control and that included location of catheter drainage bags. b. Observation on 08/27/2024 at 8:40 revealed R8 with oxygen in use at two liters. Further observation revealed oxygen tubing contained no label or date. 2. Review of R11's MDS with an ARD of 10/19/2023, revealed the facility admitted the resident on 01/16/2020 with diagnoses including non-traumatic spinal cord dysfunction, neurogenic bladder (a condition where normal bladder function is disrupted due to nerve damage), dementia, CHF. Review of R11's, MDS with an ARD of 07/05/2024, revealed the resident had a BIMS score of nine out of 15, which indicated the resident was moderately cognitively impaired. Observation on 08/26/2024 at 9:43 AM revealed R11's oxygen tubing dated 08/09/2024. 3. Review of R31's, MDS, with an ARD of 02/14/2024 revealed the facility admitted the resident on 07/08/2020 with diagnoses including unspecified neurological condition and depression. Review of R31's, MDS with an ARD of 06/24/2024, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Observation on 08/25/2024 at 11:38 AM revealed R31 with oxygen in use. Further observation revealed R31's oxygen tubing dated 08/09/2024. 4. Review of R30's, MDS, with and ARD of 07/26/2024 revealed the facility admitted the resident on 07/26/2024 with diagnoses including CHF and chronic obstructive pulmonary disease (COPD). Review of R30's, MDS with an ARD of 07/29/2024, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R30's, General Order Form with an original date of 07/26/2024 and a renewed date of 08/01/2024, revealed an order to change oxygen tubing, humidification, and filter every 14 days. Observation on 08/25/2024 at 11:18 AM revealed oxygen in use at three and a half liters. Further observation revealed tubing was not labeled or dated. 5. Review of R36's, MDS, with an ARD of 12/08/2023 revealed the facility re-admitted the resident on 12/04/2023 with diagnoses of stroke, CHF, and pneumonia. Review of R36's, MDS with an ARD of 06/09/2024, revealed the resident had a BIMS score of six out of 15, which indicated the resident was severely cognitively impaired. Review of R36's, General Order Form with an original date of 08/23/2023 and a renewed date of 08/01/2024, revealed an order to change oxygen tubing, humidification, and filter every 14 days. Observation on 08/25/2024 at 11:21 AM revealed R36 with oxygen in use at two liters. Further observation revealed R36's oxygen tubing was not dated. An interview was attempted with CNA 12 on 08/28/2024 at 9:01 PM. CNA12 was not reached and the (SSA) surveyor was unable to leave a message. An interview was attempted with CNA 13 on 08/28/2024 at 9:03 PM, but the number provided by the facility was incorrect. An interview was attempted with LPN6 on 08/28/2024 at 9:06 PM. The (SSA) surveyor left a message, but a return call was not received. During an interview with LPN5 at 08/29/2024 at 10:24 AM, she stated she did not know how often oxygen tubing was changed, but thought it was changed by night shift. LPN5 stated it should be changed on a regular basis because over time the tubing became dirty and posed a risk for infection. During an interview with the UM on 08/29/2024 at 10:48 AM, she stated oxygen tubing should be changed as needed or at least monthly because of infection risks. During an interview with the ADON/IP on 08/29/2024 at 2:28 PM, she stated oxygen tubing should be changed every seven days or per physician's order. During an interview with the Staff Development Coordinator (SDC) on 08/29/2024 at 2:41 PM, she stated she did not know if the facility had a policy related to how often O2 tubing was changed. She further stated, it should be changed regularly because of the risk for infection. During an interview with the Director of Nursing (DON) on 08/29/2024 at 3:03 PM, she stated it was her expectation staff followed facility policies and procedures related to infection. She further stated oxygen O2 tubing should be changed weekly. During an interview with the Administrator on 08/29/2024 at 3:52 PM, she stated it was her expectation staff followed the facility's policies and procedures related to infection control. The Administrator stated they did not have a specific oxygen policy and the facility followed the physician's orders related to how often oxygen tubing was changed but stated it should be changed regularly for cleanliness purposes. Based on observation, interview, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 (six) of 21 sampled residents (R8, R11, R30, R31, R36, R45). Observation on 08/26/2024 at 2:23 PM revealed R45's catheter bag on the floor. Additionally, observation of a unit manager not donning a gown prior to entering R9's room, which was in contact precautions. The findings include: Review of a facility policy titled, Isolation-Categories- Transmission-Based Precautions, not dated, revealed Transmission-Based Precautions (TBP) were initiated when a resident developed signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or had a laboratory confirmed infection; and was at risk of transmitting the infection to other residents. Contact Precautions specify that staff and visitors would wear a disposable gown upon entering the room and remove before leaving the room. Review of Appendix PP in the State Operations Manual (SOM) revealed, Contact precautions were intended to prevent transmission of pathogens that were spread by direct (e.g., person-to-person) or indirect contact with the resident or environment, and required the use of appropriate Personal Protective Equipment (PPE), including a gown and gloves before or upon entering (i.e., before making contact with the resident or resident ' s environment) the room or cubicle. Review of a facesheet revealed the facility admitted Resident #9 (R9) on11/04/2016 with diagnoses to include: Carrier of carbapenem-resistant Enterobacterales, chronic candidiasis of vulva and vagina, and neuromuscular dysfunction of bladder, unspecified. Review of a facesheet revealed the facility admitted Resident #45 (R45) on 07/28/2024 with diagnoses to include: Benign prostatic hyperplasia with lower urinary tract symptoms, exocrine pancreatic insufficiency, and peripheral vascular disease. Observation on 08/26/2024 at 2:20 PM, R45's catheter bag was laying on the floor while the housekeeping staff swept and mopped around the bag. The housekeeper exited the room and proceeded to the next room without notifying nursing staff the catheter bag was laying on the floor. Observation on 08/27/2024 at 2:40 PM revealed Unit Manager (UM) #1 answered R9's call light. A sign was posted on R9's door alerting staff and visitors that R9 was placed on Contact Precautions. Prior to entry, the UM donned gloves, reached for a gown from the PPE bin but did not remove a gown and entered R9's room without a gown on. During an interview on 08/26/2024 at 2:23 PM with Housekeeper (HK) #1, she stated she should have notified a Certified Nursing Assistant or a Nurse that the catheter bag was laying on the floor. HK1 stated she cleaned around the catheter bag on the floor instead of notifying staff that it was laying on the floor. During an interview on 08/27/2024 at 3:35 PM with Unit Manager (UM) #1, she stated staff should wear a gown and gloves prior to providing care for residents on Contact precautions. UM1 read the sign on R9's door and stated she should have put on gloves and a gown everytime she entered the room if a resident was on contact precautions. UM1 stated it was important to follow the precautions put in place to prevent the spread of infection throughout the facility. During an interview on 08/29/2024 at 2:37 PM with the Director of Nursing (DON), she stated catheter bags should always be secured to a bed or chair. The DON stated she expected non-clinical staff to notify nursing staff immediately so it could be corrected. During an interview on 08/29/2024 at 3:39 PM with the Administrator, she stated a catheter bag should never touch the floor because of cleanliness and positioning could impact the flow of urine in the tubing. She stated if someone saw a catheter bag on the floor they should always let a nurse know.

