Based on observation, interview and record review, the facility failed to ensure a resident received reasonable accommodation of needs by failing to ensure the call light was accessible by a resident for 1 (Resident #51) of 26 sampled residents. Findings: On 05/14/2025, review of facility policy titled, Answering Call Lights, with effective date of 06/01/2023 and revision Date of 9/28/2025, revealed in part . Purpose: Call lights are to serve as notice to the staff that the resident has a need or request. Prompt answering of call lights provides a sense of security to the resident . Process: Place call light within reach of the resident before leaving the room and anticipate other needs of the resident . Resident #51 Review of Resident #51's electronic medical record revealed an admit date of 02/16/2024 with diagnosis that included: Neurocognitive Disorder with Lewy Bodies, Major Depressive Disorder, Altered Mental Status, Generalized Anxiety Disorder, Aphasia, Cognitive Communication Deficit, Hallucinations, unspecified, unsteadiness on feet, and history of repeated falls. Review of Resident # 51's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 03/19/2025, revealed a BIMS (Brief Interview for Mental Status) Score of 10, indicating moderate cognitive impairment. Resident #51 required supervision/touching assistance for transfers and sit to stand positioning. Review of Resident #51's Care Plan revealed in part . Resident #51 had a self- care deficit r/t (related to) Neurocognitive d/o (disorder) with Lewy Bodies, muscle wasting and atrophy. Interventions included in part . limited assistance by (1) staff to move between surfaces. Resident #51 was at high risk for falls. Interventions included in part . Resident #51 would have call light placed within reach, encouraged to use call light for assistance as needed, receive prompt response to all requests for assistance, remain in a safe environment with a working and reachable call light . On 05/12/2025 at 10:20 a.m. Observation revealed Resident #51 lying in bed. Call light was clipped to resident privacy curtain located at the foot of the bed. Resident #51 could not reach the call light. On 05/12/2025 at 11:20 a.m. Observation revealed Resident #51 loudly calling out Help from down the hall. On 05/13/2025 at 09:01 a.m. Observation revealed Resident #51 sitting up in wheelchair in room. Call light was clipped to privacy curtain. Call light was not within reach for Resident #51. On 05/13/2025 at 2:20 p.m. observation/interview revealed Resident #51 lying across her bed, awake, alert, and confused. Resident #51 pointed in the direction of the call light system when asked how she requested help or assistance. Call light was clipped to privacy curtain located at the foot of the bed. Call light was not within reach for Resident #51. On 05/13/2025 2:55 p.m. S6 LPN accompanied surveyor to Resident #51's room. S6 LPN confirmed call light was not accessible to resident and should have been. On 05/14/2025 at 12:43 p.m. above findings were discussed with S2 DON. S2 DON acknowledged Resident #51 should have had call light within her reach while in room. S2 DON confirmed staff should be monitoring call light locations on routine rounds.

Based on record review and interview, the facility failed to inform each resident of the charges for services for which the residents may be responsible for paying for 2 (#45 and #70) of 2 (#45 and #70) sampled residents who received Advanced Beneficiary Notices of Non-Coverage (ABN). Findings: Review of the ABN notices (Form CMS-10055) signed by Resident #45 on 02/17/2025 and Resident #70 on 03/19/2025 revealed the estimated cost for continuing daily skilled nursing care was not completed but left blank. In an interview on 05/14/2025 at 12:10 p.m., S5 Accounts Manager confirmed she was responsible for completing the ABN forms and having them signed by the resident or representative. During a review of the Form CMS-10055 for Residents #45 and #70 at that time, S5 Accounts Manager confirmed the estimate of the cost of services amount per day was not completed. S5 Accounts Manager stated she would have to get that information from the Corporate Office and only does so if the resident or resident representative specifically requests it. S5 Accounts Manager confirmed she did not obtain the cost information from Corporate Office for Resident #45 or Resident #70. In an interview on 05/14/2025 at 12:15 p.m., S1 Administrator confirmed the costs for the services should be listed on the ABN form and was not.

Based on record review and interview, the facility failed to ensure the physician documented a clinical rationale for a denial of a dose reduction for 2 (#37 and #51) of 5 (#24, #37, #45, #50, and #51) residents reviewed for unnecessary medications. The facility failed to ensure the physician documented on the Pharmaceutical Consultant Report a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction. Findings: Review of the facility policy on 05/13/2025 at 11:29 a.m., titled Gradual Dose Reduction of Psychotropic Drugs with a revision date of 09/01/2024 revealed in part .Policy: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 6. For any individual who is receiving a psychotropic medication to treat expressions or indications of distress related to dementia, the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distress behavior. Resident #37 Review of Resident #37's clinical record revealed an admission date of 11/22/2022 with diagnoses that included in part., Aphasia, Major Depressive Disorder, Generalized Anxiety Disorder, and Anxiety Disorder. Review of Resident #37's Quarterly MDS with an ARD of 05/17/2025 revealed a BIMS score of 15, indicating intact cognition. Resident #37 received an antianxiety and antidepressant medication. Review of Resident #37's 05/2025 physician's orders revealed the following: Fluoxetine Hydrochloride (HCl) capsule 20 mg (milligrams) related to Major Depressive Disorder (11/12/2022) Alprazolam tablet 0.25mg related to Anxiety Disorder (11/11/2022) Review of the Pharmaceutical Consultant Report that was signed and dated by S13 ADON and S14 MD on 01/16/2025. The pharmacy consultant requested a gradual dose reduction for Alprazolam tablet 0.25mg and Fluoxetine HCl capsule 20mg. The report read, Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a hand written valid clinical rationale as to why the reduction is not desired at this time. S14 MD documented NO for if a dose reduction is appropriate. S14 MD failed to provide a hand written clinical rationale explaining why a dose reduction would be clinically contraindicated. Resident #51 Review of Resident #51's electronic health record revealed an admit date of 02/16/2024 with diagnosis that included: Neurocognitive Disorder with Lewy Bodies, Major Depressive Disorder, Altered Mental Status, Generalized Anxiety Disorder, Aphasia, Cognitive Communication Deficit, Hallucinations, unspecified, unsteadiness on feet, history of repeated falls. Review of Resident # 51's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 03/19/2025, revealed a BIMS (Brief Interview for Mental Status) Score of 10, indicating moderate cognitive impairment. Resident #51 received antipsychotic and antidepressant medication. Review of Resident #51's 05/2025 physician's orders revealed the following: Olanzapine oral tablet 5mg (milligram) one tablet by mouth daily for visual hallucinations related to Neurocognitive Disorder with Lewy Bodies (04/04/2023) Sertraline HCl tablet Give 75mg by mouth one time a day for Depression related to Major Depressive Disorder (03/15/2023) Trazadone HCl tablet 50mg Give 0.5 tablet by mouth at bedtime for dementia related to Major Depressive Disorder, Recurrent; Mild Insomnia, Unspecified (08/27/2024) Review of Resident #51's Pharmaceutical Consultant Report that was signed and dated by S13 ADON and S14 MD on 01/16/2025. The pharmacy consultant requested a gradual dose reduction for Olanzapine oral tablet 5mg (milligram), Sertraline HCl tablet 75mg, and Trazadone HCl tablet 50mg. The report read in part . Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a hand written valid clinical rationale as to why the reduction is not desired at this time. S14 MD documented NO for if a dose reduction is appropriate. S14 MD failed to provide a hand written clinical rationale explaining why a dose reduction would be clinically contraindicated. On 05/14/25 at 11:30 a.m. interview conducted with S2 DON. Pharmaceutical Consultant Reports for Resident #37 and Resident #51 reviewed with S2 DON. S2 DON confirmed S14 MD should have provided a hand written clinical rationale explaining why a dose reduction would be clinically contraindicated for Resident #37 and Resident #51, and did not.

Based on record review and interview, the facility failed to ensure the person-centered care plan was implemented for 1 (Resident #45) of 26 sampled residents. Findings: Review of Resident #45's medical record revealed an admission date of 10/07/2022 with diagnoses including, in part .Muscle Wasting and Atrophy, Unspecified Protein-Calorie Malnutrition, and Dementia. Review of Resident #45's Quarterly MDS with an ARD of 02/17/2025 revealed a BIMS score of 3, indicating severely impaired cognition. Resident #45 required supervision or touching assistance while eating. Resident #45 had significant weight loss and was not on a prescribed weight-loss regimen. Review of Resident #45's current comprehensive care plan revealed a history of unplanned/unexpected weight loss related to recent illness and hospitalization, initiated on 03/16/2023 and revised on 08/27/2023 and 11/21/2024. Interventions included, in part .monitor and record my food intake at each meal. Review of Resident #45's Nutrition - Meal Intake of Food & Drink task for 02/2025, 03/2025, 04/2025, and 05/01/2025 through 05/13/2025, revealed meal intake had not been documented for 31 meals in 02/2025, 37 meals in 03/2025, 40 meals in 04/2025, and 13 meals in 05/2025. Interview with S9 LPN on 05/13/2025 at 8:36 a.m., revealed CNAs are required to input the meal intake for residents after each meal. Interview with S17 LPN on 05/13/2025 at 10:37 a.m., revealed CNAs are required to input the meal intake for residents after each meal. Interview with S2 DON on 05/13/2025 at 11:35 a.m. confirmed Resident #45's meal intake should be documented for every meal. S2 DON confirmed Resident #45's care plan intervention of monitoring and recording food intake at each meal had not been consistently implemented during 02/2025, 03/2025, 04/2025, and 05/01/2025 through 05/13/2025, but should have been.

