**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for dignity. The facility failed to ensure staff treated Resident #5 with respect and dignity.Review of Resident #5's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnosis of Unspecified Dementia. Review of Resident #5's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/25/2025 revealed Resident #5 had a BIMS (Brief Interview for Mental Status) of 11, which indicated the resident had moderately impaired cognition. Further review revealed Resident #5 required substantial assistance for ADLs.Review of the most current Care Plan for Resident #5 revealed the following:Problem: Resident #5 required assistance with ADLs. Interventions: Assist with ADLsOn 08/26/2025 at 9:46 a.m., an interview was conducted with Resident #5. She stated on 08/08/2025, S3CNA grabbed her arm rough when assisting her. She stated she removed S3CNA's hand grip with her other hand and told her, You are being too rough. After S3CNA left the room, Resident #5 told S2LPN that S3CNA was always rude and disrespectful when she provided care to her. On 08/27/2025 at 3:34 p.m., an interview was conducted with S3CNA. She stated on 08/08/2025, she and S4CNA had just exited Resident #5's room from providing incontinent care and placing Resident #5 in her bed. She stated S4CNA stood outside of Resident #5's room and called her over to observe Resident #5. She stated she and S4CNA observed Resident #5 sitting on the side of her bed after they had just laid her down in the bed. S3CNA stated she entered Resident #5's room and asked, what are you doing?. She stated Resident #5 told her she wanted to go for a walk. S3CNA told Resident #5 she could not go for a walk because she cannot walk. S3CNA stated the nurse came into the room and before she grabbed Resident #5's arm to assist in transferring her, Resident #5 stated you are being too rough. S3CNA stated she exited the room at that time. On 08/27/2025 at 10:27 a.m., an interview was conducted with S4CNA. She stated on 08/08/2025, she and S3CNA had just exited Resident #5's room from providing incontinent care and placing Resident #5 in her bed. S4CNA stated she was standing outside of Resident #5's room and called S3CNA over to observe Resident #5. S4CNA stated she and S3CNA observed Resident #5 sitting on the side of her bed after they had just laid her down in the bed. S4CNA stated S3CNA entered Resident #5's room, she observed from outside of the room, and called S2LPN over because Resident #5 was not following S3CNA's request. S4CNA stated S3CNA and Resident #5 were verbally going back and forth disagreeing. On 08/26/2025 at 3:02 p.m., an interview was conducted with S2LPN. She stated on 08/08/2025, S3CNA observed S4CNA and Resident #5 in the residents room and called her to assist with Resident #5. She stated when she entered Resident #5's room, she heard S3CNA telling Resident #5 to stop in an aggravated and frustrated tone of voice. S2LPN intervened by speaking calmly and explaining to Resident #5 they would assist her getting up. She stated when she and S3CNA began to assist Resident #5 transfer to the wheelchair, Resident #5 told S3CNA to stop because she was being too rough. She stated S3CNA exited the room at that time. She stated she did not see S3CNA grab Resident #5's arm because she was assisting on her side but S3CNA was visibly frustrated and exhibited aggravation by her tone of voice and body language when she entered Resident #5's room. She stated after S3CNA left the room, Resident #5 stated S3CNA was always rude when she provided care. S2LPN confirmed S3CNA's behaviors were not appropriate when providing care to residents. On 08/27/2025 at 2:50 p.m., an interview was conducted with S1DON. He confirmed staff should never argue or disagree with residents and all residents should be treated with dignity and respect.

Based on observation, interviews, and record review, the facility failed to maintain a sanitary environment for 1 (#163) of 3 (#56, #59, and #163) residents reviewed for environment in the final sample. Findings: Review of Resident #163's Clinical Record revealed an admission date of 05/02/2024. Review of Resident #163's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/31/2024 revealed he was frequently incontinent of bowel. On 02/17/2025 at 10:09 a.m., observation of Resident #163's room revealed 8 quarter sized spots of dried brown liquid stool on the floor between his bed and the bathroom door. Observation further revealed a dried brown smear on the fitted sheet on Resident #163's bed. On 02/17/2025 at 10:11 a.m., an interview was conducted with Resident #163. He stated he an episode of stool incontinence on Saturday, 02/15/2025, evening while getting to the restroom. He stated staff did not clean all of the liquid stool from the floor and left his fitted sheet soiled. On 02/17/2025 at 10:23 a.m., an observation was made of S7CNA entering Resident #163's room. Surveyor entered the room and an interview was conducted with S7CNA. She stated she first noticed the stool on Resident #163's floor and fitted sheet between 8:00 a.m. and 9:00 a.m. on 02/17/2025 and did not clean it. She confirmed the brown stool on Resident #163's floor and fitted sheet should have been cleaned as soon as a staff member was made aware of it and had not been. On 02/19/2025 at 3:25 p.m., an interview was conducted with S1ADM. He stated it was the responsibility of the nursing staff, including the CNAs (Certified Nursing Assistants), to promote a clean, homelike environment. He confirmed it was not appropriate for stool to remain on a resident's floor or sheets and he expected nursing staff to clean up bodily fluids immediately when observed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#23) of 3 (#23, #75, and #135) residents reviewed for hospice. The facility failed to ensure Resident #23 was coded correctly for hospice. Findings: Review of Resident #23's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Adult Failure to Thrive. Review of Resident #23's Physician Orders revealed in part, the following: Admit to Hospice, active 05/31/2024. Review of quarterly MDS assessment with ARD of 07/30/2024 revealed in Section O0110.K1. Hospice care: While a resident: No. Review of quarterly MDS assessment with ARD of 10/02/2024 revealed in Section O0110.K1. Hospice care: While a resident: No. An interview was conducted on 02/18/2025 at 2:15 p.m. with S4MDS. She reviewed Resident #23's MDS assessments dated 07/30/2024 and 10/02/2024. She confirmed both quarterly MDS assessments were not coded correctly for Hospice and should have been. An interview was conducted on 02/19/2025 at 11:15 a.m. with S2DON. She reviewed Resident #23's MDS assessments dated 07/30/2024 and 10/02/2024. She confirmed both quarterly MDS assessments were not coded correctly for Hospice and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASRR) Level II by failing to incorporate a PASRR Level II determination and recommendations into a resident's care plan for 1 (#167) of 4 (#23, #50, #108, and #167) residents reviewed for PASRR. Findings: Review of Resident #167's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Generalized Anxiety Disorder, Schizophrenia, and Paranoid Schizophrenia. Further review revealed he was approved for admission by Level II Authority for a temporary period effective 12/07/2024 through 12/06/2025. Review of Resident #167's Level II Evaluation Summary & Determination Notice revealed the following, in part: OBH approving 365 days for nursing facility placement and the following to occur: Behavioral Health IOP, Crisis Planning, and Assessment for Dementia. On 02/19/2025 at 8:55 a.m., review of Resident #167's current Care Plan revealed no documentation of a PASRR Level II determination and recommendations. On 02/19/2025 at 1:22 p.m., an interview was conducted with S6SSD. She stated she was responsible for incorporating recommendations for residents from their PASRR Level II determinations. She verified Resident #167 had a current PASRR Level II with recommendations. She stated if a resident had a PASRR Level II, the recommendations should be incorporated into the resident's care plan. She stated the care plan nurse was responsible for adding the PASRR Level II information to the resident's care plan. On 02/19/2025 at 2:18 p.m., an interview was conducted with S5MDS. She stated she was responsible for completing Resident #167's care plan. She verified Resident #167 had a PASRR Level II. She reviewed Resident #167's current care plan and stated prior to today, Resident #167's PASRR Level II determination and recommendations were not incorporated into his care plan and should have been. On 02/19/2025 at 2:36 p.m., an interview was conducted with S4MDS and S2DON. They verified Resident #167 had a PASRR Level II. They confirmed Resident #167's care plan should have been updated to incorporate the PASRR Level II determination and recommendations in December 2024 when the facility received the PASRR Level II from OBH, and it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene by failing to ensure each resident received scheduled showers for 1 (#56) of 4 (#56, #57, # 63, and #110) residents reviewed for ADLs. Findings: Review of facility's policy titled, Bath, Shower Policy and Procedure, dated 09/14/2014 revealed the following in part: Policy: Showers are to be given as scheduled and/or as needed. Resident #56 Review of Resident #56's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Orthopedic Surgery, Seizures, Morbid Obesity, and Unsteadiness on feet. Review of Resident #56's Quarterly MDS with ARD of 01/01/2025 revealed a BIMS of 15, which indicated she was cognitively intact. Further review of the MDS revealed she used a wheelchair for mobility and required supervision or touching assistance with showering. Review of Resident #56's Current Care Plan revealed the following, in part: Problem: Problem: Resident has an ADL self-care performance deficit r/t right shoulder fracture, Osteoarthritis debility, and generalized weakness. Staff assists with bed mobility, transfers, eating, toileting, bathing, personal hygiene, dressing and grooming. Review of Resident #56's ADL Documentation revealed she was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. Further review of ADL Documentation revealed she did not receive her scheduled shower on Saturday 02/08/2025 which left her without a shower for 4 days. On 02/17/25 at 01:59 p.m. an interview was conducted with Resident #56. She stated she did not get a shower for a week when shower aide was scheduled off for vacation. She stated she was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays and she never refused her showers. On 02/18/25 at 12:50 p.m. an interview was conducted with S12CNA. She stated she was one of two shower aides in the facility. She stated she was on vacation from 02/07/2025 to 02/16/2025, returning on 02/17/2025. She stated when she is off the hall CNAs should shower the residents. She stated if a resident refused a shower she would let the CNA or nurse on the hall know and it was documented in the computer under ADLs. She confirmed Resident #56 received showers on Tuesdays, Thursdays, and Saturdays. She stated Resident #56 informed her she did not receive a shower for the week she was out on vacation. She further stated Resident #56 never refused a shower. She stated there should be documentation if a resident misses a shower and a reason given. On 02/18/25 at 1:15 p.m. an interview was conducted with S14SUP. She stated hall CNAs assist residents with showers if the shower aid is out. She stated residents should receive showers on their assigned days and it should be documented in the computer. On 02/19/25 at 1:59 p.m. an interview was conducted with S11CNA. She confirmed she was one of the aides assigned to Resident #56's hall. She stated it was her responsibility to shower residents if the shower aide was off. She further stated she always documented when a shower was given or a reason a shower was not given. She confirmed if there was no documentation on the ADL Documentation, then the shower was not given. On 02/19/2025 at 1:45 p.m. an interview was conducted with S10CNA. She confirmed she was one of the aides assigned to Resident #56's hall. She stated it was her responsibility to shower residents if the shower aid was off. She stated she had not showered Resident #56 at all in the month of February 2025. She confirmed if there was no documentation on the ADL Documentation, then the shower was not given. On 02/18/25 at 1:34 p.m. an interview was conducted with S13ADON. She reviewed Resident #56's ADL Documentation and confirmed there was no documentation for a shower being given on Saturday 02/8/2025. She confirmed if a shower was given there should have been documentation. She stated Resident #56 should have received a shower on Saturday 02/8/2025 and according to documentation she did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to administer parenteral fluids consistent with professional standards of practice for 1(#57) of 1(#57) residents reviewed for IV (Intravenous) fluid therapy. The facility failed to monitor, flush, and replace the saline lock IV access site according to professional standards. Findings: Review of the undated facility Policy Titled, Intravenous Therapy Flush and Dressing Protocol revealed, in part: Peripheral Device: 1. Follow SASH protocol daily and as needed. Flush device with 3ML Normal Saline and 2ML Heparin 100 units/ML 2. Change dressing every three days and as needed according to policy. 3. IV site to be monitored for complications. 4. IV site to be rotated every three days and as needed as appropriate. Review of Resident #57's Medical Record revealed the resident was admitted to the facility on [DATE] with a diagnoses which included Pneumonia and Dehydration. Review of Resident #57's MDS (Minimum Data Set) ARD (Assessment Reference Date) 01/20/2025 revealed BIMS (Brief Interview for Mental Status) of 15 indicating Resident #57 was cognitively intact. Review of Resident #57's physician orders, dated February 2025, revealed an order on 02/11/2025 and 02/12/2025 for Resident #57 to receive IV fluids. Further review revealed no physician orders for an assessment daily, flushing daily, or discontinuation of Resident #57's peripheral IV site. Review of Resident #57's Medication Administration Record (MAR), dated February 2025, revealed no documented evidence of an assessment daily, flushing daily, or discontinuation of Resident #57's peripheral IV site. On 02/17/2025 at 12:06 p.m., an observation of Resident #57's peripheral IV site to his right forearm was not visible and covered with an undated non-transparent, elastic ace dressing. On 02/18/2025 at 10:49 a.m., an observation of Resident #57's peripheral IV site to his right forearm was not visible and covered with an undated non-transparent, elastic ace dressing. An interview was conducted at this time, Resident #57 stated his IV hurt when he moved his hand and it had not been changed, flushed, or used since 02/12/2025 when he received IV fluids. On 02/18/2025 at 3:00 p.m., an observation of Resident #57's peripheral IV site to his right forearm was not visual and covered with an undated non-transparent, elastic ace dressing. On 02/18/2025 at 3:15 p.m., an observation of Resident #57's IV site was conducted with S8LPN. S8LPN confirmed Resident #57's peripheral IV site to his right forearm was not visual and covered with an undated non-transparent, elastic ace dressing. An interview was conducted at this time with S8LPN who stated she was assigned to Resident #57 on 02/17/2025 and 02/18/2025. She stated she did not know when Resident #57 received the peripheral IV site or when the last time the site was flushed. She confirmed she did not flush Resident #57's peripheral IV site on 02/17/2025 and 02/18/2025. On 02/18/2025 at 4:50 p.m., an interview was conducted with S2DON. S2DON confirmed Resident #57's IV site was inserted in his right forearm on 02/11/2025 and it was discontinued on 02/18/2025. She stated IV sites should be assessed and flushed daily and changed every 3 days. She further stated the above should be documented on the MAR. S2DON confirmed there was no documented evidence Resident #57's IV site was assessed or flushed daily and should have been changed or removed by 02/14/2025.