The facility failed to ensure CNAs received 12 hours of yearly training for two of three sampled CNA personnel files. The facility did not provide the required 12 hours of yearly training for the three CNAs reviewed. The findings include: Review of personnel files for Certified Nurse Aide (CNA) 10 revealed the facility hired the CNA on 05/12/2017. Review of the personnel file for CNA 13 revealed the facility hired the CNA on 12/10/2015. The facility did not provide the required 12 hours of annual training for revie for both CNAs. In interview with the Staff Development Coordinator (SDC) on 08/29/2024 at 1:43 PM, the SDC stated she worked at the facility for 3 weeks and was still looking for the CNA training hours. She stated her expectation was the training hours were completed monthly and within 1 year of the CNA's hire date. She further stated the facility had a lot of new staff and the trainings would be completed face-to-face and online. The SDC stated the purpose of the yearly training was to keep the CNAs up to date with what was going on in care. Additionally, she stated the trainings were a refresher on various topics including the facility abuse policy, resident rights, blood borne pathogens, use of the mechanical lifts, safety awareness, emergency preparedness. The SDC stated the CNAs may not be able to complete their shift until their training was up to date. On 08/29/2024 at 1:54 PM interview with the Director of Nursing (DON) revealed she was the DON for 2 weeks, although she was employed at the facility since 04/29/2024. She stated the SDC was responsible for most of the staff education. The DON stated she was unaware the SDC was unable to find any CNA training hours in the 2 weeks since she (the SDC) was hired. She stated the purpose of the yearly training hours for the CNAs was to show they received continuing education in their field to be up to date in their knowledge as a CNA. The DON stated if the CNAs did not receive the yearly training, they would not be up to date on their knowledge as a CNA and possibly not be able to renew their certification. In interview on 08/29/2024 at 3:37 PM, the Administrator stated she was employed at the facility since June 2024. She stated she was first aware of the lack of the CNA training hours during the survey. The Administrator stated the SDC was new in the last 2 to 3 weeks and filled a vacant position. She further stated the purpose of the yearly training hours was to nensure the CNAs skills and knowledge were where they needed to be . She stated if the CNAs did not have the yearly training, the CNAs may not know what they need to do which could directly impact the care they provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. Gnats were observed in common areas and resident rooms throughout the survey process. Interview with residents indicated this had been an ongoing issue, with multiple resident reporting concerns with gnats getting on their food or drinks at meal times (R3, R9, R10, R15, R42, R45, R48). The findings include: Interview with Maintenance Director on 08/29/2024 at 10:45 AM and Administrator on 08/29/2024 at 3:37 PM revealed facility did not have a pest control plan or policy. A Pest Control Agreement was requested, but not provided during survey. Review of the Homelike Environment Standard of Practice, dated 10/2020, revealed the purpose of the policy was to ensure residents are provided with a safe, clean, comfortable and homelike environment, with the facility responsible for maximizing cleanliness and order. Review of a facility Work Order #2059, created on 03/14/2024, noted broken tiles around dish machine, holding water, causing water to attract gnats. Further documentation noted Regional is supposed to bring some spare tile from another facility. Floor being cut out 05/20/24 to 05/22/24 for new plumbing in dish washing area. Review of a Customer Service Report from Ecolab pest control dated 06/07/24 revealed the facility was treated for large flies, with gluboards checked and replaced. Glueboards were documented as 25% full. Sanitation Issues were identified in the kitchen, specifically the floor under cook/steam line was observed in need of cleaning. Drains need to be cleaned pipes need to be cleaned out 20 years worth of small fly larva, and pipe. Please clean regularly. Material Applied: Ecolab Drain Cleaning Gel, targeting small flies. Review of a Customer Service Report from Ecolab pest control, 07/12/24 revealed the facility was treated for large and small flies, with glueboards checked and replaced. Glueboards were documented as 50% full. Review of a Customer Service Report from Ecolab pest control, 08/28/24 the facility was treated for large and small flies, with glueboards checked and replaced. Documentation goes on to reveal pest activity was found in the kitchen area, with small flies noted during service throughout the kitchen. Area was inspected and serviced. Observation on 08/25/24 at 10:45 AM revealed several gnats swarming around R42's overbed table. Resident had no open food items or other items in area that would be attracting gnats. Resident had a covered thermos-style cup on overbed table. Observed two gnats on resident's thermos. Counted six gnats on ceiling in area to the side and above resident bed. No gnats were observed around sink or anywhere else in resident area. Interview with R42 on 08/25/2024 at 10:45 AM revealed when he finished his breakfast that morning and put the napkin down over his plate, in just a matter of seconds there were a dozen gnats all over it. He shared the only thing he has concerns about regarding his care here is the gnats, states they are everywhere. Continued observation, returned to R42's room on 08/25/2024 at 12:30 PM following lunch service. Resident had his eyes closed, observed three gnats on resident napkin placed over his plate. Observation on 08/25/2024 at 1:10 PM revealed a gnat flying around R45's tray. Interview with R45 at that time revealed he sees gnats often. Interview on 08/25/2024 at 1:10 PM with R45 stated he sees gnats often around his tray, and won't eat his food when gnats are swarming around it. During resident council on 08/26/2024 at 2:30 PM, R9, R10, R3, R15, and R48 all complained of seeing gnats on their food or on their drink cups. R48 stated if gnats land in her food, she doesn't eat because of it. R9 stated if gnats land in her coffee cups or cokes, she doesn't drink them when that happens. On 08/29/24 at 10:20 AM surveyor observed bug attracting lights with glue paper filled mostly with gnats on small hallway beyond [NAME] Lane. Interview on 08/29/24 at 10:34 AM with the Housekeeping Supervisor (HS) from another facility here to assist as this facility housekeeping supervisor recently quit, stated maintenance handles pest control, works with eco lab, treats for gnats. The HS stated there are some rooms that gnats are more prevalent in, including one resident on [NAME] Lane, whose refusals for room cleaning and personal hygiene may contribute to the gnat problem. We have deep cleaned that room, offered to deep clean yesterday, but resident refused. When we go to clean, roommate asks us to do as much as possible. No other areas come to mind, but I'm not extremely familiar with this building either. Interview on 08/29/24 at 10:45 AM with the Maintenance Director (MD) stated there is a plumbing issue contributing to the gnat problem, we have an outside vendor coming to redo plumbing to seal off one of the drains in the kitchen. The MD stated Ecolab was here yesterday and treated for gnats, but didn't replace all the glue strips in the lights. The MD stated the gnat issue has improved, but we still have more to do to eliminate them. The MD stated gnats have been an issue for about three weeks, with the MD being newly employed as MD as of 5 weeks ago. The MD stated he has replaced the troubled part of the drain line, that got rid of a lot of them, but have an outside vendor coming in to replace the part where it goes into the floor. Observation with MD on 08/29/2024 at 10:50 AM revealed one of four bug light stations had glue strips which had not been replaced, the one at the end of the small hallway beyond [NAME] Lane which surveyor noted earlier. MD was able to replace with an extra glue strip from another bug light station. Interview on 08/29/2024 at 3:37 PM with the Administrator stated when she came to the facility as Administrator at the end of June 2024, she did see their were gnats. She stated the facility started working on it, started calling pest control, consulted a plumber. She stated her goal was to find the root cause, and fix it. She was not aware of any resident complaints specific to gnats. She stated her expectation is to be pest free, including gnats, and if something arises we figure it out and get it fixed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to immediately inform the resident's physician and guardian when there was a significant change in the resident's physical status for one (1) of three (3) sampled residents (Resident #1). On 01/09/2024, Resident #1's diet was downgraded by the Speech Therapist (ST) to a pureed diet with nectar thick liquids. Record review revealed the resident did receive a pureed diet beginning 01/09/2024; however, there was no evidence to support the physician or the resident's guardian were notified, or a physicians order written for the diet change. Further review revealed the facility did not notify the physician and guardian each time Resident #1 refused medications or meal/fluid intake. The findings include: Review of the facility's policy, titled Change of Condition Standard of Practice, dated 07/2020, revealed it was the facility's purpose to ensure all interested parties were informed of the resident's change in health status so a treatment plan could be developed which was in the best interest of the resident. Further review revealed the facility would immediately (as soon as possible/no longer than twenty-four (24) hours) inform the resident, consult the resident's physician, nurse practitioner or physician assistant, and the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly (a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Depending on the nursing assessment, appropriate notification could range from immediately to forty-eight (48) hours. Review of Resident #1's Face Sheet revealed the facility admitted the resident on 01/02/2024 with diagnoses which included unspecified severe protein-calorie malnutrition, vascular dementia, aphasia, and weakness. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was unable to complete the interview. In addition, the facility assessed Resident #1 to require partial/moderate assistance with eating. Continued review of the MDS revealed the facility had assessed the resident to have coughing or choking during meals and/or swallowing medications and complaints of difficulty or pain with swallowing. Review of Resident #1's Medication Administration Record for 01/04/2024, revealed the resident refused his/her medications on 01/02/2024, 01/04/2024, 01/05/2024, 01/06/2024, 01/11/2024, 01/12/2024, 01/13/2024, 01/15/2024, 01/17/2024, 01/20/2024, 01/21/2024, and 01/23/2024. However, there was no documented evidence to support the physician or guardian were notified the resident had refused medications on those dates. Review of Resident #1's Note dated 01/06/2024 at 1:48 PM, entered by Licensed Practical Nurse (LPN) #3, revealed the resident had refused vital signs. However, there was no documented evidence to support the physician or guardian were notified the resident refused vital signs. Review of Resident #1's Note, dated 01/06/2024 at 12:37 AM, entered by LPN #2, revealed Resident #1 had refused all nighttime medications. However, there was no documented evidence to support the physician or guardian were notified the resident refused medications. Review of Resident #1's Diet Requisition Form, dated 01/09/2024, entered by the Speech Therapist (ST), revealed a diet change request for a dysphagia pureed diet with nectar thick liquids. However, there was no documented evidence to support the physician or the resident's guardian had been notified of the change in the residents diet. Review of Resident #1's Nutrition Assessment, dated 01/09/2024 at 9:47 AM, entered by the Dietician, revealed the resident's weight was one hundred six (106) pounds, and was likely malnourished. Further review revealed the Dietician recommended the resident have fortified foods with meals to aid with meeting nutritional needs, to monitor nutritional parameters, and to notify the Dietician as needed. However, there was no documented evidence to support the physician or guardian were notified of this recommendation. Review of Resident #1's Note, dated 01/11/2024 at 5:27 PM, entered by Registered Nurse (RN) #1, revealed Resident #1 had coarse lung sounds with a cough and was presumed to have Covid-19 related to his/her roommate was Covid positive and resident refused to allow staff to test him/her. Further review revealed the resident was refusing to drink/eat much and the physician was notified with orders received to start on Paxlovid (a prescription medication used to treat Covid symptoms) and Albuterol (a medication used to treat wheezing and shortness of breath) inhaler, obtain a chest x-ray. However, there was no documented evidence to support the resident's guardian was notified of the changes in the residents medical condition, the refusal to test for Covid, the residents refusal to eat or drink, or that the resident had been started on Paxlovid to treat Covid. Review of Resident #1's Note, dated 01/15/2024 at 5:30 AM, entered by LPN #5, revealed Resident #1 refused having vital signs obtained. However, there was no documented evidence to support the physician or guardian were notified the resident refused vital signs. Review of Resident #1's Note, dated 01/17/2024 at 2:25 PM, entered by LPN #4, revealed Resident #1 refused vital signs and medications, Power of Attorney (POA) aware and Advanced Practice Registered Nurse (APRN) aware; social services addressed on 01/10/2024 and are aware of behaviors. However, review of the Social Services Director (SSD) note dated 01/10/2024 revealed no documented evidence to support the physician, APRN, or guardian were notified the resident refused vital signs or medications. Review of Resident #1's Note, dated 01/23/2024 at 8:41 PM, entered by LPN #2, revealed Resident #1 had refused all medications and the Medical Director was aware. However, there was no documented evidence to support the resident's guardian was notified the resident refused all medications. During an interview with Resident #1's Guardian on 02/04/2024 at 6:49 PM, she stated she had received notification on 01/12/2024 the resident was refusing medications and meal intake. She stated she went to the facility on that date and was able to get the resident to take his/her medications and allow staff to care for him/her while the guardian was in the building. She further stated she asked the facility to notify her in the future if the resident refused care, medications, or meal intakes, as the resident was anxious in new situations and did not yet feel comfortable in his/her new environment. She continued to state she was not made aware of any further refusals until she received a call on 01/24/2024 notifying her the resident was being sent to the hospital. During an interview with the Staff Development Coordinator (SDC) on 02/04/2024 at 7:10 PM, she stated nursing staff should have notified the physician for any signs or symptoms of nutrition or hydration problems or if the resident refused meals, fluid intake, medications, vital signs, or weights to determine if the physician wanted to change any orders. She further stated, refusals in any of those areas would trigger the facility to monitor the resident more closely to determine if a therapy referral was needed to observe for feeding assistance, weighted utensils, or if the resident did not like the food offered. During an interview with the Dietician on 02/05/2024 at 10:11 AM, she stated she did not write physicians orders directly, but instead gave her recommendations to the administrative nursing staff and the nursing staff were responsible for notifying the physician of the dietary recommendations, and obtaining orders if the physician agreed with the recommendations. During an interview with the Speech Therapist on 02/05/2024 at 10:51 AM, she stated she was responsible for assessing residents with swallowing difficulties, and she wrote orders based on any difficulties she found. She further stated after assessing Resident #1 on 01/03/2024 , she determined the resident required a diet change from a regular diet to a mechanical soft diet due to coughing with meal intake and signs that he/she was having difficulty swallowing. She continued to state the resident was scheduled for a modified barium swallow on 01/09/2024 but was unable to attend the appointment, and she downgraded his/her diet to pureed with nectar thick liquids due to his/her continued swallowing difficulties and risk for aspiration. Additionally, she stated she completed the Diet Requisition Form and gave a copy to the nursing staff and the dietary department on 01/09/2024, but was unsure why a physicians order was not written. She further stated she did not notify the physician or guardian of the diet change. Additionally, she stated she or the nursing staff should have talked with the resident's guardian and physician to make them aware the resident had increased swallowing difficulty because the resident was at increased risk for aspiration. During an interview with LPN #1 on 02/05/2024 at 2:55 PM, she stated if a resident refused medications, weights, meals, or fluid intake, it should be reported to the physician or APRN because the facility should monitor for significant weight loss or medication refusals and the physician/APRN may need to change the orders for the resident based upon the refusal. She further stated the family should be notified of any changes with the resident so they were aware of his/her care needs. During an interview with LPN #2, on 02/05/2024 at 3:10 PM, she stated the physician should be notified of any resident refusals to monitor for any weight loss or gain, to see if dietary or therapy needed to be referred to see the resident, or if the physician needed to change any orders based on the refusals. She further stated the resident's guardian should have been notified when the resident refused care so she could have assisted in getting the resident to accept care. During an interview with Advanced Practice Registered Nurse (APRN) #1 on 02/06/2024 at 9:25 AM, she stated it was important the physician or APRN be notified of any resident refusals so they could make