Based on observation, interview, and record review, the facility failed to ensure a resident's comprehensive care plan was revised after a quarterly assessment for 1 (Resident #45) of 26 sampled residents. Findings: Review of Resident #45's medical record revealed an admission date of 10/07/2022 with diagnoses including, in part .Muscle Wasting and Atrophy, Difficulty in Walking, Unsteadiness on Feet, Muscle Weakness, and Dementia. Review of Resident #45's Quarterly MDS with an ARD of 02/17/2025 revealed a BIMS score of 3, indicating severely impaired cognition. Resident #45 used a manual wheelchair and had limited range of motion to his lower extremities. He was dependent for ambulation. Review of Resident #45's current care plan revealed the resident had limited physical mobility related to generalized weakness, initiated on 10/07/2022. Interventions included, in part .the resident walks independently, initiated on 10/07/2022 and revised on 02/17/2023. Interview with S2 DON on 05/14/2025 at 11:50 a.m. revealed Resident #45 could not walk independently. S2 DON confirmed Resident #45's current care plan indicated he walked independently, but should not. S2 DON confirmed Resident #45's care plan had not been revised after his Quarterly MDS with ARD of 02/17/2025, but should have been.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (Resident #24) of 26 sampled residents. Findings: Review of the facility's policy entitled, Nail Care dated 06/01/2023 revealed in part .nail care is a routine part of grooming each day. Foot care should be provided as a part of a tub or shower bath. Review of Resident #24's medical record revealed an admission date of 05/06/2024 with diagnoses which included in part Diabetes Mellitus and Morbid Obesity. Review of Resident #24's Annual MDS with ARD of 04/16/2025 revealed in part .a BIMS score of 15, which indicated intact cognition. Resident #24 was dependent for bathing and required substantial/maximal assistance with personal hygiene. Review of Resident #24's current physician's orders revealed, in part .RN was to trim toe nails every month, dated 05/06/2024. Review of Resident #24's care plan revealed in part .the resident was dependent for meeting his physical needs initiated on 05/06/2024. Interventions included assisting the resident with ADLs. Further review revealed Resident #24 was unable to perform ADLs due to polyosteoarthritis and lower muscle wasting. Review of Resident #24's 04/2025 TAR revealed in part .his toe nails were last trimmed on 04/02/2025 and no documentation of nail care for 05/2025. Observation of Resident #24 on 05/12/2025 at 10:13 a.m. revealed long, thickened, yellow, jagged toenails of various lengths to his feet. Resident #24 stated it had been a month or more since his toenails were trimmed, and he wanted them to be trimmed. Interview with S18 Treatment Nurse on 05/14/2025 at 10:50 a.m. regarding Resident #24's toe nails revealed she had tried to trim them a little bit previously. S18 Treatment Nurse confirmed she was unable to trim Resident #24's toe nails as ordered. S18 Treatment Nurse confirmed she did not perform nail care as ordered for Resident #24, but should have. Interview with S2 DON on 05/14/2025 at 11:56 a.m. confirmed Resident #24 should have had routine nail care as ordered, but had not.

Based on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for a resident with Diabetes. The facility failed to schedule and complete podiatry appointments for toenail care and trimming for 1 (Resident #24) of 3 (Resident #17, Resident #24, and Resident #78) residents sampled for Activities of Daily Living (ADLs). Findings: Review of the facility's policy entitled, Nail Care dated 06/01/2023 revealed in part .refer residents whose toenails are too thick or difficult to cut to a Podiatrist. It is recommended a Podiatrist provides foot care for residents with Diabetes. Review of Resident #24's medical record revealed an admission date of 05/06/2024 with diagnoses which included in part Diabetes Mellitus. Review of Resident #24's Annual MDS with ARD of 04/16/2025 revealed in part .a BIMS score of 15, which indicated intact cognition. Resident #24 was dependent for bathing and required substantial/maximal assistance with personal hygiene. Review of Resident #24's current physician's orders revealed in part .may consult specialist of choice, dated 05/06/2024. Review of Resident #24's care plan revealed in part .I have Diabetes Mellitus, initiated on 05/06/2024. Review of Resident #24's 04/2025 TAR revealed in part . his toe nails were last trimmed on 04/02/2025 and no documentation of nail care for 05/2025. Further review of Resident #24's medical record revealed no documentation of a Podiatry referral nor nail care provided by a Podiatrist. Observation of Resident #24 on 05/12/2025 at 10:13 a.m. revealed long, thickened, yellow, jagged toenails of various lengths to his feet. Resident #24 stated it had been a month or more since his toenails were trimmed, and he wanted them to be trimmed. Resident #24 stated he had no appointments with a Podiatrist, but would like to be consulted by Podiatry. Interview with S18 Treatment Nurse on 05/14/2025 at 10:50 a.m. regarding Resident #24's toe nails revealed she had tried to trim them a little bit previously. S18 Treatment Nurse stated that the facility's nail care tools were ineffective due to the thickness of Resident #24's toe nails. S18 Treatment Nurse confirmed Resident #24 needed a Podiatry referral to provide effective nail care, but had not had one. Interview with S2 DON on 05/14/2025 at 11:56 a.m. confirmed Resident #24 needed a Podiatry referral to perform effective nail care, but had not had one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F692 Based on interview and record review the Facility failed to ensure that a Resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable weight range for 1 (#69 ) of 3 (#39, #45, #69) sampled Residents reviewed for nutrition. Total sample size 26. The facility failed to ensure Resident #69 received ordered nutritional supplements with meals, assistance or encouragement with eating, and accurate documentation of meal intake. Findings: Review of Resident #69's medical record revealed she was admitted to the facility on [DATE], with diagnoses that included: Aphasia, Alzheimer's disease, Depressive Disorder, Cognitive Communication Deficit, Vitamin B12 Deficiency, and Dementia. Review of Resident #69's Quarterly MDS, with ARD of 04/02/2025, revealed she had a BIMS score of 3 (indicating severe cognitive impairment). The MDS revealed Resident #69 was independent with eating. Review of Resident #69's current care plan, revealed in part .Resident #69 has a potential for a nutritional problem. Interventions included in part . Monitor/ document/ report PRN if I exhibit signs and symptoms of dysphagia, pocketing, choking, coughing, drooling, holding food in mouth, or refusing to eat. Resident #69 has unplanned/unexpected weight loss r/t poor food intake. Interventions included in part . Monitor and record my food intake at each meal; Offer my supplements as ordered. Resident #69 has an ADL self-care performance deficit r/t dementia and generalized muscle weakness. Interventions included in part . Eating: I am independent with set up assist. Review of Resident #69's weights revealed the following which represented a significant weight loss: 12/9/2024 = 136.4 pounds 1/6/2025 = 136.0 pounds 2/10/2025 = 137.5 pounds (14.3 pound/10.2% weight loss in 3 months) 3/7/2025 = 136.6 pounds 4/10/2025 = 131.2 pounds 5/9/2025 = 123.2 pounds (8 pound/ -6.10 % weight loss in 1 month) Review of Resident # 69's medical record revealed Resident #69 was weighed monthly until triggered for weight loss. Resident #69 is currently weighed weekly. Review of Health Status Note dated on 05/08/2025, revealed in part .Speech therapy evaluated Resident #69 with new recommendation for mighty shakes. Review of progress note titled Weight Change dated 05/09/2025, revealed in part . Resident #69 assessed by Speech Therapy regarding difficulty swallowing. Resident #69's weight assessed due to decreased appetite and meal intake. Speech therapist recommended mighty shakes with meals. Current weight 123.2lbs, 8lbs weight loss in 30 days. Review of Physician Orders dated on 05/09/2025, revealed in part .Mighty shakes or Magic cup with meals three times a day. Review of Dietician Progress note dated 05/11/2025, revealed in part . Trigger for significant weight loss noted. Current weight 123.2 pounds (8 pound loss in one month). Mighty Shakes added three times a day with meals and Megace added for appetite on 05/10. Continue to monitor. Lunch observation on 05/12/2025 at 12:25 p.m., revealed in part .Resident #69 sitting in the dining room. Observed Resident #69 not eating. Encouragement or assistance not provided by staff. Observation of the tray revealed entrée untouched and no mighty shake for lunch. Review of meal intake report dated 05/12/2025 at 01:02 p.m. revealed in part . S11 CNA documented intake of 76-100 % for lunch. Breakfast observation on 05/13/2025 at 09:10 a.m., revealed in part .Resident #69 exiting her room with the therapist. Observation of tray revealed meal set-up was not performed. Observed untouched food on breakfast tray and mighty shake not provided with meal. On 05/13/2025 at 9:20 a.m., observed CNA removing breakfast tray from Resident #69's room. Review of meal intake report dated 05/13/2025 at 12:49 p.m. revealed in part . S15 CNA documented meal intake of 51-75 % for breakfast. Interview on 05/13/2025 at 01:50 p.m. with S15 CNA, revealed Resident #69 does not require feeding assistance but does require meal set up. S15 CNA, revealed meal set up included: Removing cover from plate, opening beverage carton and utensils. S15 CNA confirmed she documented Resident #69's meal intake for breakfast. Lunch observation on 05/13/2025 at 11:47 a.m., revealed in part . Resident #69 sitting in the dining room. Observed Resident #69 not eating. Observation of tray revealed mighty shake served with lunch. Observed resident drink approximately fifty percent of shake. On 05/13/2025 at 12:11 p.m., observed S7 CNA assist resident from dining room back to Resident #69's room. Observed lunch tray which revealed, untouched entrée. Encouragement or assistance not offered by staff. Review of meal intake report dated 05/13/2025 at 12:49 p.m. revealed in part . S15 CNA documented meal intake of 76-100 % for lunch. Interview on 5/13/2025 at 01:40 p.m. with S7 CNA, revealed Resident #69 is independent with eating but requires meal set up. S7 CNA, revealed meal set up included: Removing cover from plate, open beverage and utensils. Interview on 05/13/2025 at 02:20 p.m. with S9 LPN, revealed Resident #69 requires cueing and encouragement during meals. S9 LPN confirmed that CNAs are responsible for documenting meal intake and are to notify nurse when a resident does not eat. Interview on 05/13/2025 at 02:32 p.m. with S10 RN clinical support, revealed weights are obtained weekly for residents with significant weight loss. Significant weight loss is reported to Registered Dietician and Physician. S10 RN clinical support confirmed CNAs should have notified nurse of Resident #69's decrease in PO intake. S10 RN clinical support confirmed weight loss was not identified until it became significant. Breakfast observation on 05/14/2025 at 08:36 a.m., revealed in part .breakfast tray on bedside table not set up and food remained untouched. Observation and interview on 05/14/2025 at 09:10 a.m., revealed in part . S11 CNA removing breakfast tray from Resident #69's room. Mighty shake was not observed on breakfast tray. S11 CNA confirmed Resident #69 did not receive a mighty shake with breakfast and should have. Interview on 05/14/2025 at 09:10 a.m. with S12 LPN, confirmed Resident #69 did not receive a mighty shake with breakfast and should have. Interview on 05/14/2025 at 12:30 p.m. with S2 DON, confirmed Resident #69 did not receive nutritional supplements as ordered and should have. S2 DON confirmed inaccurate meal intake documentation. S2 DON confirmed that Resident #69 should have been assisted/ encouraged by staff during meals.

Based on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the recipe in regard to portion size to ensure the nutritional adequacy of the meal for all 10 residents who received a puree diet. Findings: In an interview during the initial kitchen tour at 8:50 a.m. on 05/12/2025, S3 Dietary Manager stated the facility had 10 residents being served a puree diet. In an observation on 05/12/2025 at 10:30 a.m., S4 [NAME] used a 2 ounce ladle and put 6 scoops of lima beans into the blender to puree. S4 [NAME] then added 2 scoops of liquid from the lima beans to the blender. S4 [NAME] blended them together and placed them in a pan for the steam table. Review of the recipe for lima beans provided by S3 Dietary Manager revealed for 10 servings, 1 and ¼ quart (40 ounces) of beans should have been pureed. In an interview on 05/12/2025 at 11:00 a.m., S4 [NAME] confirmed she put 6 scoops of lima beans into the blender with a 2 ounce ladle. In an interview on 05/12/2025 at 11:05 a.m., S3 Dietary Manager confirmed S4 [NAME] did not follow the recipe and did not put enough lima beans in the blender to puree, but should have.

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. Food was not open to air while stored in the pantry; and 2. Food serving scoop was not left inside sugar bin in direct contact with resident food items. This deficient practice had the potential to affect 84 residents who received meals served from the kitchen. Findings: An observation on 05/12/2025 at 9:00 a.m. revealed the serving scoop was inside the bulk storage container of sugar lying on top of and in direct contact with the sugar. In an interview at that time, S3 Dietary Manager confirmed the scoop should not be in the sugar bin touching the sugar. An observation on 05/12/2025 at 9:05 a.m. revealed a package of fish breading in the pantry that was open to air. In an interview at that time, S3 Dietary Manager confirmed the fish breading in the pantry was open to air and should not be.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. Nursing carts were free of loose pills for 1 (Cart A) of 2 (Cart A and Cart B) carts reviewed, and 2. Nursing carts were free of expired supplies for 1 (Cart B) of 2 (Cart A and Cart B) carts reviewed. Findings: Review of the facility's policy entitled Storage of Medication Requiring Refrigeration revised on 09/01/2024 revealed, in part .the facility must provide safe and effective storage of all drugs and biologicals consistent with professional standards of practice. Staff should remove any expired medications from active stock and discard according to facility policy. Interview with S19 CQI on 05/14/2025 at 12:23 p.m. confirmed the facility's policy entitled Storage of Medication Requiring Refrigeration was used for all medications in the facility, not just refrigerated medications. Observation of Cart A on 05/13/2025 at 1:45 p.m., with oversight from S9 LPN, revealed 2 unidentified and loose tablets in the bottom of the 2nd drawer of the cart. S9 LPN confirmed there were 2 unidentified and loose tablets in the 2nd drawer of Cart A, that should not have been. Observation of Cart B on 05/14/2025 at 1:00 p.m., with oversight from S18 Treatment Nurse, revealed 17 Lubricating Jelly 3 gram packages with an expiration date of 03/2019, 8 Skin Protectant Cream with Lanolin 0.18 ounce packages with an expiration date of 09/2024, 1 Lubricating Jelly 3 gram package with an expiration date of 04/12/2022, and 1 Skin Protectant Ointment 5 gram package with an expiration date of 05/2024. S18 Treatment Nurse confirmed the expired supplies were in Cart B, and should not have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse for 3 (#2, #3, and #4) of 4 (#1, #2, #3, and #4) sampled residents. The facility failed to 1. Ensure Resident #2 was not physically abused by Resident #3; 2. Ensure Resident #3 was not physically abused by Resident #4; and 3. Ensure Resident #4 was not physically abused by Resident #3. Findings: Review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 07/26/2023, revealed in part .The facility's policy strictly prohibits abuse and neglect. This policy is against abuse, neglect, exploitation and misappropriation of resident property including abuse by any other person, including, but not limited to other residents. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful means the individual must have acted deliberately (not-inadvertently or accidentally), not that the individual must have intended to inflict or harm. A cognitively impaired resident that hits another resident, may be considered abusive. Resident #2 Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses that included in part . Acute Pulmonary Edema, Dementia Mild with other behavioral symptoms, Anxiety Disorder, Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease and Bronchitis. Review of Resident #2's Quarterly MDS with an ARD of 02/14/2025, revealed a BIMS score of 15, indicating intact cognition. The MDS revealed Resident #2 was independent with eating, oral hygiene, toileting, dressing, personal hygiene, transfers and ambulation. Resident #3 Review of Resident #3's medical record revealed he was admitted to the facility on [DATE], with diagnoses that included in part .Unsteadiness on Feet, Dementia, Moderate without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Hallucinations Unspecified and Cognitive Communication Deficit. Review of Resident #3's Admission's MDS with an ARD of 02/09/2025, revealed a BIMS score of 99 (resident was unable to complete the interview). The MDS revealed Resident #3 required supervision or touching assistance with eating. Resident #3 required substantial/maximal assistance with toileting, bathing and dressing; partial/moderate assistance with transfers; and used a manual wheelchair for mobility. Review of Resident #3's medical record revealed Resident #3 was sent to the ER on [DATE], and was to be transferred to a behavioral hospital due to escalating behavior at the facility. Review of Resident #3's Care Plan with a Target date of 05/12/2025, read in part . 1. I have a behavior problem, (problem onset date of 02/06/2025). I am resistant to ADL care from CNAs at times. I become easily agitated and will be combative and verbally aggressive with staff at times. I will spit out my meds and refuse care. Interventions included in part .Bring me to the nurse's station for closer supervision when I become intrusive. 2. Disrobing in public (problem onset date of 02/06/2025). I get very confused and will believe things that are not true. I do not like being corrected. 