Based on observations and interviews, the facility failed to store food under sanitary conditions by failing to ensure food was properly labeled and stored in unit refrigerators. This deficient practice had the potential to affect 81 residents who were able to store and consume food in the facility's unit refrigerator. Findings: Review of the facility's policy titled Use and Storage of Food from Outside the Facility dated 12/11/2017 revealed the following, in part: Procedure: 1. The resident may maintain food brought in by family or visitors .in the facility refrigerator as long as it is maintained/stored in a sanitary conditions: a. storage conditions: i. Sealed container, with resident's name and date. On 02/17/2025 at 11:15 a.m., a tour was made of NS1 with S3LPN. An observation was made of the resident's unit refrigerator which contained the following items: 1 brown paper bag with a wrapped breakfast sandwich with no date or name; 1 plastic container with a lid containing an unknown food with no date; 1 plastic container with a lid containing an unknown food with no date or name; 1 20 ounce foam cup with a lid containing a pink liquid with no date or name; and 1 plastic container with a lid containing an unknown food with no date or name. On 02/17/2025 at 11:18 a.m., an interview was conducted with S3LPN. She stated staff should label all outside food items with the resident's name and a date. S3LPN confirmed the above mentioned items were not properly labeled and should have been. On 02/18/2025 at 1:25 p.m., an interview was conducted with S2DON. She stated she was made aware of the unlabeled resident food items stored in the unit refrigerator located in NS1. She confirmed any food items brought in from outside of the facility should be labeled with a date and the resident's name when stored in the unit refrigerator located in NS1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure nursing staff communicated a resident's significant change in condition to the physician when a nurse identified a deformity in a resident's leg for 1 of 1 (#3) residents reviewed for an injury of unknown origin. Findings: Review of the facility policy titled, Change in Condition Policy and Procedure with a revision date of 08/27/2018 revealed the following, in part: Procedure: 3. The resident's primary physician or designated alternative will be contacted promptly of a significant change in the resident's status. Review of Resident #3's clinical record revealed the Resident was admitted to the facility on [DATE] and had diagnoses, which included Restless Leg Syndrome, Pain Unspecified, Thrombocytopenia Unspecified, and Age-Related Osteoporosis without Current Pathological Fracture. Review of Resident #3's Quarterly MDS with an ARD of 07/10/2024 revealed a BIMS of 6 which indicated severe cognitive impairment. On 10/08/2024 at 9:27 a.m., an interview was conducted with S3LPN. S3LPN stated the aide reported Resident #3's left leg looked deformed early in the morning on 09/26/2024. S3LPN stated she assessed Resident #3's left leg and it was deformed. S3LPN was unable to provide an exact time this occurred. S3LPN stated Resident #3 never complained of pain on her shift S3LPN confirmed Resident #3's deformed left leg was not reported to the physician. S3LPN confirmed she should have reported Resident #3's deformed left leg to the physician. On 10/08/2024 at 12:49 p.m., an interview was conducted with S5NP. S5NP confirmed S3LPN did not report Resident #3's left leg deformity. S5LPN confirmed she was made aware of Resident #3's left leg deformity when S4LPN notified her mid-morning on 09/26/2024. S5NP stated Resident #3 was not in pain. S5NP stated when she attempted to move the left leg the resident only winced and said ooh. S5NP stated Resident #3 did not holler during the assessment. S5NP confirmed she would have expected S3LPN to report Resident #3's deformed left leg. On 10/08/2024 at 10:02 a.m., an interview was conducted with S2DON. S2DON confirmed S3LPN did not report Resident #3's left leg deformity. S2DON confirmed if staff saw the deformity of Resident #3's left leg she would expect staff to notify her and the Nurse Practitioner.

Based on observations, interviews, and record review, the facility failed to implement a resident's comprehensive person-centered care plan by failing to implement Physician's Orders for 2 (#6 and #7) of 6 (#1, #2, #3, #6, #7, and #8) residents reviewed for comprehensive care plans. The facility failed to ensure the following Physician Orders were implemented: 1. Resident #6's wheelchair alarm and visual cue to wheelchair brakes; and 2. Resident #7's TED hose. Findings: 1. Resident #6 Review of Resident #6's Clinical Record revealed an admission date of 08/03/2017 and diagnoses, which included Acquired Absence of Right Leg Below Knee, Acquired Absence of Left Leg Below Knee, History of Falling, and Generalized Muscle Weakness. Review of Resident #6's Current Physician Orders dated October 2024 revealed the following, in part: Start date: 09/25/2024 - Chair alarm to wheelchair Start date: 06/03/2024 - Visual cue to wheelchair brakes Review of Resident #6's Quarterly MDS with an ARD of 09/11/2024 revealed, in part, a BIMS summary score of 13, which indicated she was cognitively intact. An observation and concurrent interview was conducted with Resident #6 on 10/09/2024 at 9:10 a.m. She was seated in her room in her wheelchair. There was no alarm in her wheelchair. There was no visual cue for her wheelchair brakes present. Resident #6 stated she had not had an alarm in her wheelchair. An observation was made of Resident #6 on 10/09/2024 at 9:18 a.m. with S2DON present. S2DON confirmed Resident #6 did not have a visual cue for wheelchair brakes or a wheelchair alarm present. An interview was conducted with S6LPN on 10/09/2024 at 9:21 a.m. She reviewed Resident #6's current Physician Orders and confirmed there were orders for visual cue to wheelchair brakes and a chair alarm to wheelchair. She confirmed Resident #6 had been up in her wheelchair today and had not had a wheelchair alarm and no visual cue to wheelchair brakes. She confirmed the orders should have been implemented and were not. An interview was conducted with S7ADON on 10/09/2024 at 10:16 a.m. She confirmed the orders for Resident #6's wheelchair alarm and wheelchair brake cues should have been implemented as ordered. 2. Resident #7 Review of Resident #7's Clinical Record revealed an admission date of 04/25/2023 and diagnoses, which included Encounter for Other Orthopedic Aftercare. Review of Resident #7's current Physician's Orders dated October 2024 revealed, in part, to apply TED hose in the morning and remove at bedtime. An observation was made of Resident #7 on 10/08/2024 at 3:20 p.m. Resident #7 did not have on her TED hose. An observation was made of Resident #7 on 10/08/2024 at 3:26 p.m. with S8CNA present. Resident #7 did not have on her TED hose. S8CNA confirmed Resident #7 was not wearing the TED hose. S8CNA located Resident #7's TED hose on the top of the microwave and stated they were in the same place she put them yesterday evening. An interview was conducted with S9LPN on 10/09/2024 at 3:23 p.m. She confirmed she was the day nurse for Resident #7 on 10/08/2024. She confirmed Resident #7 did not have on her TED hose on 10/08/2024 as ordered and should have. An interview was conducted with S2DON on 10/09/2024 at 3:28 p.m. She confirmed if a resident had TED hose ordered, they should have been on the resident as ordered.