appropriate referrals to dietary or therapy or make any necessary recommendations or order changes based upon the resident refusals. She further stated it was her expectation the facility staff notify her or the physician or other APRN of any resident refusals when they occurred so she could intervene as necessary to prevent weight loss, organ starvation, or death from the resident refusing medications, meals, and fluids. During an interview with APRN #2, on 02/06/2024 at 9:44 AM, she stated it was her expectation to be notified of any resident refusals so she could make any necessary changes to the resident's orders. She stated she was aware Resident #1 sometimes refused medications but was not notified of any refusals of care from 01/12/2024 to 01/24/2024. She further stated she was asked to see Resident #1 on 01/04/2024 and assessed the resident to have an oxygen saturation of seventy-seven percent (77%) at that time and ordered him/her sent to the Emergency Room. During an interview with the Medical Director (MD) on 02/06/2024 at 10:46 AM, he stated it was important that he be notified of any refusals, and if he was not notified of refusals, he could not get an accurate picture of the resident. He continued to state when he was notified of a resident's refusal of care, he made a mental note to watch that resident for any patterns of refusals and make adjustments to orders as necessary. He further stated it was his expectation all staff followed all facility policies. During an interview with the Director of Nursing on 02/06/2024 at 11:40 AM, she stated it was her expectation that staff accurately document any resident refusals and notify the physician or APRN and the guardian of any refusals. She further stated the notification would ideally be any time a resident refused care, but, as some residents have multiple refusals, the physician and guardian should be notified of refusals at least every shift so adjustments could be made to the resident's plan of care as needed. She continued to state it was her expectation staff followed all facility policies. During an interview with the Administrator on 02/06/2024 at 2:45 PM, he stated it was his expectation for staff to follow the policies of the facility, and document and report care as given or refused so the resident's care plan could be changed if needed. He further stated if Resident #1's guardian had been notified of the resident's continued refusals, after 01/12/2024, she might have been able to get the resident to eat/drink more and take his/her medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to maintain medical records on each resident that was complete and accurately documented for one (1) of three (3) sampled residents (Resident #1). On 01/09/2024, Resident #1's Nutrition Assessment revealed a recommendation from the Dietician for the resident to have fortified foods; however, there was no evidence this recommendation was relayed to the physician and an order obtained for fortified foods. On 01/09/2024, the Speech Therapy downgraded Resident #1's diet to a pureed diet with nectar thick liquids; however, there was no evidence an order was obtained from the physician regarding the diet change. In addition, record review and interview revealed the facility did not document Resident #1's weights, meal intake/output, and bowel and bladder incontinence care per the physician orders. The findings include: Review of the facility's policy, titled Medication Administration Standard of Practice, dated 10/2020, revealed if a drug was withheld, refused, or given at a time other than the scheduled time, the individual who administered the medication must document it in the resident's Medication Administration Record (MAR)/Treatment Administration Record (TAR), and the individual who administered the medication must sign the resident's MAR/TAR after giving each medication, along with any additional prior or follow up requested information. Review of the facility's policy, titled Weight Process Standard of Practice, dated 07/2020, revealed the Director of Nursing (DON) or designee was responsible to see weights were obtained regularly for all residents and recorded in the medical record. Review of Resident #1's Face Sheet revealed the facility admitted the resident on 01/02/2024 with diagnoses which included unspecified severe protein-calorie malnutrition, vascular dementia, aphasia, and weakness. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was unable to complete the interview. In addition, the facility assessed Resident #1 to require partial/moderate assistance with eating. The facility further assessed the resident to have coughing or choking during meals and/or swallowing medications and complaints of difficulty or pain with swallowing. Review of Resident #1's January 2024 Medication Administration Record (MAR) revealed the facility's nurse's responsible for administering Amlodipine 10 milligrams (mg) daily (a blood pressure medication), had not signed to indicate the medication had been offered, administered, or refused on 01/15/2024 and 01/17/2024. In addition, the resident's pain level had not been documented on the MAR on 01/14/2024, 01/17/2024, 01/18/2024, and 01/20/2024. Review of Resident #1's January 2024 Treatment Administration Record (TAR) revealed the facility's nurse's responsible for obtaining vital signs had not signed to indicate the Blood Pressure had been obtained on 01/10/2024, 01/13/2024, 01/15/2024, 01/17/2024, and 01/20/2024; the Pulse Rate had been obtained on 01/10/2024, 01/13/2024, 01/15/2024, 01/17/2024, and 01/20/2024; the Respiratory Rate had been obtained on 01/10/2024, 01/13/2024, 01/14/2024, 01/15/2024, 01/16/2024, 01/17/2024, 01/19/2024 and 01/20/2024; the Temperature Results had been obtained on 01/10/2024, 01/13/2024, 01/15/2024, and 01/17/2024; or the Oxygen Saturation Results had been obtained on 01/10/2024, 01/13/2024, 01/14/2024, 01/15/2024, 01/16/2024, 01/17/2024, 01/19/2024, and 01/20/2024. Continued review revealed the resident's weight had not been documented on 01/09/2024 or 01/23/2024. In addition, the resident's pain level had not been documented on the MAR on 01/14/2024, 01/17/2024, 01/18/2024, and 01/20/2024. Review of the Diet Requisition Form, dated 01/09/2024, entered by the Speech Therapist, revealed a diet change request for a Dysphagia pureed diet with nectar thick liquids. However, there was no documented evidence to suppot the physician or the resident's guardian were notified. In addition, the was no documented evidence to suppot a physicians order had been written for the diet change. Review of Resident #1's Note, dated 01/11/2024 at 5:27 PM, entered by Registered Nurse (RN) #1, revealed Resident #1 had coarse lung sounds with a cough and was presumed to have Covid-19 related to his/her roommate was Covid positive. Continued review revealed Resident #1 refused to allow staff to test him/her for Covid-19. Further review revealed the resident was refusing to drink/eat much and the physician was notified with orders received to start on Paxlovid (a medication used to treat Covid symptoms) and Albuterol (a medication used to treat wheezing and shortness of breath) inhaler, and obtain a chest x-ray. However, there was no documented evidence to suppot the chest x-ray had been obtained. During an interview with the Speech Therapist, on 02/05/2024 at 10:51 AM, she stated she assessed residents for any swallowing difficulties and wrote orders based on any difficulties she found. She further stated Resident #1 was changed from a regular diet to a mechanical soft diet on 01/03/2024 due to coughing with meal intake and signs that he/she was having difficulty swallowing. She continued to state the resident was scheduled for a modified barium swallow on 01/09/2024 but was unable to attend the appointment and she downgraded his/her diet to pureed with nectar thick liquids due to his/her continued swallowing difficulties and risk for aspiration. Additionally, she stated she completed the Diet Requisition Form and gave a copy to the nursing and dietary departments on 01/09/2024, but was unsure why a physicians order had not been written. During an interview with Advanced Practice Registered Nurse (APRN) #1, on 02/06/2024 at 9:25 AM, she stated it was important for nursing staff to document accurate information in the medical record so the physician or APRN could determine if referrals should be made to dietary or therapy or make any necessary recommendations or order changes based upon the resident's vital signs, weight results, and medication refusals. She further stated it was her expectation the facility staff document complete and accurate information in the residents medical record. During an interview with APRN #2, on 02/06/2024 at 9:44 AM, she stated it was her expectation staff document all vital sign results, medication administration, and refusals appropriately in order to make any necessary changes to his/her orders. She further stated she was asked to see