03/04/2025 - Intrusive, physically/verbally aggressive. Interventions included in part .I will be removed from the situation and taken to alternate location as needed. I will have interventions as necessary to protect the rights and safety of others. Resident #4 Review of Resident #4's medical record revealed he was admitted to the facility on [DATE], with diagnoses that included in part .Aphasia, Cognitive Communication Deficit, Unspecified Dementia severe without behavioral disturbance, Psychotic Disturbance Mood Disturbance and Bipolar Disorder. Review of Resident #4's Quarterly MDS with an ARD of 02/12/2025, revealed a BIMS score of 5, indicating severe cognitive impairment. The MDS revealed Resident #4 required substantial/maximal assistance with transfer, toileting, bathing and dressing. Resident #4 used a manual wheelchair for mobility. Review of a facility Incident Report dated 03/04/2025 at 5:15 p.m., read in part .Resident #2 yelled up the hall Help, we have a problem down here. Staff went down hall and observed Resident #2 standing in her room, and Resident #3 was in hallway in front of her (Resident #2's) room. Resident #2 stated Resident #3 came in her room, and she asked him to get out. In return, Resident #3 kicked her in her right shin before she could get assistance. Immediate Action Taken: Inspected Resident #2's skin. No redness, bruising, or opened area noted at this time. Resident #2 denies injury or pain at this time. DON notified of situation. Resident #3 immediately removed by another staff member from hallway. Injuries observed at time of incident - No injuries observed. Review of the facility Incident Report dated 03/04/2025, revealed a note dated 03/07/2025 (no time), that read in part .Upon investigation, it was noted that Resident #3 was showing signs of increased agitation in the dining room and was not easily re-directed. Staff then escorted him to his room to be in a lower stimulating environment. Moments later, Resident #2 was calling for assistance. Investigation revealed that Resident #3 had entered Resident #2's room trying to get her snacks. Resident #2 stated that she started yelling at him to get out of her room, when he kicked her in her right lower leg. Resident #2 stated that Resident #3 was backing out of her room when Resident #4 intervened on her behalf. Resident #2 stated Resident #4 hit Resident #3 in the back, and started pulling his (Resident #3's) wheelchair out of her doorway. Meanwhile, Resident #2 called for staff assistance. Resident #4 stated that as soon as he had Resident #3 in the hallway, Resident #3 managed to turn around facing Resident #4, then kicked him (Resident #4) on the right lower leg. Staff immediately deescalated the situation by removing Resident #3 from the area, and by placing him on 1:1 supervision. Interview on 04/09/2025 at 9:46 a.m. with S1 DON, revealed video surveillance captured the following in part . 03/04/2025 at 5:00 p.m. - staff brought Resident #3 into the dining room for meal service. Resident #3 was placed at the back table. Resident #3 immediately unlocked his wheelchair and moved from table to table, attempting to take other residents' belongings. Several residents were calling to someone to move him elsewhere. Staff attempted re-direction. During this time Resident #3 was observed touching what seemed to be everything. He was also seen trying to eat from dirty dishes that were placed in the window. Resident #3 was re-directed again. 03/04/2025 at 5:15 p.m. - S1 CNA removed Resident #3 from the dining room and escorted him to his room. S1 CNA then walked up the hall to tell Resident #3's nurse. 03/04/2025 at 5:16 p.m. - Resident #3 came out of his room and opened Resident #2's room door and entered her room. Resident #3 was seen slowly backing out of Resident #2's room. 03/04/2025 at 5:17 p.m. - Resident #4 came out of his room and hit Resident #3 in his back, and started to pull Resident #3's wheelchair out of Resident #2's doorway. Resident #2 was seen standing in the hallway looking towards the nurse's station calling for assistance. While Resident #4 had a hold of Resident #3's wheelchair, Resident #3 managed to turn his wheelchair around and then kicked Resident #4 on the leg. S1 DON confirmed at that time that Resident #2 and Resident #4 were victims of resident to resident physical abuse by Resident #3, and Resident #3 was a victim of physical abuse by Resident #4 on 03/04/2025. Interview on 04/08/2025 at 1:30 p.m. with Resident #2 revealed about a month ago (03/04/2025), Resident #3 who resided across the hallway from her attempted to enter her room. Resident #2 stated she told Resident #3 no, but he continued to try and enter her room. Resident #2 stated Resident #3 kicked her on the right shin. Resident #2 stated Resident #4 (roommate to Resident #3), came to get Resident #3 out of her room. Resident #2 stated Resident #4 hit Resident #3 on the back, and Resident #3 kicked Resident #4 on the leg. Interview on 04/08/2025 at 12:18 p.m. with Resident #4, revealed he remembered the evening when Resident #3 tried to enter resident #2's room; however, he was unable to remember the date. Resident #4 stated he heard Resident #2 call for help, so he went across the hall to see what was going on. Resident #4 stated Resident #3 was trying to push past Resident #2 to enter he room. Resident #4 stated he went to grab resident #3's wheelchair to get him away from Resident #2, and he hit Resident #3 across his back. Resident #4 revealed Resident #3 then turned in his wheelchair and kicked him on the leg. Telephone interview on 04/09/2025 at 10:23 a.m. with S2 CNA, revealed on 03/04/2025 at 5:00 p.m. Resident #3 was in the dining room in a wheelchair. S2 CNA stated Resident #3 left his table and went to where the dirty dishes were in the kitchen window, and was trying to get food off the dirty plates. S2 CNA stated she re-directed Resident #3 back to his table and he became verbally aggressive calling her the N word. S2 CNA stated Resident #3 left his table again and was messing with other residents in the dining room. S2 CNA stated Resident #3 rolled up to a blind resident and was trying to get something out of his back pack. Another resident intervened, and Resident #3 became verbally aggressive towards that resident. S2 CNA stated she took Resident #3 out of the dining room back to his room, and stopped by the nurse's station and told S3 LPN about Resident #3's behaviors. Telephone interview on 04/09/2025 at 11:41 a.m. with S3 LPN revealed on 03/04/2025 Resident #3 had been upset that day after his Care Plan meeting, because it had been determined Resident #3's still required a pureed diet. S3 LPN stated S2 CNA had reported to her she had to remove Resident #3 from the dining room during the evening meal, because he was being disruptive in the dining room, and messing with other residents. S3 LPN stated Resident #3 had no behaviors at the other meal services that day. S3 LPN stated she told S2 CNA that's fine, I'll check on him in a few minutes. S3 LPN revealed before she could check on Resident #3, he exited his room and tried to enter Resident #2's room and kicked her on the leg. When Resident #4 tried to intervene, he (Resident #4) hit Resident #3 in the back, and in turn Resident #3 kicked Resident #4 on the leg.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for the treatment of a skin tear was followed for 1 (#3) of 3 (#1, #2, and #3) sampled residents. The facility had a total census of 90. Findings: Review of the Facility policy titled: Skin Tears, with an effective date of 04/04/2024 revealed in part . Process: 2 (b). Tropical treatments in accordance with current standards of practice will be provided for residents who have a skin tear. 4. Monitoring b. Licensed nurses will participate in the management of skin tears and medical conditions by following physician orders. Assessment of residents, and reporting changes in condition to the resident's physicians. Review of Resident #3's clinical record revealed an admit date [DATE] with diagnoses which included in part . Alzheimer's Disease with Late Onset, Impulse Disorder Unspecified, Generalized Anxiety, History of Falling and Dementia. Review of Resident #3's Quarterly MDS with an ARD of 09/04/2024 revealed a BIMS score of 99 (indicating interview was unsuccessful), Resident #3 required setup or clean-up assistance with eating. Resident #3 was dependent on staff for oral hygiene, toileting, bathing, dressing and personal hygiene. Review of Resident #3's care plan with a target date of 12/01/2024 revealed in part .I have a skin tear to right lower leg. Interventions that included: if I receive a skin tear, treat per facility policy protocol. Review of Resident #3's Physician's orders revealed: 10/15/2024: Cleanse skin tear to right lower leg with normal saline, pat dry, and apply tegaderm, every 3 days until healed. ? Review of Resident #3's TAR (Treatment Administration Record) revealed in part . Cleanse skin tear to right lower leg with normal saline, pat dry and apply Tegaderm every 3 days until healed. S2 RN initialed the above treatment on the TAR as completed on 11/02/2024. S3 RN initialed the above treatment as completed on 11/05/2025. Observation on 11/07/2024 at 1:01 p.m. revealed Resident #3 was seated in a wheelchair near the nurse's station. Resident #3's right lower leg was noted with a skin tear, and had a blood stained clear bandage, that did not cover the entire area of the skin tear. Observation revealed the clear bandage was dated 11/02/2024. Observation and interview of Resident #3 on 11/07/2024 at 1:10 p.m. with S2 RN revealed a clear bandage to Resident #3's right lower leg. The clear bandage was blood stained and dated 11/02/2024 with initials on it. S2 RN confirmed the date on the bandage read 11/02/2024 and it was her initials on the bandage from 11/02/2024, indicating she completed Resident #3's treatment on that date Interview on 11/12/2024 at 9:01 a.m. with S1 DON revealed she had spoken with S3 RN regarding the clear bandage on Resident #3's right lower leg having a date of 11/02/2024. S1 DON stated S3 RN revealed she had initialed Resident #3's TAR on 11/05/2024 , but when she got to Resident #3, she was unable to do the treatment at that time, and forgot to go back to do it. S1 DON confirmed Resident #3's dressing change to her right lower leg skin tear should have been done on 11/05/2024, and it had not been. Telephone interview on 11/12/2024 at 1:45 p.m. with S3 RN revealed she initialed the treatment on the TAR for Resident #3 as having changed the bandage to a skin tear to her right lower leg on 11/05/2024. S3 RN revealed she had attempted to change the bandage on Resident #3's right lower leg, but the resident became agitated. S3 RN revealed she left Resident #3 to calm down, and failed to go back and change the bandage. S3 RN confirmed she did not change the dressing to Resident #3's right lower leg on 11/05/2024 as ordered, but she should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3 Resident #4, Resident #5) sampled residents. Findings: Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident property, Suspicious Injuries of Unknown Source, Exploitation, with a revision date of 04/25/2024, revealed in part .This policy is against abuse, neglect, exploitation and misappropriation of resident property including abuse by any other person, including, but not limited to: other residents. Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. A cognitively impaired resident that hits another resident, may be considered abusive. Physical Abuse: Physical abuse includes, hitting, slapping, pinching, and kicking. Resident #4 Review of the clinical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses that included in part .Parkinson's Disease with Dyskinesia, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Dysarthria, Dysphagia, Aphasia, Unspecified Lack of Coordination, and Age Related Physical Debility. Review of Resident #4's Annual MDS with an ARD of 07/24/2024, revealed Resident #4 had a BIMS score of 8, indicating moderately impaired cognition. The MDS revealed Resident #4 required supervision or touching for: toileting, dressing, personal hygiene and transfers. Resident #4 was independent with eating and partial/moderate assistance for shower/bath. The MDS revealed Resident #4 utilized a walker for mobility. Review of Resident #4's care plan with a target date of 11/04/2024 read in part .I have Impaired Cognitive Function/Dementia or Impaired Thought Process related to Dementia, with interventions that included: I will be provided cues, reoriented and supervised as needed. Resident #5 Review of Resident #5's clinical record revealed an admission date of 09/12/2019, with diagnoses that included in part . Dementia in other Diseases classified elsewhere, Mild with Mood Disturbance, Impulse Disorder, Other Alzheimer's Disease and Major Depressive Disorder. Review of Resident #5's Annual MDS with an ARD of 04/24/2024, revealed Resident #5 had a BIMS score of 11, indicating moderately impaired cognition. The MDS revealed Resident #5 was independent with eating and oral hygiene; required supervision or touching assistance with upper body dressing, personal hygiene, and toilet transfer; partial/moderate assistance with shower/bath. The MDS revealed Resident #5 used a manual wheelchair independently for mobility, and had impairment on one side to upper and lower extremities. Review of Resident #5's care plan with a target date of 07/31/2024, revealed in part .I have a behavior problem and will cuss at staff and others; resists care, refuses medications, history of aggression. Diagnosis Impulse Control Disorder with behaviors, with interventions that included: I will be assisted to develop more appropriate methods of coping and interacting with staff and others. I will have interventions as necessary to protect the rights and safety of others. I will be removed from the situation and taken to alternate location as needed. Monitor my episodes of behavior and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document my behavior and potential causes. Review of a facility incident report documented by S2 LPN, and dated 05/21/2024, revealed in part . on 05/21/2024 at 11:40 a.m. while in the dining room, Resident #4 and Resident #5 were involved in a resident to resident altercation. Review of the facility's investigation, documented by S1 Administrator, revealed in part . on 05/21/2024 video surveillance revealed residents were gathering in the dining room for lunch. Resident #5 was observed maneuvering his way through the dining room to his table in a wheelchair, when he encountered Resident #4's walker. Resident #5 was then observed to kick Resident #4's walker to clear the path to his table. Resident #4 was observed grabbing Resident #5's wheelchair to move Resident #5 away from his walker. Resident #5 then threw a small plastic bowl and hit Resident #4 on the left side of his head above the eyebrow area, which resulted in a small laceration. Resident #4 then grabbed Resident #5's arm and both Resident #4 and Resident #5 started hitting at each other. This resulted in a skin tear to Resident #5's left arm. Review of a Treatment Administration Record dated May 2024 read in part .Cleanse laceration to left upper brow with normal saline, apply Bacitracin, cover with Band-Aid one time a day for laceration. Interview with Resident #4 on 08/06/2024 at 12:51 p.m., revealed on 05/21/2024, while in the dining room, Resident #5 kicked his walker, then threw a bowl and hit him over the eye (resident pointed above his left eyebrow). Resident #4 revealed the bowl had caused a cut. Resident #4 stated it hurt when it happened, but it doesn't hurt now. Interview on 08/06/2024 at 1:06 p.m. with S1 Administrator, confirmed video surveillance revealed on 05/21/2024 right before the start of the noon meal, Resident #5 threw a small plastic bowl and hit Resident #4 on the left side of his head above the eyebrow, which resulted in a small laceration. S1 Administrator revealed Resident #4 was administered first-aid and treated at the facility for the small laceration. Interview on 08/06/2024 at 1:42 P.M. with S3 CNA, revealed on 05/21/2024, while leaving the dining room before the start of lunch, she heard a commotion and turned to see Resident #5's hand coming down out the air, and a plastic bowl hitting Resident #4 above his eye, causing it to bleed. S3 CNA revealed Resident #4 and Resident #5 started hitting each other. S3 CNA revealed Resident #5 had scratches to his arm. S3 CNA stated Resident #5 had a habit of pushing his way through the dining room and bumping into other resident's chairs, and then becoming upset. Interview on 08/06/2024 at 2:00 p.m. with S4 CNA revealed she was summoned to the dining room by S3 CNA to help separate Resident #4 and Resident #5 because they were hitting each other.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (#46) out of a total of 23 sampled Residents, by failing to ensure she was free of facial hair. Findings: Review of Resident #46's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included in part .Schizoaffective Disorder Unspecified, Dementia, Aphasia, Cognitive Communication deficit, Major Depressive Disorder, Chronic Atrial Fibrillation Unspecified and Transient Ischemic Attack. Review of Resident #46's Annual MDS with an ARD of 01/10/2024 revealed she had a BIMS score of 3 (indicating severe cognitive impairment). The MDS revealed Resident #46 required partial/moderate assistance with personal hygiene, and substantial/maximal assistance with bathing. Review of Resident #46's care plan with a target date of 04/21/2024 read in part .I have impaired cognitive function and impaired thought processes related to mild cognitive impairment, Dementia with behavioral disturbances and interventions that included to provide cues, reoriented and supervise as needed. Observation on 02/26/2024 at 10:10 a.m. revealed Resident #46 lying in bed. Long facial hair approximately half an inch long observed to her chin and lip. Observation and interview on 02/27/2024 at 9:47 a.m. revealed Resident #46 with long facial hair approximately half an inch long to chin and lip. Resident #46 revealed she didn't know the last time the facial hair had been removed. Resident #46 stated she would like the facial hair removed. Interview on 02/27/2024 at 10:07 a.m. with S3 CNA revealed she provided care for Resident #46. S3 CNA revealed Resident #46 required limited assistance with her ADL's; and received a whirlpool on Monday, Wednesday and Friday. S3 CNA revealed it had been a week since she had removed Resident #46's facial hair. Observation and interview on 02/27/2024 at 10:15 a.m. of Resident #46 with S5 LPN in attendance revealed Resident #46 lying in her bed. Resident #46 was observed to have long facial hair to her chin and lip approximately half an inch long. S5 LPN confirmed Resident #46's facial hair was long and it absolutely should not have been.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure a resident (Resident #53) personal furniture was maintained in good sanitary condition. The sample resident size was 23. Findings: Observation on 02/26/2024 at 10:55 a.m. revealed Resident #53 lying in bed with an oversized brown message type recliner position next to his bed. The recliner was noted to have a dried brown sticky substance on the left side near the head, brown substance scattered in the bottom cushion, and a small amount of sand type substance inside the right/left enclosed foot rest. Observation on 02/27/2024 at 10:00 a.m. revealed an oversized brown message like recliner position next to his bed. The recliner was still noted to have a dried brown sticky substance on the left side near the head, brown substance scattered in the bottom cushion, and a small amount of sand type substance inside the right/left enclosed foot rest. Interview on 02/27/2024 at 10:10 a.m. with S18 LPN revealed the recliner is used by Resident #53 to sit up while out of bed and had been purchased by his family. S18 LPN stated it has been about 2 weeks since the resident was last up in the recliner. S18 LPN stated the facility had an outbrealk of virus was the reason the resident had not been up in recliner for 2 weeks. Interview on 02/27/2024 at 10:20 a.m. with S9 CNA revealed the resident uses the recliner whenever he is up out of bed. S9 CNA stated the resident is up in the recliner every Monday, Wednesday, and Friday. S9 CNA stated there was an outbreak of a virus and the resident was last in the recliner 2 weeks ago. S9 CNA sated housekeeping is responsible for cleaning the recliner and the CNAs will wipe spills. Interview on 02/27/2024 at10: 25 a.m. with S10 Housekeeping revealed housekeeping is responsible for cleaning Resident #53's recliner. S10 Housekeeping stated the recliner was last cleaned 2 weeks ago and supposed to be cleaned weekly by housekeeping. Observation of Resident #53 on 02/27/2024 at 10:45 a.m. accompanied by S18 LPN after observation of Resident #53's recliner confirmed it was dirty and needed to be cleaned. S18 LPN stated housekeeping is responsible for cleaning the recliner.