Based on observations, interviews, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as possible by failing to implement an intervention after a fall for 1 (#6) of 3 (#1, #3, and #6) residents reviewed for accidents. Findings: Review of the facility's policy titled, Incident and Accident Policy and Procedure dated 05/08/2018 revealed the following, in part: Purpose: To assure that any resident who is involved in an incident or accident is evaluated and received treatment as warranted and that we monitor the resident's status with appropriate intervention applied to prevent further incidents. Procedure: 4. Investigative Action: c. The Director of Nursing or designee ensures that the resident is assessed for intervention to prevent future incidents. 7. Instructions for further follow-up by Director of Nursing or designee: a.This discussion should include intervention and update of plan of care. b. The Director of Nursing or designee should review incidents and accidents in high risk meeting to follow up and evaluate the effectiveness of interventions implemented. Review of Resident #6's Clinical Record revealed an admission date of 08/03/2017 and diagnoses, which included Acquired Absence of Right Leg Below Knee, Acquired Absence of Left Leg Below Knee, History of Falling, and Generalized Muscle Weakness. Review of Resident #6's Current Physician Orders dated October 2024 revealed the following, in part: Start date: 09/25/2024 - Chair alarm to wheelchair Review of Resident #6's Quarterly MDS with an ARD of 09/11/2024 revealed, in part, a BIMS summary score of 13, which indicated she was cognitively intact. Review of Resident #6's Incident Report dated 09/23/2024 revealed the following, in part: Description: Called by CNA to resident's room at 10:50 p.m. Upon arrival, resident was lying on the floor. Review of the Incident Audit Report for incident date of 09/23/2024 revealed the following, in part: Nurse Practitioner ordered chair alarm to be placed in wheelchair. Review of Resident #6's current Care Plan revealed the following, in part: Problem: The resident at risk for falls related to Bilateral Below the Knee Amputations. 09/23/2024 Resident was found on the floor in her room. Interventions: 09/23/2024 - Chair alarm to wheelchair An observation and concurrent interview was conducted with Resident #6 on 10/09/2024 at 9:10 a.m. She was seated in her room in her wheelchair. There was no alarm in her wheelchair. Resident #6 stated she had not had an alarm in her wheelchair. An observation was made of Resident #6 on 10/09/2024 at 9:18 a.m. with S2DON present. S2DON confirmed Resident #6 did not have a wheelchair alarm present. An interview was conducted with S10CNA on 10/09/2024 at 9:30 a.m. She stated Resident #6 fell recently. She stated she always encouraged Resident #6 to call for assistance before trying to get up on her own, however, a lot of times Resident #6 performed things without calling for assistance. She confirmed Resident #6 did not have a wheelchair alarm in her chair. An interview was conducted with S6LPN on 10/09/2024 at 9:21 a.m. She stated Resident #6 had a fall recently. She reviewed Resident #6's current Physician Orders and confirmed there was an order for a chair alarm to her wheelchair. She stated the wheelchair alarm was an intervention to help prevent Resident #6 from falling, and it should have been implemented. She confirmed Resident #6 had been up in her wheelchair today and had not had a wheelchair alarm. An interview was conducted with S7ADON on 10/09/2024 at 10:16 a.m. She stated the intervention for Resident #6's fall on 09/23/2024 was a chair alarm in her wheelchair. She stated the wheelchair alarm should have been in place to help prevent falls for Resident #6, and it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident received the necessary services to maintain personal hygiene for 1(#3) of 3(#1, #2, and #3) residents reviewed for Activities of Daily Living. Findings: Review of the facility's policy titled, Bath, Shower Policy and Procedure, dated 09/04/2014 revealed the following, in part: Policy: Showers are to be given as scheduled and/or as needed. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #3's admission MDS with an ARD of 05/22/2024 revealed Resident #3 required substantial/maximum assistance with bathing. Review of Resident #3's Care Plan revealed the following, in part: Onset: 05/29/2024 Problem: Require staff assistance with ADLs Interventions: I prefer morning showers and assist me with bathing, I require assistance with ambulation. On 06/26/2024 at 1:22 p.m., an interview was conducted with S7CNA. She stated the bath aides were only responsible for providing showers and the floor aides were responsible for performing bed baths. She stated either the bath aide or the floor aides could document when a resident received a bath or a shower; however, she documented when she administered a shower. She confirmed Resident #3's scheduled bath days were Mondays, Wednesdays, and Fridays. She stated Resident #3 did not ever refuse a shower and if she had she would have documented the refusal. Review of Resident #3's Bath log dated 05/01/2024 through 05/31/2024 revealed Resident #3 did not receive a bath on 05/20/2024. On 06/26/2024 at 4:50 p.m., a telephone interview was conducted with S5CNA. She confirmed she was assigned Resident #3 on 05/20/2024. She stated Resident #3's scheduled bath days were Mondays, Wednesdays, and Fridays. She stated the bath aides were responsible for administering all baths. She stated the bath aide or the floor aide would document if they administered the baths. She stated Resident #3 never refused a bath. She stated she does not recall if she gave Resident #3 a bath on 05/20/2024, but if she administered a bath she would have documented it. On 06/26/24 at 1:42 p.m., an interview was conducted with S2ADON. She stated the bath aides were responsible for showers and floor aides were responsible for bed baths. She stated either could document baths depending on who administered the bath. She stated she expected staff to document the task if it was performed. She stated Resident #3 did not refuse baths. She confirmed Resident #3's scheduled bath days were Mondays, Wednesdays, and Fridays. After reviewing the bath logs dated 05/01/2024 through 05/31/2024, S2ADON confirmed Resident #3 did not received a bath on 05/20/2024 and should have. On 06/26/2024 at 4:00 p.m., an interview was conducted with S1DON. She stated Resident #3's scheduled bath days were Mondays, Wednesdays, and Fridays. She stated she expected Resident #3, who was admitted on [DATE], to have been bathed on 05/20/2024, her scheduled bath day, and confirm she was not. She stated she expected staff to document care provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced proper hand hygiene and cleaning techniques during incontinence care for 1 (#1) of 2 (#1 and #2) residents reviewed for incontinent care. Finding: Review of the facility's policy labeled, Hand Hygiene with no revision date, revealed the following: Policy: Hand Hygiene shall be performed: 3. Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. 8. Before and after assisting a resident with personal care 14. Before and after assisting a resident with toileting 18. After contact with a resident's mucous membranes and body fluids or excretions 19. After handling soiled or used linens 22. After removing gloves 23. If hands will be moving from a contaminated body site to a clean body site during patient care. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE]. On 06/26/2024 at 9:31 a.m., an observation was made of S3CNA and S4CNA performing incontinent care on Resident #1. With clean gloves, S3CNA and S4CNA removed soiled top sheet and blanket off of Resident #1. S3CNA unfastened Resident #1's stool soiled brief. S3CNA and S4CNA both cleaned Resident #1's perineum area, then Resident #1 turn to her left side. S3CNA then wiped resident's sacrum removing the stool, while S4CNA assisted her by disposing the soiled wipes. S3CNA then tucked the stool soiled brief, bed pad, and fitted sheet under the resident towards her left side. With the same soiled gloves, S4CNA then handed S3CNA the clean fitted sheet, bed pad, and brief. S3CNA applied the clean items under the right side of Resident #1. Resident #1 then turned to her right side while S4CNA removed the dirty linen from under resident completely, and finished applying the new fitted sheet, bed pad, and brief under Resident #1. Resident #1 then turned on to her left side again and S3CNA grabbed the resident's barrier cream, applied it to her sacral area, then removed only her right glove that had the cream residue on it, reapplied a new glove to her right hand without performing hand hygiene, grabbed the resident's lotion and applied lotion to residents back per resident's request with the left hand which had the same glove she used to provide incontinence care. Then without removing soiled gloves or performing hand hygiene, S3CNA and S4CNA fastened each side of resident's brief. S3CNA then went into the bathroom, grabbed resident's clean gown and applied it to Resident #1 with S4CNA's assistance. S4CNA then grabbed the Resident's bed remote to adjust the bed, and applied the clean top sheet to Resident #1. S3CNA then removed soiled gloves, performed hand hygiene and stepped out to grab the linen bin. S4CNA grabbed the soiled linen put it in the linen bin and removed her soiled gloves and without performing hand hygiene, repositioned the bedside table over resident, and exited room to grab a blanket for the resident. S4CNA returned to resident's room and applied blanket to resident. On 06/26/2024 at 9:46 a.m., an interview was done with S3CNA. S3CNA confirmed she did not remove her soiled gloves or perform hand hygiene during the above observation. She stated she should have removed her gloves and performed hand hygiene after removing the soiled brief, linen, cleaning the stool from Resident #1's sacrum, and before touching the resident or her belongings. She also confirmed she did not remove her left glove, or perform hand hygiene at all during the entire care and before applying lotion to the resident, and should have. On 06/26/2024 at 9:50 a.m., an interview was conducted with S4CNA. S4CNA confirmed she did not remove her soiled gloves or perform hand hygiene during the above observation. She stated she should have removed her gloves and performed hand hygiene after removing the soiled brief, linen, cleaning the stool from Resident #1's sacrum, and before touching the resident or her belongings. She confirmed she did not perform hand hygiene after incontinence care was completed and prior to exiting Resident #1's room and should have. On 06/26/2024 at 12:05 p.m., an interview was conducted with S1DON. She stated staff should perform hang hygiene and apply clean gloves upon entering a resident's room, when going from soiled to clean during incontinence care, after completing incontinence care, and prior to exiting the resident's room. S1DON confirmed staff should not touch the resident or their belongings with soiled gloves. S1DON confirmed staff were trained to perform hand hygiene correctly and should have done so during incontinence care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to document and make prompt efforts to resolve grievances for 1 (#44) of 3 (#43, #44, and #151) residents reviewed for grievances. Findings: Review of the facility's policy titled, Grievance Policy and Procedure revealed the following, in part: Policy: The resident, family member, visitor, volunteer individual or employee has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their long term care facility stay. Policy Interpretation and Implementation: The grievance official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions, leading any necessary investigations by the facility; maintain the confidentiality of all information associated with grievances, for example the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident, family member Documentation: 1.Document grievances made by a resident, resident's family member . the grievance shall include: a. Date the grievance was received. b. A summary statement of the grievance. c. Steps taken to investigate the grievance. d. A summary of the pertinent findings or conclusions regarding the concerns. i. Record the grievance on the facility's Grievance log. Follow Up/Resolution: 1.The grievance official/compliance liaison or designee will follow up with the complainant with a resolution within 5 business days of the date that the grievance was filed. Resident #44 Review of Resident #44's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Hemiplegia unspecified affecting left side, Muscle Weakness, and Difficulty Walking. Review of Resident #44's MDS with an ARD of 12/15/2023 revealed Resident #44 had a BIMS of 15, which indicated she was cognitively intact. Review of the Grievance Log revealed no grievances filed for Resident# 44. On 03/04/2024 at 12:26 p.m., an interview was conducted with Resident #44. She stated she had ongoing problems not receiving baths/showers as scheduled. She stated she made a complaint to the staff nurse and administrator, but the issue was not resolved. In her complaint to nurse and administrator she stated she was left dirty most of the time, and goes days in the same clothes. She stated she rarely received a bath. She stated she gets angry at times due to the situation. On 03/06/2024 at 2:45 p.m., a telephone interview was conducted with Resident #44's personal representative. He stated he visited Resident #44 and her hair was dirty and there was an odor in her room on several occasions. He stated he notified S22SW Resident #44 was not getting her baths, and requested staff start bathing her. He stated he reported this several times. He stated the problem was ongoing and not resolved. He stated Resident #44 verbalized staff were not bathing her as scheduled. On 03/06/24 at 10:31 a.m., an interview was conducted with S13LPN. She stated the CNA's responsible for baths