Resident #1 on 01/04/2024 because his/her breathing was more rapid and the nurse thought he/she might be having an anxiety attack. She stated she assessed the resident to have an oxygen saturation of seventy-seven percent (77%) at that time and ordered him/her sent to the Emergency Room. However, review of the Progress Note for 01/24/2024 revealed the resident had an oxygen level of 99%, and there was no evidence to support staff had documented vital signs on the MAR/TAR for 01/24/2024. During an interview with the Medical Director (MD), on 02/06/2024 at 10:46 AM, he stated it was important for each residents information be documented accurately and completely because he needed a complete picture of the resident in order to make informed decisions regarding the care of the resident. He further stated he expected the nursing staff to maintain a complete and accurate medical record for each resident. During an interview with the Director of Nursing, on 02/06/2024 at 11:40 AM, she stated it was her expectation that staff accurately document complete and accurate information on the resident's MAR/TAR per physician orders. She further stated it was ultimately her responsibility to ensue the information was documented and the facility had identified any issues with documentation and she stated she was working to educate staff on accurately documenting complete information each shift. During an interview with the Administrator, on 02/06/2024 at 2:45 PM, he stated it was his expectation staff follow the policies of the facility and document and report care as given or refused so the resident's care planning could be changed if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review it was determined the facility failed to ensure a resident was treated in a dignified and respectful manner for one (1) of thirty-two (32) sampled residents, Resident #7. Observations revealed the Director of Nursing (DON) conversed with Resident #7 at the resident's bedside. Interview with Resident #7 revealed the resident cried because he/she was angry and stated he/she felt the DON was rude and was treated the resident as a child. The findings include: Review of the facility policy, Quality of Life-Dignity, revised 10/2009, revealed the facility was to care for a resident in a manner which promoted respect. The facility was to treat residents with dignity and respect at all times. The staff were to speak to the resident respectfully at all times. Review of the facility policy, Resident Rights Standard of Practice, reviewed 09/17, revealed the facility's standard of practice included the right to a dignified existence which included communication with persons inside of the facility. Review of the facility resident admission packet, undated, revealed a form titled, Resident Rights under Federal Law, revealed item number three (3) indicated the resident was to have the right to a dignified existence. Review of the DON's Orientation Packet, dated 06/15/15, the DON signed the Resident Rights to acknowledge to have read and understand the rights of facility residents. The DON's signature was dated 02/07/16. Review of Resident #7's clinical chart revealed the facility admitted the resident on 11/04/16 with the diagnoses including Multiple Sclerosis, Quadriplegia, and Major Depressive Disorder. Review of Resident #7's Quarterly Minimal Data Set (MDS), dated [DATE], revealed the facility evaluated Resident #7's cognition with the Brief Interview for Mental Status (BIMS) exam, dated 09/07/19, and assessed the resident with a score of fifteen (15) and determined the resident was interviewable. Observation, on 09/12/19 at 11:16 AM, revealed the DON entered Resident #7's room and the door to the room was not shut. The DON and Resident #7 discussed the requirement of moving to a room further up the hallway to have better Internet connectivity. The DON stated to Resident #7 in order to acquire better internet connectivity, as the Administrator had already discussed with him/her, it would require a change of rooms. The DON asked Resident #7 if he/she wished to change his/her room and the resident stated no. Observation, on 09/12/19 at 11:18 AM, revealed Resident #7 was red in the face and appeared to be upset. Interview with Resident #7, on 09/12/19 at 11:18 AM, revealed the DON came across in the discussion as so forceful he/she was taken aback by the whole attitude. Resident #7 stated he/she cried because he/she was angry with the DON's tone of voice. Resident #7 stated he/she was admitted to the room he/she was in and he/she was a large person and the items needed to take care of him/her would not fit in a double occupancy room. Interview with the DON, on 09/12/19 at 11:39 AM, revealed he expected staff to approach residents in a professional manner which included speaking to the resident with respect. He further stated he would not want to be spoken to in a rude and demeaning tone or manner and he stated Resident #7 did not have a reaction while he was conversing with the resident. The DON stated he was not aware his approach and demeanor to the resident was received as forceful. He stated treating a resident with dignity included the way you spoke to a resident and staff were to be respectful to residents at all times. Further interview with Resident #7 on, 09/13/19 at 10:38 AM, revealed he/she told the administrator he/she cried yesterday after the DON left the room because he/she was in shock as to how he/she was spoken too. The resident stated he/she told the administrator the DON came at him/her forcefully, spoke to him/her like a child, and it was demeaning. Resident #7 stated he/she was still in shock from yesterday. Interview with Staff Development Director, on 09/12/19 at 02:21 PM, revealed staff were trained on resident dignity and respect and staff were to treat residents with respect and dignity as they would treat their parents at home. She stated staff were to show respect and dignity by tone of voice and body language and speak to residents in a calm and collected voice. She stated speaking to residents in any other manner it could be considered disrespectful and undignified. She stated the DON was not educated by her on respect and dignity. Interview with the Administrator, on 09/12/19 at 3:06 PM, revealed Resident #7 stated to her he/she was hurt and the DON was very rude. She further stated facility staff were to follow policy and procedure in regard to resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview it was determined the facility failed to revise a comprehensive care plan for one (1) resident out of thirty-two (32) residents, Resident #9. Resident #9 had behaviors of entering resident's room without consent and watching them sleep. Resident #9's comprehensive care plan was not updated to reflect this behavior. The findings include: Record review of the facility policy titled, Comprehensive Care Plan Standard of Practice, with revised date of 11/2017, revealed a comprehensive person-centered care plan for each resident, consistent with resident right, include measureable objective and time frames to meet a resident's medical, nursing, and mental and psychosocial need are identified in the resident's comprehensive assessment. The policy further revealed each comprehensive care plan would reviewed and revised by the interdisciplinary team after each comprehensive, significant change of condition and quarterly Minimum Data Set (MDS) assessment. Record review of the clinical record for Resident #9 reviewed the facility admitted the resident on 04/11/19 with diagnoses of Chronic Obstructive Pulmonary Disease, Benign Prostatic Hyperplasia, Chronic pain syndrome, Muscle weakness, lack of coordination, cognitive communication deficit, and mood disorder due to known physiological condition. Record review of the admission MDS, dated [DATE], revealed Resident #9 had a Brief Interview of Mental Stats (BIMS) of ten (10) out of fifteen (15), which indicated the resident was moderately cognitive impaired and interviewable. Resident #9 was assessed to not be a wanderer, needed limited assistance for bed and transfers. Resident #9 used mobility devices of a walker and a wheelchair. Review of Psychiatric note, dated 08/08/19, revealed Resident #9 to be mildly confused, had memory borderline, mood was labile, unorganized thought process, and impaired psychomotor activity along with impaired impulse control. Review of the Comprehensive Care Plan (CCP), initiated 04/17/19, revealed the resident exhibited alteration in mood/behavior as evidenced by: at times resident had aggression and verbal behavior symptoms toward others. Interview with Licensed Practical Nurse (LPN) #4, on 09/12/19 at 3:05 PM, revealed Resident #9 was found in Resident #1's room at the foot of Resident #1's bed, while the resident was sleeping. She stated Resident #9 only went into Resident #1's room and thought Resident #9 just wanted to see the resident. Further review of the CCP revealed there was no evidence the CCP was updated