Based on interview and record review the Facility failed to ensure their grievance policy and procedure was followed by failing to complete a grievance for 1 (#62) of 23 sampled residents. Findings: The Facility'sv undated Policy Titled Grievance Program reviewed on 02/26/2024 read in part .when there is a grievance it will be: Process: a. Documented on the facility's Grievance Report. b. Routed to the Grievance officer. e. Investigated accordingly. Review of Resident #62's medical record revealed an admit date of 12/01/2023 with diagnoses which included in part .Paroxysmal Atrial Fibrillation, Type 2 Diabetes Mellitus, Cognitive Communication Deficit, Major Depressive Disorder and Generalized Anxiety Disorder. Review of Resident #62's admission MDS with an ARD 12/07/2023 revealed she had a BIMS score of 15 (indicating intact cognition), and required supervision or touching assistance with personal hygiene, toileting hygiene and lower body dressing; independent with eating and partial/moderate assistance with shower/bath. Interview on 02/26/2024 at 11:05 a.m. Resident #62 revealed she had missing underwear that had not been found or replaced (Resident #62 stated she could not remember the exact date but it was in December 2023). Interview on 02/27/2024 at 9:51 a.m. with Resident #62 revealed she had 8 pair of new underwear that she had never worn, with her name on them. Resident #62 revealed she reported to S17 Housekeeping Supervisor that her underwear were missing, but she never got her underwear back or replaced. Interview on 02/27/2024 at 10:14 with S17 Housekeeping Supervisor revealed Resident #62 had reported to her she had missing underwear. S17 Housekeeping Supervisor stated the facility's process was if she could not locate the missing underwear she should have informed the SSD so they could have been replaced. S17 Housekeeping Supervisor confirmed she did not initiate a grievance or notify the SSD of Resident #62's missing underwear and she should have.

Based on interview and record review, the facility failed to implement a person-centered care plan for recurrent Urinary Tract Infections (UTI) for 1 (#25) of 1 (#25) residents reviewed for UTIs. Findings: Interview with Resident #25 on 02/26/24 at 1:54 p.m. revealed she had a recurrent UTI every 6-8 weeks since admission and had been placed on antibiotics each time. Interview with S11 LPN on 02/27/2024 at 10:35 a.m. revealed Resident #25 may have had a UTI when she first came in, but doesn't remember her having recurrent UTIs. Review of the Nurses' Notes: 12/02/203 at 1:49 p.m. revealed Resident #25 was sent to the emergency room due to a fall and returned that same day with a new diagnosis of UTI and new order for Macrobid 100 mg BID X 7 days. 01/31/2024 at 2:45 p.m. revealed the Nurse Practitioner made rounds and placed Resident #25 on Levaquin 500 mg one QD X 7 days for UTI. Review of the care plan revealed no history of or current history of Resident #25 having a UTI. Interview with S7 RN/CCN on 02/27/2024 at 3:30 p.m. revealed that he had not care planned Resident #25 for her UTI's but had care planned her medication. S7 RN/CCN confirmed he should have developed a care plan that included UTIs and interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 Residents (Resident #10 and Resident #21) of 23 sampled residents. Findings: Review of the facility policy titled: Activities of Daily Living (ADLs) Maintain Abilities revealed in part: 1. Based on the resident's comprehensive assessment and consistent with the resident's need and choices, the facility will provide the necessary care and services. 3. The facility will provide care and services for the following activities of daily living: a. Hygiene- bathing, dressing, grooming, and oral care. Policy Explanation and Compliance Guidelines: 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #10 Review of Resident #10's EHR revealed he was admitted to the facility on [DATE], diagnosis included Cerebrovascular Disease, Impulse Disorder, Unspecified Psychosis, Essential (Primary) Hypertension, and Major Depression. Review of the Care Plan revealed Resident #10 had a deficit in ADL self- care performance r/t Stroke (right hemiplegia), resident was totally dependent on staff for all ADLs including personal hygiene. Review of Resident #10's MDS Significant Change Assessment with an ARD of 11/30/2023 revealed BIMS should not be conducted as resident is rarely/never understood. Resident #10's functional status revealed he required total staff assistance with personal hygiene. Observation on 02/26/2024 at 10:30 a.m. revealed Resident #10 lying in bed with stubble salt/pepper facial and chin hair, fingernails noted to be jagged and untrimmed. Observations on 02/27/2024 at 11:43 a.m. and 1:48 p.m. revealed Resident #10 lying in bed with stubble salt/pepper facial and chin hair, fingernails noted to be jagged and untrimmed. Interview on 02/27/2024 at 1:52 p.m. with S2 DON after observation of Resident #10's face and fingernail confirmed the resident needed to be shaved and his fingernails needed to be trimmed. Resident #21 Review of Resident #21's EHR revealed she was admitted to the facility on [DATE], diagnosis included Displaced Intertrochanteric Fracture of Left Femur, subsequent encounter for closed fracture, Anxiety Disorder, Psychosis, Other Alzheimer's Disorder, and Dementia with other behavioral disturbances. Review of the Care Plan revealed Resident #21 had a deficit in ADL self- care performance r/t Musculoskeletal impaired and required extensive assistance by one staff for personal hygiene. Review of Resident #21's admission MDS with an ARD of 02/10/2024 a revealed BIMS of 12 (moderately impaired cognition), and required one person extensive assistance for personal hygiene. Observation on 02/26/2024 at 12:10 p.m. revealed Resident #21 in the dining room. The resident was noted to have jagged and untrimmed fingernails. Interview on 02/26/2024 at 12:12 p.m. with Resident #21 stated her fingernails were too long and needed to be trimmed. Resident #21 stated she prefers her fingernails to be short. Observation on 02/27/2024 at 9:45 a.m. of Resident #21 lying in bed still with jagged and untrimmed fingernails. Resident#21 revealed she would still like to have her fingernails trimmed. Interview on 02/27/2024 at 10:52 a.m. with S4 RN Treatment Nurse after observation of Resident #21's fingernail, confirmed the resident's fingernails needed to be trimmed. S4 RN Treatment Nurse stated the CNAs are responsible for fingernail care during ADLs. S4 RN Treatment Nurse stated Resident #21 should have been offered to have her fingernails filed and trimmed.