for Resident #44 should have documentied when they give her a shower/bath. She stated if the CNA's did not document the shower/ bath, it was not done. She stated Resident #44 has complained to her she was not receiving baths. She stated she was aware the resident representative complained Resident #44 was not getting bathed. She stated S11CNA was on the schedule in January to bathe Resident #44. On 03/06/24 at 10:52 a.m., an interview was conducted with S9CNA. She stated Resident #44's bath schedule was Tuesday, Thursday, and Sunday. She stated she observed Resident #44 with dirty hair, dirty clothes and unclean on several occasions. She stated she received many complaints from Resident #44 about not getting a bath. She stated the Residents representative calls and complains Resident #44 was not getting bathed. She stated the resident would have the same clothes on for days at a time. She stated she reported it to the nurse. She stated Administration was aware of the problem, and it was not resolved. On 03/06/24 at 2:31 p.m., an interview was conducted with S1DON. She confirmed S11CNA was responsible for giving and documenting the bath for Resident #44 on her scheduled shower days in January. She stated the resident representative for Resident #44 called and complained to S22SW that staff was not bathing her. She stated she was not aware if a grievance was filed. On 03/06/2024 at 2:31 p.m. an interview was conducted with S22SW. She confirmed the resident representative for Resident #44 called and complained Resident #44 was not getting her baths. S22SW confirmed no grievances were filed, and stated they should have been. She stated she handled the grievances internally herself, which was not standard policy. S22SW confirmed she was responsible for filing grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (#8 and #149) residents out of a total of 34 sampled residents by failing to ensure: 1. Resident #8 was coded correctly for the use of a chair alarm; and 2. Resident #149 was coded correctly for dialysis services. Findings: Resident #8 Review of Resident #8's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Dementia and Cognitive Communication Deficit. Review of Resident #8's Quarterly MDS with an ARD of 02/07/2024 revealed a BIMS of 3, which indicated she was severely cognitively impaired. Further review revealed the following: Section P-Restraints Chair alarm: 0. Not used Review of Resident #8's Physician Orders dated January 2024-March 2024 revealed the following: 01/29/2024-Chair alarm placed in wheelchair On 03/05/2024 at 2:23 p.m., an observation was made of Resident #8. She was sitting in her wheelchair in her room. She was observed sitting on a chair alarm pad. On 03/06/2024 at 9:23 a.m., an observation was made of Resident #8. She was sitting in her wheelchair in her room. She was observed sitting on a chair alarm pad. On 03/06/2024 at 9:55 a.m., an interview was conducted with S2LPN. She verified Resident #8 used a chair alarm while in her wheelchair. On 03/06/2024 at 10:18 a.m., an interview was conducted with S3LPN. She stated she was responsible for completing Resident #8's MDS assessments. She reviewed Resident #8's Physician Orders and verified there was an order for a chair alarm dated 01/29/2024. She reviewed Resident #8's Quarterly MDS dated [DATE], and confirmed she was not coded for the chair alarm and should have been. On 03/06/2024 at 1:35 p.m., an interview was conducted with S1DON. She reviewed Resident #8's last Quarterly MDS dated [DATE], and confirmed she was not coded for a chair alarm and should have been. Resident #149 Review of Resident #149's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus and End Stage Renal Disease. Review of Resident #149's Physician Orders dated November 2023 through March 2024 revealed he received dialysis three times weekly. Review of Resident #149's admission MDS with and ARD of 11/26/2023 revealed the following, in part: Dialysis on admission was blank, which indicated he was not receiving dialysis and dialysis while a resident was unchecked, which indicated he was not receiving dialysis. On 03/05/2024 at 12:26 p.m., an interview was conducted with Resident #149. He stated he had been on dialysis three times weekly prior to admission to the facility, and he had continued three times weekly since admission On 03/05/2024 at 1:40 p.m., an interview was conducted with S16LPN. She stated Resident #149 had been on dialysis three times weekly since admission to the facility. On 03/05/2024 at 2:17 p.m., an interview was conducted with S17MDSN. She confirmed Resident #149 had been receiving dialysis since admission. She reviewed Resident #149's admission MDS Assessment with an ARD of 11/26/2023 and confirmed dialysis was not coded on the MDS and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement a person-centered plan of care by failing to follow Physician's Orders for 1 (#43) of 3 (#36, #43, and #149) residents reviewed for nutrition. The facility failed to ensure Resident #43 received ice cream with lunch and dinner as ordered. Findings: Review of the facility's policy titled, Nourishments and Supplements revealed the following, in part: Policy: The food and nutrition service department shall adequately supply bulk nourishments/snacks, prescribed supplements, and individual snacks to meet the nutritional needs of the residents. Procedures: 1. The nutrition director maintains an updated list of prescribed supplements, individual snacks . 2. Daily, the nutrition staff will prepare and distribute prescribed supplements. Review of Resident #43's Clinical Record revealed she admitted to the facility on [DATE]. Review of Resident #43's Yearly MDS with an ARD of 12/27/2023 revealed she had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #43's current Physician Orders revealed the following, in part: (Start date: 05/29/2017) Ice cream with lunch and dinner. An observation was made of Resident #43's lunch tray on 03/05/2024 at 1:09 p.m. She did not have ice cream with her meal. An observation was made of Resident #43 eating lunch on 03/06/2024 at 1:25 p.m. She did not have ice cream with her meal. An interview was conducted with Resident #43 on 03/06/2024 at 1:25 p.m. She stated she would have liked to have ice cream with lunch and dinner. An observation was made of Resident #43 on 03/06/2024 with S20ADON present. S20ADON confirmed Resident #43 did not have ice cream on her lunch tray. An interview was conducted with S21CNA on 03/06/2024 at 10:32 a.m. She stated Resident #43 had not received ice cream on her meal trays. An interview was conducted with S19LPN on 03/06/2024 at 1:36 p.m. She stated Resident #43 liked ice cream. She confirmed Resident #43 had an order for ice cream with lunch and dinner. She confirmed Resident #43 should have received her ice cream with lunch and dinner as ordered. An interview was conducted with S7CS on 03/06/2024 at 1:42 p.m. She stated if Resident #43 had an order for ice cream with lunch and dinner, it should have been provided. She reviewed Resident #43's lunch and dinner meal cards and confirmed the ice cream should have been listed and was not. An interview was conducted with S1DON on 03/06/2024 at 2:59 p.m. She confirmed Resident #43 had an order for ice cream with lunch and dinner. She confirmed Resident #43 should have received the ice cream as ordered.

Based on observations, interviews, and policy review, the facility failed to ensure medications were stored properly in accordance with current accepted professional principles during medication administration for 1 (Cart A) of 3 (Cart A, Cart B, and Cart C) Medications Carts observed during medication administration. The facility failed to ensure: 1. Medications were not left unattended on top of Cart A; and 2. Cart A was locked while unattended. Findings: Review of the facility's policy titled, Med Pass Guidelines revealed the following, in part: 13. Do not leave medications on top of cart. An observation was made of Cart A during medication administration on 03/05/2024 at 7:19 a.m. with S15LPN. S15LPN prepared Resident #146's morning medications from blister packs and medication bottles. There was a resident seated in the hallway near the medication cart. S15LPN entered Resident #146's room with her medications in a medication cup. S15LPN left the following medication blister packs and bottles on top of the medication cart: Potassium Chloride 20 MEQ, Bethanechol 10 mg, Nebivolol 5 mg, Citalopram HBR 10 mg, Omeprazole Dr 40 mg, Claritin 10 mg, Chewable Aspirin 81 mg, Calcium 500 mg, and Vitamin D3 25 mcg (1000IU). S15LPN left the second drawer on the right side of the medication cart partially open and the cart unlocked. S15LPN administered Resident #146's medication in the resident's room and the medication cart was not in her view. An interview was conducted with S15LPN on 03/05/2024 at 7:22 a.m. She confirmed she left Resident #146's medication blister packs and bottles on top of the medication cart, the second drawer on the right side of the cart partially open, and the cart unlocked and out of her view when she went into Resident #146's room to administer medications. She confirmed she should have put all the medications away and locked the cart prior to leaving it unattended. An interview was conducted with S1DON on 03/05/2024 at 9:55 a.m. She confirmed there should never be medications left on the medication cart and the cart should always be locked prior to the nurse leaving the cart and entering a resident's room to administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 677 Based on observations, interviews, and record reviews, the facility failed to ensure residents, who were unable to carry out ADLs, received the necessary services to maintain personal hygiene for 1 (#44) of 4 (#44, #63, #78 and #93) residents reviewed for ADLs. Findings: Review of Resident #44's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Hemiplegia unspecified affecting Left Side, Muscle Weakness, and Difficulty Walking. Review of Resident #44's admission MDS with an ARD of 12/15/2023 revealed she had a BIMS of 15 indicating she was cognitively intact. Further review revealed she required maximal assistance to complete the activity of a shower/bath. Review of the facility's January and February 2024 Shower Logs revealed Resident #44 did not receive baths on the following scheduled days: Bath Day Roster: January 2024 01/02/2024 - No bath given 01/04/2024 - No bath given 01/07/2024 - No bath given 01/09/2024 - No bath given 01/14/2024 - No bath given 01/16/2024 - No bath given 01/18/2024 - No bath given 01/21/2024 - No bath given 01/23/2024 - No bath given 01/25/2024 - No bath given 01/28/2024 - No bath given 01/30/2024 - No bath given February 2024 02/01/2024 - No bath given 02/04/2024 - No bath given 02/06/2024 - No bath given 02/11/2024 - No bath given 02/13/2024 - No bath given 02/18/2024 - No bath given 02/20/2024 - No bath given 02/22/2024 - No bath given Review of Resident #44's Nurses Notes from December 2023 to March 2024 revealed documentation of Resident #44 refusing one bath. On 03/04/24 at 12:26 p.m. an observation was made of Resident #44 in her room. She was in soiled clothes, unclean, and her hair was matted and oily. There was a foul odor in the room. On 03/05/24 at 8:39 a.m. an observation was made of Resident #44. She was in soiled clothes, unclean, and her hair was matted and oily. There was a foul odor in the room. On 03/06/24 at 2:19 p.m. an observation was made of Resident #44. She was in soiled clothes, unclean, and her hair was oily. There was a foul odor in the room. On 03/06/2024 at 2:45 p.m., an interview was conducted with Resident #44's resident representative. He stated when he visited his wife on several occasions, her hair was dirty and there was an odor in her room. On 03/04/2024 at 12:26 p.m., an interview was conducted with Resident #44. She stated she asked multiple nursing staff for a bath on her scheduled bath days, which were Tuesday, Thursday, and Sunday. She stated she was rarely given one. She stated she was left dirty most of the time, and went days in the same clothes. She stated she felt frustrated at times due to the situation. On 03/06/2024 at 10:31 a.m., an interview was conducted with S13LPN. She stated Resident #44 bath schedule was on Tuesday, Thursday and Sunday evening. She stated S11CNA was the CNA responsible for bathing Resident #44 on her scheduled days in January. She stated the CNA's who performed baths for Resident #44 documented every time they gave her a shower/bath. She stated if CNAs did not document the shower/bath, it was not done. On 03/06/2024 at 10:52 a.m., an interview was conducted with S9CNA. She stated she cared for Resident #44. She stated Resident #44's bath schedule was Tuesday, Thursday, and Sunday. She stated she noticed Resident #44 was not receiving her baths. She stated she has seen Resident #44 with dirty hair, dirty clothes and unclean on many of her scheduled shifts. When she noticed Resident #44 dirty, she gave her a wipe down. She stated she did not report it, because it was known by nursing staff she was not getting her baths. She stated the resident had the same clothes on for days at a time. She stated if the baths were not documented, the baths were not given. On 03/06/2024 at 1:16 p.m., an interview was conducted with S4CNA. She stated CNAs were responsible for bath/showers. She stated she expects the CNAs to document when they give baths/showers. She stated if it was not documented it was not done. She stated S11CNA on the 400 Hall was responsible for giving the baths to Resident #44 and she did not. On 03/06/2024 at 1:46 p.m., an interview was conducted with S11CNA. She stated she was listed on the schedule in January to give baths to Resident #44, she confirmed she did not give Resident #44 baths as scheduled. On 03/06/2024 at 2:31 p.m., an interview was conducted with the S1DON. She confirmed the evening shift CNA was responsible for giving Resident #44 baths as scheduled. S1DON further confirmed if the bath was not documented, it was not done.