for Resident #9's conduct. Interview with Resident #1, on 09/12/19 at 11:17 AM, revealed she/he felt afraid at night because Resident #9 would enter his/her room and watch him/her sleep without his/her consent. Resident #1 stated he/she did not want Resident #9 watching him/her sleep because it was creepy. Resident #1 reported the incident to the nursing staff and staff would re-directed Resident #9 out of his/her room; however, it continued to occur. Resident #1 stated, Resident #9 was not his/her significant other, and was old enough to be his/her parent. Observations of Resident #9, from 09/11/19 through 09/13/19, revealed resident was either sleeping in bed, in the dining area, or self-propelling down the hallway. Observations of Resident #9, on 09/11/19 at 3:28 PM, revealed he/she was in bed with eyes closed. Observation of Resident #9, on 09/12/19 at 10:20 AM, revealed self-propelling to the dining area alone and sat with others. Interview with Resident #9's daughter, on 09/12/19 at 11:00 AM, revealed she was the Power of Attorney (POA) for the resident and had attended each care plan meeting. However, during these meeting there was no mention of resident wandering into other resident's rooms or re-directed from resident's rooms. Interview with Minimum Data Set (MDS) Coordinator, on 09/13/19 at 2:49 PM, revealed she was not aware of Resident #9's behavior of entering Resident #1's room while he/she was sleeping and watching him/her sleep. She stated care plans were created and updated to represent resident's individual needs. Furthermore, nursing staff could update the care plan at any time, with interventions for resident safety. The interdisciplinary team (IDT) met five (5) days per week at the clinical morning meeting to review the interventions on the care plan for appropriateness. If a resident report having concerns about being scared of another resident, the resident's care plan intervention should be updated. Interview with the Unit Manager (UM), on 09/13/19 at 4:02 PM, revealed she was aware Resident #9 went into Resident #1's room without his/her consent at night. However, had not followed up to ensure the plan of care was revised to meet Resident #1's care needs. She stated care plans painted a picture of the resident for the nursing staff to follow their care needs. The UM expected staff to follow the care plan so each resident would have the proper care and if not, the resident could have an adverse effect, such as behaviors. She reported she did not conduct audits on care plans; but assumed the Director of Nursing completed audits. Interview with Assistant Director of Nursing (ADON), on 09/13/19 at 4:10 PM, revealed stated if Resident #1 was sleep and Resident #9 tried to enter the room, Resident #9 would be asked to leave due to lack of consent. However, she was unaware of Resident 39's behavior of entering Resident #1's room without consent. She stated the care plans were to provide individual care to the resident, and should reflect the care for nursing staff to refer back to the intervention. The ADON states the CNAs conveyed resident behaviors to the nursing staff, who documented the behaviors in the nursing notes.Furthermore, if the behaviors were a safety concern, any nurse could update the care plan, at any time. She went on to explain, care plans were to be update immediately when a care need was identified with a new intervention or treatment for the resident. Care plans were reviewed in the clinical meeting every morning five (5) days per week and once per week at the IDT meeting for a second review. The ADON reported if the care plan was not updated with a new intervention, it could lead to harm and the staff would not be aware. Interview with Advanced Practice Registered Nurse (APRN), on 09/13/19 at 5:26 PM, revealed he was not aware of the allegation of sexual abuse between Resident #1 and Resident #9. APRN state if Resident #1 reported a problem such as sexual abuse against another resident, the concern needed to be care planned. He stated the purpose of the care plan was to provide the facility with a strategy for staff to follow, which would influence the resident's safety and dignity. Interview with Director of Nursing, on 09/13/19 at 5:06 PM, revealed care plans were developed for residents everyday care needs with the expectation for nursing staff to follow at all times. If the care plans was not follow or updated, it could lead to a negative outcome for the resident. Furthermore, at the IDT meeting, the care plans were reviewed and updated as needed. Interview with the Administrator, on 09/13/19 at 7:02 PM, revealed Care Plan meetings were significant to gain information from the resident, resident's representative and the interdisciplinary team in developing and revising the care plan. Further, the care plan served as a guideline for staff in caring for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide accessible water to encourage hydration for one (1) of thirty-two (32) sampled residents, Resident #7. Observations for four (4) of four (4 ) survey days revealed no [NAME] water container within access for Resident #7. The findings include: The facility did not provide any policy related to resident hydration. Review of the clinical record revealed the facility admitted Resident #7 on 11/04/16 with diagnoses including Multiple Sclerosis. Review of the comprehensive care plan for Resident #7 revealed the problem, potential for constipation related to immobility with the intervention resident prefers [NAME] pack to left shoulder. Observation and interview of Resident #7, on 09/10/19 at 10:43 AM, revealed no [NAME] pack near the resident. Continued observations revealed a [NAME] pack on the other bed in the resident's room. Resident #7 stated he/she was a full assist and relied on staff to provide hydration when the [NAME] pack was not in place. Observation of Resident #7's room, on 09/11/19 at 3:28 PM, revealed the [NAME] pack appeared full and lying on the refrigerator, out of the resident's reach. Observation of Resident #7's room, on 09/12/19 at 10:10 AM, revealed the [NAME] pack lying on top of the refrigerator, across the room from the resident. Observation of Resident #7's room, on 09/13/19 at 10:26 AM, revealed the [NAME] pack lying on top of the refrigerator, across the room from the resident. Interview with Certified Nursing Assistant (CNA) #4, on 09/13/19 at 3:06 PM, revealed she was aware Resident #7 utilized a [NAME] pack for hydration but stated we don't use it. CNA #4 stated a resident who did not receive enough fluids could become dehydrated which could affect the residents bowels. Interview with Licensed Practical Nurse (LPN) # 1, on 09/13/19 at 3:12 PM, revealed she was aware Resident #7 utilized a [NAME] pack for hydration. LPN # 1 stated Resident #7 also had a cup with straw at the bedside but added the resident could not access the cup and straw without assistance. She stated Resident #7 could also call for assistance if he/she wanted some water. LPN # 1 stated a resident without adequate hydration could become constipated. Interview with the Unit Manager (UM), on 09/13/19 at 4:02 PM, revealed staff assisted with resident hydration needs by passing ice water and assisting with fluids when residents requested assistance. The UM stated the facility care planned a [NAME] pack for Resident #7 to have at all times, but staff provided the [NAME] pack when requested. The UM stated if Resident #7 did not receive adequate hydration the resident could suffer from constipation and added staff should insure the [NAME] pack was in reach of Resident #7 at all times. Interview with the Assistant Director of Nursing (ADON), on 09/13/19 at 4:33 PM, revealed the facility care planned Resident #7 to have a [NAME] pack at his/her head daily and to remove only per resident' request. The ADON stated if the [NAME] pack is not at the resident's head then the facility needed to educate staff as the [NAME] pack provided hydration for Resident #7. Interview with the Director of Nursing (DON), on 09/13/19 at 5:06 PM, revealed staff assisted Resident #7 with all meals and hydration needs. The DON stated the facility care planned a [NAME] pack for Resident #7 to allow the resident to receive hydration without waiting for staff assistance. Interview with the Administrator, on 09/13/19 at 7:02 PM, revealed the facility had not identified concerns regarding resident hydration concerns.