Based on observation and interview, the facility failed to ensure that food was properly stored in accordance with professional standards for food service safety. The facility failed to ensure that expired/outdated items were not available for resident consumption. Findings: Review of the facility's Policy and Procedure titled, Storage of Canned and Dry Food read in part . Policy: The facility ensures the quality and safety of canned and dry food through accepted storage practices. Procedure #5. Canned goods and dry foods are dated when received. The first in, first out method is used: Products with the earliest date are stored in front of products with a later date. On initial tour of the kitchen on 02/26/2024 at 9:20 a.m. accompanied by S6 Dietary Manager in the dry food storage room revealed the following items on the shelf available for use: 1. One 2.12 ounce grinder bottle of sea salt with an expiration date of 03/2023. 2. One open box of 48 - 4 ounce thickened orange juice containers with an expiration date of 02/22/2024. The opened box dated 02/15/2024 was missing 6 containers. Interview with S6 Dietary Manager on the above date and time confirmed the above findings. S6 Dietary Manager revealed she was not aware of the thickened orange juice containers were outdated. S6 Dietary Manager stated the dietary staff should have removed the box from the dry storage room in order for her to send it back to the company due to outdated and to receive credit. S6 Dietary Manager stated she did not recall the box of orange juice opened on the shelf before today. S6 Dietary Manager stated she did not know when the 6 missing containers were taken out of the box and distributed to the residents. S6 Dietary Manager stated that the week-end dietary staff must have opened the box and used the 6 missing containers this past week-end and should not have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure pain management was provided to residents who required such services, that was consistent with professional standards of practice for 1 (#1) of 5 (#1, #2, #3, #4, & #5) sampled residents reviewed for pain. The facility failed to ensure Resident #1 received timely intervention for complaint of pain when he displayed verbal indications of pain in his left upper extremity on 05/09/2023 and 05/10/2023, after experiencing a fall on 05/08/2023. Resident #1 was sent to the hospital by the dialysis NP on 05/10/2023 when Resident #1 complained that his arm hurt really bad, and observation revealed the arm was bruised and swollen. Resident #1 was diagnosed with an Acute Proximal Ulnar Fracture of the left arm. Findings: Review of the facility's policy titled Pain Assessment and Management revealed in part: Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain . Document the resident's reported level of pain with adequate detail (i.e. enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. Upon completion of the pain assessment, the person conducting the assessment shall record information obtained from the assessment in the resident's medical record. Review of Resident #1's medical record revealed an admit date of 01/25/2019, with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, COPD, DM, Morbid Obesity, Dementia, and Acquired absence of left and right leg above the knee. Review of Resident #1's MDS with an ARD of 03/15/2023, revealed a BIMS score of 5, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #1 required extensive two person physical assistance with bed mobility and toileting, and was totally dependent on two person physical assistance with transferring. Review of Resident #1's 05/2023 physician orders revealed the following orders: 01/24/2023: Acetaminophen (an analgesic and fever reducer) 1000 mg po q 4 prn pain or fever; do not exceed 3000mg in 24 hours. 11/21/2020: Hydrocodone-Acetaminophen (an opiate narcotic analgesic agent) 5-325 mg give one tablet by mouth q 6 hours as needed for pain. Review of Resident #1's plan of care revealed the resident was care planned for chronic pain related to neuropathy with approaches that included: I will be evaluated for the effectiveness of pain interventions every shift. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability, and impact on cognition. There was no plan of care with interventions regarding pain due to the problem of Acute Proximal Ulnar Fracture after Resident #1 was diagnosed 05/10/2023. Review of a facility accident report dated 05/08/2023 at 9:00 p.m. read in part . Resident #1 was found on the floor lying on his stomach on his fall mat. Resident #1 was assisted back into bed by 4 person assist. A full body assessment was done by S2 LPN. No bruising or skin tears noted. Resident #1 denied pain at this time. No injuries observed at time of incident. Review of Resident #1's nurses' notes revealed the following in part . 05/09/2023 at 12:30 p.m. - Resident complained of left wrist hurting. This nurse lightly touched resident's wrist and resident hollered out. Slight swelling noted to left wrist. No redness or bruising noted to area. MD notified. New order noted: Obtain x-ray of left wrist. RP aware. Documented by S3 RN. 05/10/2023 at 3:10 p.m. - (Resident #1's) dialysis center called and stated resident's left arm was swollen and that dialysis NP wanted an x-ray of left upper extremity performed. Documented by S4 LPN. 05/10/2023 at 7:40 p.m. - Hospital called report to this nurse that resident had a spiral fracture to left arm. Reported resident's arm was splinted and placed in a sling. Resident to return to facility. Documented by S5 LPN. 05/10/2023 at 9:45 p.m. - Resident arrived back to facility on stretcher by ambulance. Alert and oriented x 2 with clear speech. Resident has sling in place at this time. Complained of pain when left arm is touched . Documented by S5 LPN. Review of Resident #1's X-ray of Left Upper Extremity-Forearm dated 05/10/2023 revealed: History: pain with trauma/injury Findings: Osteopenia limits the exam. There is an acute, obliquely oriented and minimally displaced fracture of the proximal ulnar diaphysis. Bones are otherwise intact. Impression: Acute Proximal Ulnar Fracture. Observation on 05/22/2023 at 10:30 a.m., revealed Resident #1 lying in bed with his left arm wrapped in an ACE bandage, and in a sling. Resident #1 stated his left arm hurt. In a telephone interview on 05/22/2023 at 1:46 p.m., the RN/charge nurse at Resident #1's Dialysis Center stated that on 05/10/2023 the dialysis nurse reported to her that Resident #1's arm was bruised, swollen, and hurt really bad. The RN/charge nurse further explained their NP wanted to get an x-ray of Resident #1's arm so they sent him to the emergency room. In a telephone interview on 05/23/2023 at 11:11 a.m., S5 LPN reported she worked the night of 05/10/2023, the night Resident #1 returned from the hospital. S5 LPN stated she received report via a telephone call from the hospital, and was informed that Resident #1 had a fractured arm. S5 LPN reported Resident #1 complained of pain when his arm was moved up to put a pillow under it. S5 LPN reported she did not give Resident #1 any pain medication that night. S5 LPN stated she did assess his pain, it only hurt when moved, and she did not get him to rate the pain. S5 LPN confirmed she did not offer Resident #1 any pain medication. In an interview on 05/23/2023 at 12:00 p.m., S6 LPN stated she worked with Resident #1 on the day shift of 05/10/2023 and 05/11/2023. S6 LPN reported on 05/11/2023 she called Resident #1's physician to get his pain medication, Norco (Hydrocodone-Acetaminophen), refilled because they were out of it. S6 LPN reported Resident #1 denied he was in any pain, and she called the physician's office and asked the nurse to get the doctor to prescribe his pain medication because she thought he may need it on the 12th before being moved around to go to dialysis. S6 LPN stated the pain medication would have been delivered to the facility that night (05/11/2023) between 8:00 p.m. and 9:00 p.m. In an interview on 05/23/2023 at 12:13 p.m., S7 RN reported she assisted the ambulance personnel transfer Resident #1 to the stretcher on 05/12/2023 to be transported to dialysis by holding his left arm because he had pain with movement, and moaned when it was moved. In a telephone interview on 05/23/2023 at 12:40 p.m., S8 CNA reported Resident #1 was having some pain when he returned from the hospital on the night of 05/10/2023, and he would say Oh, oh, oh when you moved his arm. S8 CNA stated she did not report to the nurse because Resident #1's arm only hurt with movement. In a telephone interview on 05/23/2023 at 1:35 p.m., S2 LPN reported the hospital did not send a script for pain medication when Resident #1 returned from the hospital on [DATE]. S2 LPN stated they had to call and get Resident #1 some pain medication, but he didn't complain much about pain. S2 LPN stated she worked the night of 05/11/2023, and could not remember if she gave Resident #1 any pain medicine or not. In an interview on 05/23/2023 at 2:20 p.m., S9 CNA confirmed she sat in the room with Resident #1 on the evening of 05/10/2023 because he was hollering out. S9 CNA said she was trying to keep him calm so he wouldn't wake up the other residents. S9 CNA stated Resident #1 could have been in pain, but she thought he was just lonely. In a telephone interview on 05/24/2023 at 11:24 a.m., a representative for the facility's contract pharmacy confirmed Resident #1's Hydrocodone 5-325 mg, #60, was delivered to the facility on [DATE]. The contract pharmacy representative stated the Hydrocodone was placed into their tote to be delivered at 4:54 p.m. and said the driver usually leaves at about 6:00 p.m. which meant it should have arrived at the nursing facility at