Based on observations, record review and interviews, the facility failed serve food in accordance with professional standards for food service safety. The facility failed to ensure milk was held at a safe temperature for consumption of 41 degrees Fahrenheit or below prior to being served to residents. This had the potential to effect all 169 residents who were served meals from the kitchen. Findings: Review of the facility's policy and procedure titled Food Storage Labeling revealed, in part, the following: Procedures: 3. The First In, First Out (FIFO) method of food storage is used to rotate all food in all storage areas. 5. Storage temperatures are routinely monitored and documented using the appropriate temperature logs. On 03/04/2024 at 11:53 a.m. an interview and observation was made of S8KC performing temperature checks of milk from a plastic container on the serving line. A recording of two milk temperatures were measured to be 43.8 degrees Fahrenheit and 43.6 degrees Fahrenheit. He stated the temperature of the milk should be between 38 degrees Fahrenheit and 42 degrees Fahrenheit prior to being served to residents. During the interview, it was observed the food line staff remove milk from the container where S8KC was checking the milk temperature. S8KC allowed the milk to be served by the food line staff. On 03/04/2024 at 12:05 p.m. an observation was made of S7CS performing temperature checks of milk from a plastic container on the serving line. The first reading obtained of the milk's temperature was 47 degrees Fahrenheit. The temperature was rechecked with a second thermometer, with a reading of 46 degrees Fahrenheit. S7CS stated the serving point for milk should be between 39 - 40 degrees Fahrenheit. S7CS confirmed the milk was available to be served for resident consumption.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 2 (#63 and #93) of 4 (#44, #63, #78, and #93) sampled residents reviewed for ADL Care. Findings: Resident #63 Review of Resident #63's clinical record revealed she was admitted to the facility on [DATE], with diagnoses, which included Generalized Muscle Weakness and Reduced Mobility. Review of Resident #63's Task Care Plan revealed she was to receive baths every Tuesday, Thursday, and Saturday. Review of Resident #63's Bath Day Roster revealed no documented showers from 01/14/2024 through 02/07/2024. On 03/05/2024 at 2:06 p.m. an interview was conducted with S18CNA. She stated she was the floor Certified Nursing Assistant assigned to Resident #63. She stated it was the floor certified nursing assistant responsibility to document baths or showers when given. She stated Resident #63 was assigned shower days on Tuesday, Thursday and Saturday. She reviewed the bath day roster log which revealed no documented baths given from 01/14/2024 through 02/07/2024. She stated Resident #63 always received her bath as scheduled. She confirmed the documentation did not show a bath was performed and should have. On 03/06/2024 at 1:25 p.m. an interview was conducted with S11CNA. She stated she was the floor Certified Nursing Assistant assigned to Resident #63. She stated it was the floor certified nursing assistant responsibility to document baths or showers when given. She stated Resident #63 was assigned shower days on Tuesday, Thursday, and Saturday. She reviewed the bath day roster log which revealed no documented baths given from 01/14/2024 through 02/07/2024. She stated Resident #63 always received her bath as scheduled. She confirmed the documentation did not show a bath was performed and should have. Resident #93 Review of Resident #93's clinical record revealed she was admitted to the facility on [DATE], with diagnoses, which included Cerebrovascular Disease and Muscle Wasting and Atrophy. Review of Resident #93's Task Care Plan revealed she was to receive baths every Monday, Wednesday, and Friday. Review of Resident #93's Bath Day Roster revealed one documented shower on 01/15/2024 for the dates of 12/22/2023-01/31/2024. On 03/06/2024 at 11:20 a.m., an interview was conducted with S6CNA. She stated she was Resident #93's shower aid. She stated Resident #93's assigned shower days were Monday, Wednesday and Friday. S6CNA stated she showered Resident #93 on her assigned shower days. S6CNA stated after she gave a resident a shower, she verbally notified the floor CNA, and it was their responsibility to document it. On 03/06/2024 at 1:00 p.m., a telephone interview was conducted with S5CNA. She stated she worked Monday through Friday on the 6:00 a.m. to 2:00 p.m. shift. She stated Resident #93 received showers by S6CNA every Monday, Wednesday, and Friday. She stated the floor Certified Nursing Assistant (CNA) documented the resident's showers. She verified it was her responsibility to document the showers for Resident #93. She confirmed she was working the month of January, and Resident #93's showers should have been documented. On 03/06/2024 at 1:15 p.m., an interview was conducted with S4CNA. She stated she was the CNA Supervisor. She verified Resident #93 received showers from S6CNA on Mondays, Wednesdays, and Fridays. She stated S6CNA verbally notified the floor CNA after she gave a resident a shower. She stated it was the floor CNA's responsibility to document showers were given for all residents. She reviewed Resident #93's Bath Day Roster and verified there was only one shower documented from 12/22/2023-01/31/2024. She confirmed Resident #93 showers were not accurately documented and should have been. On 03/06/2024 at 1:40 p.m., an interview was conducted with S1DON. She stated it was the floor CNA's responsibility to document showers were given. She reviewed Resident #63's and #93's Bath Day Roster and verified there were no documented showers from 01/14/2024 to 02/07/2024 for Resident #63, and there was only one shower documented from 12/22/2023-01/31/2024 for Resident #93. She confirmed Resident #63 and #93's showers were not accurately documented and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to report an allegation of physical abuse to the state survey agency for 1 (#165) of 34 residents screened for abuse in the initial pool. Findings: A review of the Facility's policy titled Abuse - Prevention and Prohibition revealed in part: Procedures: II. Types of Abuse: 3. Physical Abuse includes hitting, slapping . 7. Reporting/Response The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services . Review of Resident #165's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses which included Non-Alzheimer's Dementia, Anxiety Disorder, Cognitive Communication Deficit, and Mood Swings. Review of the most recent MDS (Minimum Data Set) for Resident #165 with an ARD (Assessment Reference Date) of 12/21/2022 revealed that the resident had a BIMS (Brief Interview for Mental Status) of 7 which indicated the resident was severely impaired for cognition. Further review revealed the resident required extensive staff assistance with two persons for transfers. Review of the facility's state agency reportable incidents revealed no entries for Resident #165. Review of the facility's investigation report for Resident #165 revealed, in part: Abuse type in Review: Abuse Date: 03/09/2023 Brief Summary: Resident #165 made comment that he was in a fight last night and was slapped. An interview was conducted on 03/13/2023 at 9:40 a.m. with Resident #165. He stated that one night a staff member hit him in his head and he reported it to his wife. He stated he did not remember when it occurred or who hit him. A telephone interview was conducted on 03/13/2023 at 12:12 p.m. with Resident #165's wife. She stated about a week ago during her visit with Resident #165, he reported to her that a staff member hit him in the head in the middle of the night. She confirmed she reported this allegation to S18SW. An interview was conducted on 03/16/2023 at 10:00 a.m. with S18SW. She said last week Resident #165's family reported to her that a staff member hit the resident in the head. She said she immediately reported the allegation to S1ADM and S2DON. An interview was conducted on 03/16/2023 at 10:08 a.m. with S2DON. She said S18SW reported to her that Resident #165 said he was hit in the head by a staff member. She stated she did not know the date the allegation was reported to her, but thought it was one day last week. She confirmed hitting or slapping was considered abuse, and she reported the allegation to S1ADM. An interview was conducted on 03/16/2023 at 11:10 a.m. with S1ADM. He stated Resident #165's family member reported Resident #165 said he got in a fight and was slapped by a staff member on 03/09/2023. He confirmed he did not report the allegation of abuse to the state agency. He stated he considered hitting abuse but not in this case because Resident #165 was not cognitive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure alleged violations of physical abuse were thoroughly investigated for 1 (#165) of 34 residents screened for abuse in the initial pool. Findings: A review of the Facility's policy titled Abuse - Prevention and Prohibition revealed in part: III. Abuse Prohibition Practice 5. Investigation- Administrator completes a thorough investigation, including interviews of employees who were working in resident's room during the time in question and obtaining signed statements from these employees. The investigator interviews the resident if the resident is cognitively able to answer questions. If the resident is not able to be interviewed, the investigator interviews roommate. Resident family and friends may be questioned. A licensed professional nurse examines the resident for signs of injury and notifies the resident's physician of any injuries noted. The investigator maintains a private and confidential file in the administrator's office. Review of Resident #165's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses which included Non-Alzheimer's Dementia, Anxiety Disorder, Cognitive Communication Deficit, and Mood Swings. Review of the most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/21/2022 revealed Resident #165 had a BIMS (Brief Interview for Mental Status) of 7, which indicated the resident was severely impaired for cognition. Review of the facility's investigation report revealed, in part: Abuse type in Review: Abuse Date: 03/09/2023 Brief Summary: Resident #165 made a comment that he was in a fight last night and was slapped. Rationale for determination: RP stated Resident #165 always has wild vivid dreams and would make these claims at home. A full body audit was completed by DON and no bruising/red marks or any evidence that this occurred was found. RP called back and stated, please do not look into this matter for one more second. A state agency report was not completed because nothing happened per resident and family. An interview was conducted on 03/13/2023 at 9:40 a.m. with Resident #165. He stated that one night a staff member hit him in his head and he reported it to his wife. He stated he did not remember when it occurred or who hit him. A telephone interview was conducted on 03/13/2023 at 12:12 p.m. with Resident #165's wife. She stated about a week ago during her visit with Resident #165, he reported to her that a staff member hit him in the head in the middle of the night. She confirmed she reported this allegation to S18SW. An interview was conducted on 03/16/2023 at 10:08 a.m. with S2DON. She stated the normal process for an alleged abuse investigation included the following: a complete body audit and interviewing family, staff and other residents. She stated she completed a body audit on Resident #165, S1ADM spoke with the family, and the investigation was stopped because the family did not have an abuse concern. She confirmed staff and other residents were not interviewed regarding the allegation of abuse. An interview was conducted on 03/16/2023 at 11:10 a.m. with S1ADM. He said the normal process for investigations of alleged abuse included body audits, witness statements, interviews with family, staff and other residents, and review of video footage. He confirmed the investigation for Resident #165 included an assessment of Resident #165 and speaking with the family. He stated the family did not have any concerns so the investigation was stopped. He confirmed staff and other residents were not interviewed regarding the allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure staff observed residents take their medications. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part: 3. Development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with compassion, including increased and ongoing development of self-awareness, sound judgement, [NAME], ethical thing and behaviors, problem solving and critical thinking abilities. 7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team. Review of the facility's Policy titled Medication Pass Guidelines revealed the following: Notes: 6. Do not leave resident with meds in cup. Make sure you see them take their medications. An observation was made on 03/13/2023 at 1:35 p.m. of Hall D. 7 medication pills were noted inside the left hand rail, 4 of the pills were partially dissolved. 3 medication pills were noted inside the right hand rail and were partially dissolved. An interview and observation was conducted on 03/13/2023 at 2:01 p.m. with S2DON. She confirmed there was 7 pills noted inside the left hand rail, 3 pills were noted inside the right hand rail and were partially dissolved. She stated she expected staff to remain with the residents during medication pass until the pills were swallowed. She confirmed the pills should not have been in the hand rail and it was not safe.