Based on interview, review of grievance forms and logs, and facility policy review, it was determined the facility failed to report the findings and actions of the facility to the Resident Council. Interviews with resident council members revealed the monthly meetings with the facility representative, the Activity Director (AD), did not include review of the previous grievances, and the facility resolution. In addition department heads responsible for the grievance review, investigation and resolution did not meet the next month with the resident council members to discuss findings, resolution and to follow up on the facility continued audit of the grievance. The finding include: Review of the facility policy, Grievance/Concern Standard of Practice, revised 03/2019, revealed the administrator of the facility was the grievance officer. The facility administrator or assigned designee was to notify the party within five (5) working days unless an extension was needed. The resident council members were able to verbalize a grievance at the council meeting. The grievance was to be documented on the facility grievance form, recorded and tracked, assigned to the department manager as it applied, review root cause and resolution, and log the resolution to the grievance log. Furthermore the name and date of when and whom the resolution was provided to be included with the process. Review of the facility Grievance/Concern Form, undated, revealed the bottom of the form contained the area for notification of resolution. The area included date of notification, name of the person who was notified by the facility, method of notification, if a written response was requested, date the response was provided and the signature of the person who completed the notification. Interview with Resident Council Members, on 09/11/19 10:01 AM, revealed Residents #7, #8, #10, #20, #30, #32, #33,#44, and #53 were in attendance for interview. Resident #7 stated the council filed complaints on staff shortages, food, and Internet connection for the facility residents. Resident #7 stated the council requested absentee ballots to vote in the Kentucky elections because residents were not able to go vote. Resident #7 stated the facility did not respond to the council for any filed grievances. Resident #7 stated the Activity Director (AD) wrote the grievance on the grievance form. The members of the council verbally agreed the facility was not responsive. Review of the facility Grievance Tracking Log, dated 6/28/19, revealed resident council reported a grievance on garbage pickup, food trays not picked up after meals, and interruptions during care. Review of the facility Grievance Form, dated 6/28/19, revealed resident council voiced concerns over the meal tray pick up times. The form was completed by the Activity Director (AD). Review of the facility Grievance Form, dated 6/28/19, revealed resident council voiced concern staff were not removing trash after staff removed wound dressings and placed the soiled dressings into the resident's trash. The form was completed by the AD. Review of the facility Grievance Form, dated 6/28/19, revealed resident council voiced concern staff were not removing trash after staff removed wound dressings and placed into the resident's trash and the form was completed by the AD. Review of the Resident Council Notes, dated 07/26/19, revealed the facility notes of the meeting lead by the AD did not include follow-up notes or discussion for the complaints of 06/28/19. Review of the facility Grievance Tracking Log, dated 7/26/19, revealed the resident council filed complaints for dietary food temperatures, the date of the meal of the month, dishes were not clean, and night snacks were not timely. Review of the facility Grievance from, dated 7/26/19, revealed three (3) forms completed by the AD. The facility did not complete or identify the staff person who investigated the concern on the three (3) forms. Further review revealed the facility did not complete the area of the grievance form for the date of notification as well as all other areas in the section and the facility staff who completed the notification was blank. Review of the facility Resident Council Notes, dated 08/30/19, revealed the AD read the notes of the last resident council notes aloud to the members who attended to the meeting but did not review results of previously filed greivances. Interview with Licensed Practical Nurse (LPN) #1, on 09/13/19 at 3:26 PM, revealed the facility staff completed a grievance form when a resident complained. LPN #1 stated the resident was to have follow up with the department head responsible for the grievance and she was unsure of a time limit for the response from the facility. Interview with the AD, on 09/13/19 at 03:36 PM, revealed she wrote up grievance forms for the resident council meetings. She stated she gave the department head a copy of the concern and gave the original to the Administrator. She stated the Administrator was the grievance officer for the facility. Additionally, the AD stted she did not bring completed grievance forms with her to the next resident council meeting for review with the council. She stated she was unaware she was to review the grievance results with the resident council at the next scheduled meeting. She stated the Administrator ensured the complaint was addressed and the facility discussed the concern and the actions the facility completed to address the concern. She stated the person who addressed and completed the grievance was to complete the form. She stated as the facility representative for the resident council she reviewed the notes from the last meeting however the results of the grievances were not included. Interview with the Unit Manager (UM), on 09/13/19 at 04:02 PM, revealed as UM she did not participate in grievance. She stated she filled out grievances and gave the form to the DON or administrator for follow through. She stated the facility was required to respond to the grievance within five (5) days . She stated the person who completed the grievance was to follow through with the person who filed the grievance to ensure the resident was knowledgeable as to what was done and completed. Interview with the Assistant Director of Nursing (ADON), on 09/13/19 at 04:33 PM, revealed grievances were to be written on the facility form and given to the department head. She stated the administrator logged the grievance and follow through to ensure it was addressed and completed. She stated the facility was to complete and report to the residents within 5 days. The person in the facility who was addressed the concern was to complete the form to ensure the process was completed. She stated concerns which were identified with the resident council meeting were to be reported back to the resident council at the next meeting. Interview with the DON, on 09/13/19 at 05:06 PM, revealed the facility grievance policy required the person who received the complaint to fill out the grievance from and pass it to the department head and to the administrator. He stated the facility investigated and followed up with the concern. The DON stated grievances from the resident council were to be handled in the same manner as if it were an individual resident. The DON stated to his knowledge the AD did not review the findings of a completed grievance with the resident council at the next meeting. He stated if the grievance form was not completely filled out then the grievance was not completed. He stated the grievance process was to ensure the residents' needs were met and to make the facility better as it addressed resident concerns which could impact all residents. Interview with the Administrator, on 09/13/19 at 07:02 PM, revealed the facility followed the grievance per the policy. She stated when the facility staff completed a grievance form a copy was given to her to track and ensure the concern was resolved. She stated when the department manager completed the process they returned the form to her and she logged it onto the grievance log. She stated if the concern required further follow through the facility would implement a Quality Assurance (QA) plan. She stated the facility department head was to complete the process by follow through with the person and or entity who requested a grievance form to be written. She stated the facility required five (5) days for follow through with grievances. She stated the AD was to follow through with resident council and get feedback from the residents. The DON follows through with the resident council president. She stated if the department head didn't follow through with the resident council members she was unable to provide an answer when the members of the resident council were notified of what was found and done to resolve the issues. She further stated the facility was to follow through with the findings of the grievance with the resident council at the monthly meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an effective infection control program to reduce the risk of the spread of infection on one (1) of two (2) units. Observation revealed three (3) soiled, unlabeled, uncovered bedpans and an uncovered and unlabeled urine hat in a resident bathroom on Heritage Hall. In addition, staff failed to maintain gastrostomy tube (G-tube) equipment cleanliness during medication administration for Resident #14. The findings include: Review of the facility's policy, Infection Control Program Standard of Practice, dated November 2017, revealed the facility was to prevent the spread of infection including clinical equipment disinfection. 