Based on record review and interviews, the facility failed to ensure, it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being as evidenced by failure to: 1. Report allegations of physical abuse to the required state agency, and 2. Complete a thorough investigation upon the allegation of physical abuse. The failed practice had the potential to affect all 174 residents who currently reside in the facility. Findings: Cross Reference F609 and F610. A review of the Facility's policy titled Abuse - Prevention and Prohibition revealed, in part: Procedures: II. Types of Abuse: 3. Physical Abuse includes hitting, slapping . 7. Reporting/Response The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services) . III. Abuse Prohibition Practice 5. Investigation Administrator completes a thorough investigation, including interviews of employees who were working in resident's room during the time in question and obtaining signed statements from these employees. The investigator interviews the resident if the resident is cognitively able to answer questions. If the resident is not able to be interviewed, the investigator interviews roommate. Resident family and friends may be questioned. A licensed professional nurse examines the resident for signs of injury and notifies the resident's physician of any injuries noted. The investigator maintains a private and confidential file in the administrator's office. Review of the facility's investigation report revealed, in part: Abuse type in Review: Abuse Date: 03/09/2023 Brief Summary: Resident #165 made a comment that he was in a fight last night and was slapped. Rationale for determination: RP stated Resident #165 always has wild, vivid dreams and would make these claims at home. A full body audit was completed by DON and no bruising/red marks or any evidence that this occurred was found. RP called back and stated, please do not look into this matter for one more second. A state agency report was not completed because nothing happened per resident and family. An interview was conducted on 03/13/2023 at 9:40 a.m. with Resident #165. He stated one night a staff member hit him in his head and confirmed he reported it to his wife. He stated he did not remember when it occurred or who hit him. A telephone interview was conducted on 03/13/2023 at 12:12 p.m. with Resident #165's wife. She stated about a week ago during her visit with Resident #165, he told her a staff member hit him in the head in the middle of the night. She confirmed she immediately reported this allegation to S18SW. An interview was conducted on 03/16/2023 at 11:10 a.m. with S1ADM. He confirmed on 03/09/2023, S18SW informed him of Resident #165's allegation of physical abuse. He stated his investigation of the allegation consisted of S2DON performing a full body assessment while he contacted the resident's family. He confirmed the family told him not to investigate the allegation of abuse any further because they had no concerns of abuse. He confirmed he completed his investigation of the entire allegation in less than 2 hours and did not substantiate Resident #165's allegation of physical abuse. He then confirmed the allegation of physical abuse was not reported to the state agency and did not need to be because Resident #165's BIMS was 7 and he had a history of vivid dreams. He stated all allegations of abuse were not required to be reported to the state agency. He determined what allegations of abuse to report based on each individual allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure a resident's comprehensive plan of care was implemented for 3(#2, #168 and #223) of 10(#2, #51, #70, #100, #109, #134, #144, #155, #168, and #223) residents reviewed in the final sample. The facility failed to ensure: 1. Resident #2 received the correct diet as ordered by the physician; 2. Resident #168's Wound Vac operated continuously as ordered by the physician; and 3. Anti-roll backs and a chair alarm was installed on Resident #223's wheelchair as ordered by the physician. Resident #2 Review of the clinical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses which included Depression and Severe Protein Calorie Malnutrition. Review of the Care Plan for Resident #2 revealed the following, in part: I will have minimal to no dental problems. Intervention: Serve my diet as ordered. Review of the Physician Orders for Resident #2 revealed the following: 02/15/2023 Mechanical soft diet. An interview was conducted on 03/13/2023 at 1:00 p.m. with Resident #2. Resident #2 reported she had difficulty chewing her food. She stated she had dental work done and did not have bottom teeth. She stated she should be served a soft diet. An observation was made, during this interview, of Resident #2's meal tray on her bedside table. Resident #2 was served ribs on the bone, corn on the cob and baked beans. The meal ticket on Resident #2's tray revealed the following: Regular diet. An observation was made on 03/15/2023 at 12:35 p.m. of Resident #2's meal tray. The tray contained a whole boneless chicken thigh, rice and gravy, green beans, cornbread and apple pie. The meal ticket revealed Regular diet. An interview was conducted with the resident at the time of the observation. She stated she could only eat the rice and gravy. An interview was conducted on 03/15/2023 at 12:40 p.m. with Resident #2 and her daughter. The resident stated she tried to eat the greens but the stems were too hard, and she would like something easier to eat. Resident #2's daughter stated she would prefer a softer meal since her mother did not have bottom teeth. The daughter stated she had requested this before. An interview was conducted on 03/15/2023 at 2:41 p.m. with S10LPN. She confirmed Resident #2 had a physician's order for a mechanical soft diet. An interview was conducted on 03/16/2023 at 2:39 p.m. with S2DON. She confirmed Resident #2 should receive a mechanical soft diet. She confirmed the meal ticket revealed Regular diet. S2DON confirmed Resident #2 received a regular diet and should have received a mechanical soft diet per the physician's order. Resident #168 Review of the clinical record for Resident #168 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses which included Pressure Ulcer of Sacral Region, Stage 4. Review of the Care Plan for Resident #168 revealed the following, in part: I have infection to my wound. Intervention: Provide me treatment as ordered by my MD Review of the Physician Orders for Resident #168 revealed the following: 03/07/2023 Sacral Stage IV Pressure ulcer, cleanse with wound cleanser. Apply 2 grams Tobramycin/Vancomycin 39/40% Topical power. Apply black foam to wound bed. Cover with clear drapes. Set Wound Vac to 125mmhg continuous. Review of the sign posted behind Resident #168's bed revealed the following: Wound Vac must be plugged in at all time while in room. An observation was made on 03/13/2023 at 9:00 a.m. of Resident #168's Wound Vac. Resident #168's Wound Vac machine was placed on the floor on the left side of his bed. The Wound Vac was in the off position. Resident #168 said he did not know how long it had been turned off. An observation was made on 03/13/2023 at 12:00 p.m. of Resident #168's Wound Vac. Resident #168's Wound Vac machine was placed on the floor on the left side of his bed. The Wound Vac was in the off position. Resident #168 said he did not know how long it had been turned off. An observation was made on 03/13/2023 at 2:30 p.m. of Resident #168's Wound Vac. Resident #168's Wound Vac machine was placed on the floor on the left side of his bed. The Wound Vac was in the off position. Resident #168 said he did not know how long it had been turned off. An interview was conducted on 03/13/2023 at 2:40 p.m. with S3ADON. She said Resident #168's Wound Vac should be on at all times and should be set at 125mmhg continuous. She verified Resident #168's Wound Vac was turned to the off position. She said the staff were not following Resident #168's plan of care as ordered by the Physician. Resident #223 Review of the clinical record for Resident #223 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses which included Fracture Unspecified part of neck of Femur, Cerebral Infarction, Other lack of Coordination, Muscle Weakness, Unsteadiness on Feet, History of Falling, Cognitive Communication Deficit, and Foot Drop. Review of the current MDS with an ARD of 03/07/2023, revealed Resident #223 had a BIMS of 3, which indicated severe cognitive impairment. Review of the Care Plan for Resident #223 revealed the following, in part: I am at risk for falls related to CVA. Interventions: 11/06/2019 - Antiroll backs on wheelchair, 09/26/2022 - Chair alarm Review of the Physician Orders for Resident #223 revealed the following: 09/27/2022 Chair alarm 11/7/2019 Anti roll backs to wheelchair An observation was made on 03/13/2023 at 10:00 a.m. of Resident #223 sitting in her wheelchair. There was no anti-roll backs or chair alarm on her wheelchair. An observation was made on 03/14/2023 at 10:10 a.m. of Resident #223 sitting in her wheelchair. There was no anti-roll backs or chair alarm on her wheelchair. An interview was conducted on 03/14/2023 at 10:20 a.m. with S6LPN. She verified Resident #223 did not have an anti-roll back or a chair alarm on her wheelchair and should have according to the Physician's orders. An interview was conducted on 03/16/2023 at 10:30 a.m. with S2DON. She confirmed Resident #223's wheelchair did not have an anti-roll back or a chair alarm on her wheelchair and should have according to the Physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to have sufficient Certified Nursing Assistant staff to provide direct care and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (#39 and #138) of 4 (#2, #6, #39, and #138) residents reviewed for staffing. This deficient practice had the potential to affect the facility's total census of 174 residents. Findings: Review of the PBJ Staffing Report for Fiscal Year 2023 Quarter 1 (10/01/2022 - 12/31/2022), with a run date of 03/06/2023, revealed the facility had a 1-star staffing rating. Review of the Facility Assessment Tool dated 01/24/2023 revealed the facility assessed the following staffing needs: Nurse Aides: 6:00 a.m. to 2:00 p.m. - 18 CNAs, 2:00 p.m. to 10:00 p.m. - 16 CNAs, and 10:00 p.m. to 6:00 a.m. - 10 CNAs. Review of the Personnel Staffing Pattern Form, dated 02/26/2023 through 03/11/2023, revealed, in part, the facility staffed the following number of CNAs on the following dates and times: 02/26/2023: 6:00 a.m. to 2:00 p.m. - 13 CNAs 2:00 p.m. to 10:00 p.m. - 14 CNAs 10:00 p.m. to 6:00 a.m. - 7 CNAs 02/27/2023: 10:00 p.m. to 6:00 a.m. - 7 CNAs 02/28/2023: 2:00 p.m. to 10:00 p.m. - 14 CNAs 10:00 p.m. to 6:00 a.m. - 9 CNAs 03/01/2023: 2:00 p.m. to 10:00 p.m. - 13 CNAs 10:00 p.m. to 6:00 a.m. - 8 CNAs 03/02/2023: 2:00 p.m. to 10:00 p.m. - 12 CNAs 10:00 p.m. to 6:00 a.m. - 7 CNAs 03/03/2023: 6:00 a.m. to 2:00 p.m. - 16 CNAs 2:00 p.m. to 10:00 p.m. - 7 CNAs 10:00 p.m. to 6:00 a.m. - 7 CNAs 03/04/2023: 6:00 a.m. to 2:00 p.m. - 14 CNAs 2:00 p.m. to 10:00 p.m. - 12 CNAs 10:00 p.m. to 6:00 a.m. - 7 CNAs 03/05/2023: 6:00 a.m. to 2:00 p.m. - 10 CNAs 2:00 p.m. to 10:00 p.m. - 10 CNAs 10:00 p.m. to 6:00 a.m. - 7 CNAs 03/06/2023: 2:00 p.m. - 10:00 p.m. - 14 CNAs 10:00 p.m. - 6:00 a.m. - 6 CNAs 03/07/2023: 6:00 a.m. - 2:00 p.m. - 17 CNAs 2:00 p.m. - 10:00 p.m. - 14 CNAs 10:00 p.m. - 6:00 a.m. - 7 CNAs 03/08/2023: 6:00 a.m. - 2:00 p.m. - 17 CNAs 2:00 p.m. - 10:00 p.m. - 15 CNAs 10:00 p.m. - 6:00 a.m. - 7 CNAs 03/09/2023: 10:00 p.m. - 6:00 a.m. - 8 CNAs 03/10/2023: 6:00 a.m. - 2:00 p.m. - 17 CNAs 2:00 p.m. - 10:00 p.m. - 15 CNAs 10:00 p.m. - 6:00 a.m. - 7 CNAs 03/11/2023: 6:00 a.m. - 2:00 p.m. - 15 CNAs 2:00 p.m. - 10:00 p.m. - 12 CNAs 10:00 p.m. - 6:00 a.m. - 6 CNAs Further review revealed on 03/05/2023, the facility's census was 172 residents, which required 404 hours. The hours provided were 393 hours, which indicated the facility was short 11 hours. Review of the Daily Nursing Assignment Log, dated 03/05/2023, revealed the following, in part: 6:00 a.m. to 2:00 p.m. - S16CNA was assigned to Hall C, and 2:00 p.m. to 10:00 p.m. - S20CNA was assigned to Hall C. Review of the Employee Timecard, dated 03/05/2023, revealed the following, in part: S16CNA clocked in for work at 8:02 a.m. and clocked out at 2:00 p.m. S20CNA clocked in for work at 4:04 p.m. Review of the Daily Nursing Assignment Log, dated 03/13/2023, revealed from 6:00 a.m. to 2:00 p.m., S13CNA was the only CNA assigned to Hall A. Resident #39 Review of the Clinical Record for Resident #39 revealed she was admitted to the facility on [DATE] with diagnoses which included Generalized Muscle Weakness, Unsteadiness of Feet, and History of Falling. Review of the MDS with an ARD of 03/02/2023 revealed Resident #39 had a BIMS of 12, which indicated she was moderately cognitively impaired. Further review revealed she was always incontinent of bowel and bladder and required extensive assistance of two staff members for bed mobility, transfers, and toileting. Review of the current Care Plan for Resident #39 revealed the following, in part: Problem Onset: 03/06/2023 Problem: Self-care deficit in toileting hygiene. I require max assistance with this task. Approaches: I require assistance with toilet transfers. I require assistance in maintaining perineal hygiene, adjusting clothes before and after using the toilet, commode, or bedpan. An interview was conducted with Resident #39, who resided on Hall C, on 03/13/2023 at 12:08 p.m. She stated on the afternoon of Sunday, 03/05/2023, she needed her incontinence brief changed and there was not a CNA working on her hall. She stated she was unsure of the exact time, but she had to wait two hours for a CNA to assist her after she pressed her call light. She explained she had to wait for another CNA to come from another hall to assist her. An interview was conducted with S15CNA on 03/14/2023 at 8:40 a.m. She verified she was the only CNA working on Hall C from 6:00 a.m. to 2:00 p.m. today and was responsible for 20 residents. An interview was conducted with S21CNA on 03/15/2023 at 11:15 a.m. She stated a week or two ago she was the only CNA working on Hall C and she was assigned to 20 residents. She stated the residents complained about long wait times because there was not enough staff. An interview was conducted with S15CNA on 03/15/2023 at 12:37 pm. She stated the residents often complained to her the facility did not have enough staff. An interview was conducted with S9LPN on 03/15/2023 at 1:20 p.m. She verified she worked on Sunday, 03/05/2023, from 7:00 a.m. to 11:00 p.m. on Hall C. She stated the two CNAs scheduled that day both called in. She stated S16CNA was the only CNA on Hall C that day until 2:00 p.m. She confirmed there was no CNA assigned to Hall C from 2:00 p.m. until after 4:00 p.m. when S20CNA arrived. S9LPN confirmed she was the only staff member working on Hall C until S20CNA arrived after 4:00 p.m. She further stated S20CNA was the only CNA on Hall C until S19CNA came in at 6:00 p.m. A telephone interview was conducted with S16CNA on 03/16/2023 at 10:20 a.m. She verified she worked on Sunday, 03/05/2023, after she was asked to come in and help out due to staff call ins. She verified she worked 8:00 a.m. to 2:00 p.m. on 03/05/2023 and was the only CNA on Hall C that shift. She stated when she left at 2:00 p.m. there was no CNA to relieve her on Hall C, and S9LPN was by herself with 20 residents. She stated the facility was usually short staffed and she frequently worked by herself on her assigned hall. An interview was conducted with S9LPN on 03/16/2023 at 10:30 a.m. She stated Hall C had two residents who required feeding assistance, ten residents who required transfer assistance, and ten incontinent residents. An interview was conducted with S15CNA on 03/16/2023 at 10:32 a.m. She stated Hall C had two residents who required feeding assistance, ten residents who required transfer assistance, and ten incontinent residents. An interview was conducted with S12CNAS on 03/16/2023 at 11:48 a.m. She stated she was responsible for CNA staffing. She reviewed the Daily Nursing Assignment Log, dated 03/05/2023, and verified there was only one CNA assigned to the following hallways from 6:00 a.m. to 2:00 p.m. and from 2:00 p.m. to 10:00 p.m. on 03/05/2023: Hall A, Hall B, Hall C, Hall D, Hall E, Hall F. She reviewed the time cards for staff that worked on 03/05/2023 and verified S16CNA worked from 8:00 a.m. to 2:00 p.m. and S20CNA clocked in for work at 4:04 p.m. She stated based on the Time Cards and Daily Nursing Assignment Log, there was no CNA assigned to Hall C from 2:00 p.m. to 4:04 p.m. She further verified S20CNA was the only CNA assigned to Hall C from 4:04 p.m. until 6:12 p.m. She confirmed it was not feasible for one nurse to be able to meet the needs of all the residents on Hall C by herself. Resident #138 Review of the Clinical Record revealed Resident #138 was admitted to the facility on [DATE] and had diagnoses which included Hemiplegia Following Unspecified Cerebrovascular Disease Affecting Left Non-dominant Side, Dysphagia Following Cerebral Infarction, Generalized Muscle Weakness, Unspecified Lack of Coordination, Aphasia, and Major Depressive Disorder. Review of the MDS with an ARD of 01/03/2023 for Resident #138 revealed she had a BIMS of 14, which indicated she was cognitively intact. Further review revealed she was totally dependent on two staff members for transfers and had hemiplegia or hemiparesis. Review of the current Care Plan for Resident #138 revealed she was an unsafe smoker and required assistance, supervision, and a smoking apron while smoking. An interview was conducted with Resident #138, who resided on Hall A, on 03/13/2023 at 10:45 a.m. She stated she was a smoker. She stated sometimes there was only one CNA assigned to her hall and the staff told her they could not get her up to go outside and smoke. An interview was conducted with S13CNA on 03/15/2023 at 11:22 a.m. She stated she sometimes was the only CNA on Hall A. She stated on days when she was by herself, she did not have time to get some residents out of bed. She stated that meant the residents had to stay in the bed all day. She confirmed she was the only CNA on Hall A on 03/13/2023 from 6:00 a.m. to 2:00 p.m. She stated Resident #138 was a smoker and had to have staff sit outside with her while she smoked. She stated there had been multiple times Resident #138 had asked to go outside and smoke but she had to tell her no because she did not have time. She confirmed Resident #138 asked to smoke this morning but had to wait until after lunch because there was no one available to bring her. An interview was conducted with S4LPN on 03/15/2023 at 11:35 a.m. She confirmed she was assigned to Hall A and there were 20 residents on the hall. She stated it was not possible for one CNA to provide adequate care timely to each resident on Hall A if they were the only CNA on the hall. She confirmed she was assigned to Resident #138. She explained Resident #138's smoking supplies were kept with the nurse, and she required assistance and supervision while smoking. An interview was conducted with S14CNA on 03/15/2023 at 2:48 p.m. She stated she worked Hall A from 2:00 p.m. to 10:00 p.m. She stated there were 20 residents on Hall A. She stated there were three residents on the hall that required feeding assistance, and five of the residents required assistance of two staff members for transfers. She stated all of the residents got out of bed daily when there was enough staff. She stated there had been times she was the only CNA assigned to the hall. She stated it was difficult to get everybody out of the bed when she was by herself. She confirmed she has had to tell residents she could not get them up. She stated Resident #138 required a Hoyer lift with assistance of two staff members for transfers. She confirmed there had been times she told Resident #138 she could not go outside to smoke due to staffing. A telephone interview was conducted with S5LPN on 03/16/2023 at 10:31 a.m. She stated she was a full time LPN on Hall A. She confirmed there were 20 residents on Hall A. She stated it was frequent that she only had one CNA assigned to Hall A on day and evening shift. She stated it was not feasible to have one CNA on the hall. She stated she attempted to help the CNA on the hall as much as possible, but sometimes they could not get residents out of the bed. She stated there were three residents on the hall that required feeding assistance and three Hoyer lifts that regularly got out of the bed. She stated the residents that required a Hoyer lift had to have two staff present for the transfer. She stated Resident #138 required a Hoyer lift for transfers. She stated there had been times when the staff could not get Resident #138 out of bed to go smoke because there was not enough staff on the hall and nobody to sit outside with her. An interview was conducted with Resident #160, who resided on Hall A, on 03/13/2023 at 10:50 a.m. He stated there was frequently only one CNA assigned to his hall. An interview was conducted with S11CNA on 03/16/2023 at 12:05 p.m. She stated she was assigned to Hall B from 6:00 a.m. to 2:00 p.m. She stated she had been employed at the facility for two weeks and had been the only CNA assigned to Hall B on 6:00 a.m. to 2:00 p.m. since she started. An interview was conducted with S12CNAS on 03/16/2023 at 11:48 a.m. She stated she was responsible for CNA staffing. She stated it was not feasible for one CNA to be able to meet the needs of all the residents on a hall when they were the only CNA assigned to the hall. She stated there should be two CNAs on each hall and two shower aides from 6:00 a.m. to 2:00 p.m. She stated the facility did not utilize agency staffing. She stated she regularly had call-ins. She stated she did not reassign bath aides to the hall. She confirmed S11CNA was the only CNA assigned to Hall B from 6:00 a.m. to 2:00 p.m. today. S12CNAS stated she was not assigned to Hall B. An interview was conducted with S2DON on 03/16/2023 at 2:23 p.m. She stated S12CNAS was responsible for CNA staffing. She stated, ideally, there should have been two CNAs per hall and 2 shower aides on day shift, two CNAs per hall on evening shift, and one CNA per hall on night shift. She stated most of the halls had 20 residents and on the day shift she did not feel it was ideal to have only one CNA on the hall. She stated she had never tried to fill a CNA assignment with nursing or administrative staff. She confirmed the facility did not use agency staff. She stated it was not acceptable to not get a resident out of bed because there was not enough staff. She reviewed the CNA schedule and time cards for 03/05/2023 and verified there was no CNA assigned to Hall C from 2:00 p.m. until 4:04 p.m. She stated she was not aware there was no CNA assigned to Hall C from 2:00 p.m. to 4:04 p.m. on 03/05/2023. She stated she would not have expected a nurse to work a hall without a CNA. An interview was conducted with S1ADM on 03/16/2023 at 2:35 p.m. He stated S12CNAS was responsible for CNA staffing. He stated the facility scheduled two CNAs per hall and two shower aides on day shift, two CNAs per hall on evening shift, and one CNA per hall on night shift. He stated at times there was only one CNA on the hall due to call ins and no shows. He confirmed the facility did not utilize agency staff. He stated it was not ideal, however, it was ok to have one CNA on a hall with 20 residents. He stated the shower aides were responsible for showers only. He stated, on 03/05/2023, he was aware the nurse worked by herself on Hall C from 2:00 p.m. to 4:04 p.m. He stated it was not acceptable for a CNA to not get a resident out of bed related to staffing. He explained if there was only one CNA on the hall, the nurse and the CNA could manage the resident care for a couple hours but not long term. He confirmed the facility had regularly not staffed CNAs consistent with their facility assessment. He further confirmed, on 03/05/2023, the facility did not provide the required hours based on the resident census.