1. Observation, on 06/26/18 at 9:27 AM, of rooms [ROOM NUMBERS]'s shared bathroom revealed three (3) uncovered bedpans on a shelf above the toilet. There was no visible resident labels and two (2) of the bedpans were stacked together. In addition, one (1) white urine hat (used to measure urine) was on the shelf, uncovered with no visible resident label. Observation, on 6/27/18 at 4:11 PM, of rooms [ROOM NUMBERS]'s shared bathroom revealed the urine hat and three (3) bedpans remained uncovered with no visible resident labels to identify which item belonged to which resident. Two (2) of the bedpans were stacked together. Examination by Licensed Practical Nurse (LPN) #3 revealed the two (2) stacked bedpans were soiled with a yellow and brown substance. Upon further examination, one (1) of the two (2) stacked soiled bedpans was labeled for a resident and the other was unlabeled. In addition, the third bedpan remained unlabeled. Interview with Certified Nursing Assistant (CNA) #1, on 06/28/18 at 10:52 AM, revealed bedpans were to be labeled with the resident's name, room, and bed, and after use, they were to be cleaned and placed in a bag and put on the shelf in the resident's bathroom. She stated if bedpans were not cleaned and labeled for the intended resident, there was a risk of spreading infection to other residents. Interview with CNA #4, on 06/28/18 at 3:44 PM, revealed staff was to assure urine hats were clean, labeled, and bagged before placing them on the shelf in the resident's bathroom. In addition, staff was to empty bedpans into the toilet and wipe clean of any bowel movement, then bag the bedpan, take it to the hopper room, and clean it thoroughly. She stated staff was to assure urine hats and bedpans were clean, bagged, and labeled with the resident's last name and date and placed on the shelf in the designated area for the resident as indicated by labeling on the shelf (A for bed A or B for bed B). The CNA stated without proper cleaning and labeling, the contaminated items could have been used for the wrong resident, and could have caused a resident to be infected and become sick. She stated staff was trained on proper labeling, cleaning, and storage of urine hats and bedpans multiple times including the previous week. Interview with CNA #3, on 06/28/18 at 4:02 PM, revealed he cared for the resident in room [ROOM NUMBER] on 06/26/18 during the day shift, but had not looked in the bathroom and so he was not aware the urine hat and bedpans were unlabeled, uncovered, and soiled. He stated the facility provided training to staff through computer programs, and for topics needing more attention; the Staff Development Coordinator provided an in-service to CNAs in the hall. He stated he did not know when the last time training covered proper labeling, cleaning, and storage of bedpans and urine hats. Review of In-Service Training Records, dated 05/24/18 and 06/20/18, revealed CNAs attended the trainings which included infection control related to urinals and bedpans. The trainings included when a more thorough cleaning was needed, such as after a resident's bowel movement, staff was to place the bedpans or urinals in a bag and take them to the hopper room, spray clean, place in a clean plastic bag, and return to the resident's room. Interview, on 06/27/18 at 4:12 PM, with LPN #3 revealed bedpans and urine hats were to be clean, labeled with the resident's name, room, and bed number, and placed in a bag on the bathroom shelf. She stated if bedpans were not cleaned, covered, and labeled properly there was a risk of use with the wrong resident, which could cause the spread of infection, and residents could become sick. Interview, on 06/28/18 at 4:14 PM, with the Staff Development Coordinator revealed the facility was to follow standards of practice on infection control for proper use of urine hats and bedpans. She stated she was unaware staff had left a urine hat and bedpans unlabeled, uncovered, and soiled in a resident bathroom. She stated staff was to maintain clean equipment that was labeled and bagged, and placed on the shelf in the bathroom in the area designated for the resident to reduce the risk of infection. She stated she identified problems with the practice and provided staff training in May 2018 and June 2018. Interview with Certified Medication Technician (CMT) #1, on 06/28/18 at 4:40 PM, revealed she was responsible for making rounds in rooms [ROOM NUMBERS], which included ensuring the bathroom was clean. She stated she had not seen the soiled and unlabeled urine hat and bedpans in the bathroom. She stated the items should have been labeled for the resident they were used for with the resident's room and bed number, and the date the item was placed in the bathroom to ensure the items were used for the intended resident. She stated the residents could have handled contaminated bedpans, contracted an infection, and became sick. She stated the facility provided training within the last week, which focused on whether or not bedpans and urine hats were bagged. Interview, on 06/28/18 at 4:27 PM, with the Assistant Director of Nursing (ADON) revealed urine hats and bedpans were to be cleaned appropriately, covered with a bag, labeled with the resident's name, room number, and bed, and stored in the appropriate slot on the shelf designated for the resident. He stated equipment staff left soiled, unlabeled, and uncovered could have been used on the wrong resident, which could have resulted in cross contamination and resident infection. Interview with the Administrator, on 06/28/18 at 5:19 PM, revealed she was not aware of any problems regarding staff not following expected procedures with urine hats and bedpans. She stated staff was to assure urine hats and bedpans were labeled with the resident's name and after use, they were to be dumped in the commode, cleaned, placed in a clean bag, and returned to the resident's bathroom to prevent infection from spreading. She stated unlabeled, soiled, uncovered urine hats or bedpans could be used on the wrong resident and spread infection. The Administrator stated nurses were to supervise the CNAs, make rounds, observe bathrooms, and assure items were labeled, clean, and stored properly. She stated the facility trained staff on procedures regarding bedpans in May 2018. 2. Observation of Resident #14, on 06/27/18 at 7:53 AM, revealed the resident had a G-tube and LPN #4 administered medications through the G-tube using a feeding tube syringe. The LPN removed the plunger from the syringe barrel and placed the plunger on the soiled bedside table, without a clean barrier between the plunger and tabletop. After administering medications, the LPN placed the plunger back into the barrel of the syringe and stored the syringe in the resident's bedside table, available for continued use to administer the resident's medication and flushes. Interview with LPN #4, on 06/27/18 at 8:22 AM, revealed she placed Resident #14's feeding tube syringe plunger directly on a visibly soiled bedside table and then placed the plunger back in the barrel of the syringe and stored it for later use. The LPN stated storing the contaminated plunger for later use was an infection control issue and there was a potential for the resident to acquire an infection. The LPN revealed she should have assured the bedside table was clean or should have placed the plunger on a clean barrier on the bedside table. Interview with the ADON, on 06/28/18 at 4:59 PM, revealed nurses should place feeding tube syringe plungers on a clean surface and store the plunger with the syringe barrel in a clean bag. He stated the syringe plunger contacting a soiled surface and then stored for later use posed an infection risk to the resident. He further stated nurses were trained in G-tubes and infection control. Interview, on 06/28/18 at 5:06 PM, with the Staff Development Coordinator revealed she was not aware of any issues with nursing practice regarding infection control techniques during G-tube procedures. She stated nurses were trained on G-tube procedures upon hire, and should place feeding tube syringe plungers on a clean surface. She further stated when a plunger was placed on a soiled surface; the plunger became contaminated and could cause an infection. She stated she was not aware of rounds made to assure G-tube procedures, including infection control techniques, were followed. Interview with the Administrator, on 06/27/18 at 1:51 PM, revealed the ADON had been trained on the Infection Preventionist role and the Staff Development Coordinator was to be trained in the future to assume the role. She stated the facility tracked and trended infections, which was reviewed monthly. Continued interview on 06/28/18 at 5:20 PM, revealed the nurses should follow standards of practice to prevent infection from spreading, and she was not aware of problems regarding infection control techniques with G-tube procedures.