Based on observations, interviews, and record reviews, the facility failed to ensure medications and supplies were stored and labeled properly in accordance with current accepted professional principles. The facility failed to ensure: 1. Medications were not left unattended on top of Cart A during medication administration; 2. Cart A was locked while unattended during medication administration; 3. Expired medications were not available for administration to residents for 2 (Cart C and Cart D) of 5 carts (Cart A, Cart B, Cart C, Cart D and Cart E) reviewed; and 4. Medications were labeled properly for 1 (Cart B) of 5 carts (Cart A, Cart B, Cart C, Cart D and Cart E) reviewed. Findings: Review of the policy titled Medication Administration revealed, in part: Policy: Nursing personnel shall ensure the safe and effective administration of medications. Procedure: 1. Medication Administration: Prior to administration, the Nursing staff member administering the medication shall ensure that the following steps are accomplished. c. Verify the medication has not expired 7. Multi-dose Vials: b. All multi dose vials shall be labeled with the initials of the person opening the vial and an expiration date of 28 days. c. Opened multi-dose vials that lack dates or initials shall be discarded. 8. Medication Preparation and Security: c. Medications must be secured at all times. When not in use, medication cart drawers should be locked. Medications shall not be left unattended on counters or at workstations. Review of the document entitled Med Pass Guidelines revealed, in part: 13. Do not leave medications on top of the cart. Notes: 3. Must check cart for out of date medications. 5. Bedside Medications - discuss, care planning. On 03/15/2023 at 7:45 a.m., an observation was made of Cart A during medication administration with S7LPN. She stated Resident #223's Lovenox was discontinued on 03/09/2023. She removed two syringes of Lovenox and placed them on top of Cart A. She then entered Resident #223's room and left the two syringes of Lovenox on top of Cart A. On 03/15/2023 at 7:55 a.m., an interview was conducted with S7LPN who confirmed she left two syringes of Lovenox on top of Cart A unattended and should not have. On 03/15/2023 at 8:35 a.m., an observation was made of S7LPN entering a Resident's room on Hall G. Cart A was observed unlocked and unattended in the hall with residents near the medication cart. On 03/15/2023 at 8:40 a.m., an interview was conducted with S7LPN. She confirmed she left Cart A unlocked when she entered a Resident's room on Hall G and should not have. On 03/15/2023 at 8:50 a.m., an interview was conducted with S2DON and S3ADON. S2DON and S3ADON confirmed medications should not be left on top of an unattended medication cart, and medication carts should be locked when unattended. On 03/15/2023 at 2:45 p.m., an observation was made of Cart C with S8LPN. The following medication was expired in the cart: -One opened bottle of Brimonidine-Timolol 0.2% eye drops for Resident #6, with an opened date of 12/20/2022. This indicated the eye drops expired on 01/17/2023. On 03/15/2023 at 2:50 p.m., an interview was conducted with S8LPN. She stated eye drops should be discarded 30 days after opening. She confirmed Resident #6's eye drops were available for use and were being administered to the resident daily. On 03/15/2023 at 3:00 p.m., an observation was made of Cart D with S6LPN. The following medications were expired in the cart: -One opened vial of Novolin R 100 units/ml pen for Resident #143, with an opened date of 02/11/2023. This indicated the insulin expired on 03/11/2023. -One opened vial of Novolin R 100 units/ml pen for Resident #159, with an opened date of 02/07/2023. This indicated the insulin expired on 03/07/2023. On 03/15/2023 at 3:05 p.m., an interview was conducted with S6LPN. She stated Novolin R insulin pens should be discarded 28 days after being opened. She confirmed the Novolin R pens for Resident #143 and Resident #159 were available for use, opened longer than 28 days, and should have been discarded. On 03/15/2023 at 3:17 p.m., an observation was made of the Cart B with S4LPN. The following medications were unlabeled in the cart: -One opened vial of Insulin Lispro 100 units/ml for Resident #323, with no date to indicate when the vial was opened. -One opened vial of Insulin Lispro 100 units/ml for Resident #373, with no date to indicate when the vial was opened, the vial had 100 units missing. On 03/15/2023 at 3:25 p.m., an interview was conducted with S4LPN. She stated Insulin Lispro pens should be dated after being opened. She confirmed the Insulin Lispro pens for Resident #323 and Resident #373 were available for use, were unlabeled, and should have been discarded. On 03/15/2023 at 3:45 p.m., a telephone interview was conducted with the facility's pharmacist. With S2DON present, he stated Novolin R pens and Insulin Lispro pens were to be discarded 28 days after opening. He further stated Brimondine-Timolol eye drops should be discarded four weeks after opening. On 03/15/2023 at 3:50 p.m., an interview was conducted with S2DON. She stated the hall nurses were responsible for checking their medication carts daily for expired and unlabeled medications. She confirmed when opening multi-dose containers, the date opened should be labeled on the container. She stated insulin pens should be discarded 28 days after opening. She confirmed the above eye drops were expired and should have been discarded.

Based on observations, interviews and record reviews, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to: 1. Maintain documentation of daily chemical sanitation checks for dishwasher and 2. Maintain documentation of freezer and cooler temperatures checks. This deficient practice had the potential to affect 107 residents who were served meals from the facility's kitchen. Findings: A tour of the kitchen was conducted on 03/13/2023 at 2:00 p.m. with S17DS, the following observations were made: The kitchen had two freezers and two coolers that required temperature checks. Review of the facility's four freezer/cooler temperature logs revealed missing temperature checks for the following: 01/30/2023 - upright freezer, walk in cooler, walk in freezer 01/31/2023 - 02/12/2023 - upright cooler, upright freezer, walk in cooler, walk in freezer Review of the chemical sanitation logs for the facility's dishwasher revealed there were no logs from 11/2023 to present. On 03/13/2023 at 2:30 p.m. an interview was conducted with S17DS. She confirmed there was no documentation of chemical sanitation testing logs from the dates of 11/2023 to present. She confirmed the dishwasher's chemical sanitation testing should have been documented at least once per shift. She confirmed there was no documentation to show the kitchen staff had been performing the required chemical sanitation checks for the dishwasher. S17DS confirmed her staff did not document temperatures for the upright freezer, walk in cooler and walk in freezer for the date of 01/30/2023 and the upright cooler, upright freezer, walk in cooler and the walk in freezer for the dates 01/31/2023 - 01/12/2023.

Based on observations, interviews and policy review, the facility failed to implement appropriate infection control practices during the provision of resident care as evidenced by failing to ensure staff appropriately changed gloves and performed hand hygiene for 3 (Resident #2, RR1, and RR6) of 3 (Resident #2, RR1, and RR6) residents observed for incontinence care. Findings: A review of the facility's policy titled Hand Hygiene Policy and Procedure revealed the following: Policy: Hand hygiene shall be performed: 2. When hands are visibly soiled. 3. Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. 8. Before and after assisting a resident with personal care. 18. After contact with a resident's body fluids and excretions. 22. After removing gloves. 23. If hands will be moving from a contaminated body site to a clean body site during patient care. On 12/13/2022 at 8:57 a.m., an observation was made of S3CNA performing incontinent care on RR1. S3CNA donned gloves, unclasped the soiled brief, and tucked it between RR1's legs. S3CNA then walked to the foot of the resident's bed and lowered the bed using the crank controls with her soiled gloves still donned. S3CNA cleaned feces and urine from the resident using wipes and disposed the soiled brief into the trash can. Using her soiled gloves, she then placed a clean brief under the resident and straightened the draw sheet. S3CNA then opened a single packet of cream, scooped the cream out of the packet and applied the cream to RR1's buttock. S3CNA then fastened the clean brief and straighten the resident's gown. S3CNA took the glove off of her right hand, placed it in the trash can and did not perform hand hygiene. She then proceeded to pull up the resident's socks, place the bed sheets over the resident, readjust the bed using the crank controls, move the bedside table, and adjust the air conditioner controls using her soiled ungloved hand. S3CNA then exited the room by turning the door knob and walked down the hall to dispose of the trash. She then entered the code on the keypad to the dirty utility room and placed the trash in the bin. S3CNA then removed her soiled glove and performed hand hygiene. On 12/13/2022 at 9:05 a.m., an interview was conducted with S3CNA. The above observation was reviewed with S3CNA. S3CNA stated she should have changed gloves and applied hand sanitizer during the brief change after soiling her gloves and before touching anything else in the resident's room. On 12/13/2022 at 1:57 p.m., an observation was made of S4CNA performing incontinent care on Resident #2. With gloved hands, S4CNA unclasped the feces soiled brief and tucked it between Resident #2's legs. S4CNA then walked to the foot of the bed, lowered it using the crank controls, and opened the nightstand drawer with her soiled gloves. S4CNA proceeded to wipe the feces from Resident #2, dispose the soiled brief into the trash can, place a clean brief under the resident, assist Resident #2 to her side, reposition the brief, fasten the clean brief, straighten the resident's shirt, touch the bed sheets, blankets and bedside table, remove both soiled gloves and place them in the trash without performing hand hygiene. S4CNA then readjusted the resident's bed using the crank controls and air mattress controls, opened Resident #2's bathroom door, and washed her hands with soap and water. On 12/13/2022 2:06 p.m., an interview was conducted with S4CNA. The above observations were reviewed with S4CNA. S4CNA stated she did not need to change her gloves during incontinent care because there was two people assisting the resident. She stated she not need to change her gloves and perform hand hygiene after wiping feces and urine off the resident because she did not soil her gloves. On 12/15/2022 at 11:19 a.m. an observation was made of S3CNA performing incontinent care on RR1 during a bed bath. S3CNA donned gloves prior to starting the procedure. S3CNA unclasped the soiled brief and tucked it between RR1's legs. S3CNA cleaned RR1's perineal area using a wet and soapy washcloth and disposed of the soiled brief into the trash can. S3CNA placed the visibly soiled washcloth in the dirty linen bag. S3CNA's gloves were observed to be visibly soiled with feces. She then proceeded to retrieve a clean brief from the bedside table, place the clean brief under the resident, straighten the draw sheet, retrieve a clean gown from the bedside table, place the clean gown on RR1, touch the bathroom door, touch the light switch, touch RR1's personal body washes, and touch door. Upon exiting RR1's room, S3CNA removed her visibly soiled gloves. On 12/15/2022 at 12:00 p.m. an interview was conducted with S3CNA. The above observations were reviewed with S3CNA. S3CNA confirmed her gloves were soiled during this procedure. She further confirmed not removing or changing her gloves nor performing proper hand hygiene during this procedure. On 12/15/2022 at 2:20 p.m., an observation was made of S5CNA performing incontinent care on RR6. S5CNA opened the brief and wiped feces and urine off RR6 with wipes. S5CNA then had RR6 turn on his side and wiped his buttock with wipes. Without changing gloves or performing hand hygiene, S5CNA grabbed the clean brief and placed it under RR6, assisted him in taking off his jacket, opened the bathroom door, grabbed the resident's pajama bottoms, placed them on RR6, touched his hat, pulled the blanket up to his face, touched the side rail, removed the garbage bag from the garbage bin, and then removed her left glove. S5CNA proceeded to walk past the hand sanitizer station in the resident's room and open the door. S5CNA walked down the hall, enter the door code in keypad to dirty linen room using her left soiled hand and then removed the right soiled glove. S5CNA disposed of trash and glove then washed her hands with soap and water. On 12/15/2022 at 2:38 p.m., an interview was conducted with S5CNA. The above observations were reviewed with S5CNA. S5CNA stated she will complete hand hygiene and replace gloves during incontinent care if the resident had a heavy bowel movement. S5CNA stated she didn't think she needed to change her gloves or perform hand hygiene when changing a brief with urine only. On 12/15/2022 at 3:18 p.m., an interview was conducted with S2CS. The observations from above were reviewed with S2CS. S2CS stated once staff wiped urine or feces off the resident, their gloves were considered soiled and should be changed. She stated after gloves are taken off, hand hygiene should be performed before donning new gloves. She stated she expected staff not to contaminate the resident or their belongings with soiled gloves. On 12/15/2022 at 3:31 p.m., an interview was conducted with S1DON. The observations from above were reviewed with S1DON. S1DON stated she expected staff to change gloves and perform hand hygiene after gloves were soiled with feces or urine. She stated she expected staff not to contaminate the resident or their belongings with soiled gloves. She stated staff should also be performing hand hygiene once exiting the resident's room.