about 8:00 p.m. Attempted to contact S10 RN twice by telephone on 05/23/2023 unsuccessfully. Review of Resident #1's Medication Administration Record revealed Resident #1 was not given any doses of Acetaminophen 1000 mg by mouth every 4 hours as needed for pain from 05/01/2023 through 05/23/2023. The MAR revealed Resident #1 received the first dose of Hydrocodone-Acetaminophen 5-325 mg at 08:16 a.m. on 05/13/2023. With each dose of Hydrocodone-acetaminophen given, staff documented Resident #1's pain level using a number between 1-10. On 05/13/2023 at the 08:16 a.m. dose, staff documented Resident #1's pain level was 6. Review of Resident #1's Narcotic Record with S3 RN revealed Resident #1 did not receive any doses of Hydrocodone-Acetaminophen 5-325 mg on 05/08/2023 - 05/11/2023. The Narcotic Record revealed the first dose of Hydrocodone-Acetaminophen 5-325 mg Resident #1 received was on 05/12/2023 at 11:00 a.m. Interview with S3 RN at that time revealed the medication card was date stamped with the date of 05/11/2023, which meant it probably arrived at the facility between 8:00 p.m. and 9:00 p.m. on 05/11/2023, the time the pharmacy delivers their medications each day. S3 RN confirmed they do not keep narcotics in their emergency kit and they would not have had any Hydrocodone-Acetaminophen to give Resident #1 until it arrived the night of 05/11/2023. Review of Resident #1's Narcotic Record and MAR revealed Hydrocodone was ordered 5-325 mg 1 every 6 hours. After the Hydrocodone 5-325 mg was delivered, Resident #1 received Hydrocodone 5-325mg that was either documented on the narcotic log and MAR, or narcotic log only, as follows: 05/12/2023 at 11:00 a.m. - pain level = No pain level documented/ narcotic log. 05/12/2023 at 9:00 p.m. - pain level = No pain level documented/ narcotic log. 05/13/2023 at 08:15 a.m. - pain level = 6 - MAR and narcotic log. 05/13/2023 at 8:29 p.m. - pain level = 6 - MAR and narcotic log. 05/14/2023 at 08:30 a.m. - pain level = 5 - MAR and narcotic log. 05/14/2023 at 7:50 p.m. - pain level = No pain level documented/narcotic log. 05/15/2023 at 11:15 a.m. - pain level = No pain level documented/narcotic log. 05/16/2023 at 12:29 a.m. - pain level = 5 - MAR and narcotic log. 05/17/2023 at 10:45 a.m. - pain level = 5 - MAR and narcotic log. 05/17/2023 at 8:26 p.m. - pain level = No pain level documented/narcotic log. 05/18/2023 at 8:31 a.m. - pain level = 5 - MAR and narcotic log. 05/19/2023 at 11:10 a.m. - pain level = 4 - MAR and narcotic log. 05/20/2023 at 4:45 a.m. - pain level = 5 - MAR and narcotic log. 05/21/2023 at 8:20 a.m. - pain level = 2 - MAR and narcotic log. 05/22/2023 at 6:05 a.m. - pain level = 5 - MAR and narcotic log. 05/22/2023 at 8:18 p.m. - pain level = 6 - MAR and narcotic log. Review of Resident #1's medical record failed to reveal documentation of a pain assessment each shift and with each dose of pain medication as indicated in the facility's Pain Assessment and Management policy. In an interview on 05/24/2023 at 12:19 p.m., S1 DON reported on Tuesday, 05/09/2023, Resident #1 was uncomfortable and staff saw his left arm was swollen at the wrist. S1 DON reported they obtained an x-ray of the wrist and it was negative. S1 DON reported on Wednesday, 05/10/2023, Dialysis called and reported Resident #1 was complaining of pain to his left arm and Dialysis sent him to the ER to get an x-ray. S1 DON reported Resident #1 returned to the facility the evening of 05/10/2023 without pain medication. S1 DON stated she was unaware Resident #1 didn't have any pain medication at the facility, but said they could have given the resident Tylenol. S1 DON acknowledged if Resident #1 had pain with movement of his arm, he should have been treated for it. S1 DON reported Resident #1 had dementia, but could tell staff if he was hurting. S1 DON acknowledged Resident #1 did not receive any pain medication or Tylenol from 05/09/2023 through 05/11/2023.

Resident #71 Based on observation, interview and record review, the facility failed to ensure resident assessments were accurate for 1 (Resident #71) of 34 sampled residents. Findings: Review of Resident #71's medical record revealed an admission date of 06/18/2021 with diagnoses that included: Dysarthria, Dysphagia, Hemiplegia, Hemiparesis and Facial Weakness following unspecified Cerebrovascular Disease and CVI affecting right dominant side, Encephalopathy, Cognitive Communication Deficit and Essential Primary Hypertension. Review of Resident #71's Quarterly MDS with an ARD of 11/16/2022 revealed Resident #71's dental/oral status was not coded for broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). Review of Resident #71's Quarterly MDSs with ARD of 05/18/2022 and 08/17/2022 revealed dental/oral status was not coded for broken or loosely fitting full or partial denture or tooth fragments, mouth or facial pain, and discomfort or difficulty with chewing. Review of Resident #71's Care Plan with a target date of 02/15/2023 revealed Resident had top partial dentures and missing teeth on bottom, with a goal to be free of infection, pain or bleeding in the oral cavity by review date. Approaches included to monitor/ document/ report prn if exhibit s/s of any oral /dental problems needing attention: pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue (black, coated, inflamed, white, smooth). Observation on 02/06/23 at 11:35 a.m. revealed Resident #71 awake sitting up in his wheelchair in his room eating breakfast. Interview at this time with Resident #71 he was hard of hearing, and complained of a toothache while pointing to his bottom teeth. Observation of Resident #71's bottom teeth revealed there were multiple dental caries, and broken and missing teeth noted. Resident #71's front upper teeth were also missing. Resident #71 stated he told the nurse last night that his tooth hurt and she gave him some Tylenol. Interview on 02/07/2023 at 1:05 p.m. with S6 DM confirmed she had completed Resident #71's dental/oral and swallowing/nutrition sections of his admission and Quarterly assessments. S6 DM stated she tries to look into the Resident's mouth to evaluate, and did not know that he had partial dentures. Observation of Resident #71 on 02/07/2023 1:05 p.m. with S6 DM revealed Resident #71 opened his mouth to allow S6 DM to inspect his mouth. S6 DM revealed Resident #71 had some natural teeth on the sides on the top, missing front top teeth and multiple dental caries and missing and broken teeth on the bottom. When Resident #71 was asked by S6 DM if he had difficulty eating food, Resident #71 stated that she (S6 DM) would have trouble eating if you had missing and broken teeth too. Interview at this time with S6 DM revealed she did not complete an accurate dental and oral assessment on Resident #71, and should have. Interview on 02/07/23 at 2:30 p.m. with S3 RN revealed he is responsible for other sections of the MDS and ensuring Resident #71's assessment is completed. S3 RN revealed S6 DM is responsible for the assessment of Resident #71's dental/ oral and swallowing /nutrition status sections. S3 RN revealed he was not aware of Resident #71's dental /oral status. S3 RN nurse verified Resident #71's MDS assessments did not accurately reflect his dental/oral status and should have. Interview on 02/07/23 at 3:20 p.m. with S2 DON confirmed she was aware that Resident #71 had dental caries, broken and missing teeth, and had partial dentures. S2 DON confirmed Resident's MDS assessments did not accurately reflect Resident #71's dental/oral status, and should have been.

Based on record review and interview, the facility failed to develop a comprehensive person centered care plan to meet a Resident's medical needs for 1 (#63) of 34 sampled residents. The facility failed to ensure Resident #63 had a comprehensive person centered care plan to address the Resident receiving antidepressant and anticoagulant medications as ordered. Findings: Review of Resident #63's electronic medical record revealed an admit date of 05/22/2020 with admitting diagnosis of Acute Kidney Failure. Other diagnoses include in part: Neuromuscular Dysfunction of Bladder, Type2 Diabetes Mellitus, Heart Failure, Atrial Fibrillation, Pressure Ulcer of Right and Left Buttocks, Chronic Pain, Major Depressive Disorder, and Edema. Review of Resident #63's Annual MDS with ARD date of 12/28/2022 revealed in part: Resident had a BIMS score of 15. Further review revealed Resident #63 received the following medications during the 7 day look back period: Insulin, Antidepressant, Anticoagulant, Diuretic, and Opioid 7 out of 7 days. Review of Resident # 63's 02/2023 physician's orders revealed in part: 11/24/2021 Monitor for signs and symptoms of depression two times a day and document. 10/18/2022 Monitor for side effects of anticoagulant therapy two times a day and document. 04/07/2022 Eliquis 2.5mg Give 1 tablet by mouth every morning and at bedtime for atrial fibrillation. 10/08/2020 Sertaline HCL 50mg Give 1 tablet by mouth one time a day for depression. Review of Resident #63's Care Plan with last review date 01/04/2023 revealed no documentation to address Resident receiving antidepressant and anticoagulant medications as ordered. Interview on 02/08/2023 at 12:55 p.m. with S4 RN revealed Resident #63's care plan did not address the Resident receiving antidepressant and anticoagulant medications as ordered with interventions and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to review and revise a Resident's care plan to include significant weight loss for 1 (#79) of 3 Residents who were reviewed for nutrition (#53, #79 and #84). There was a total of 34 sampled Residents. Findings: Review of Resident #79's medical records revealed he was admitted to the facility on [DATE] with diagnoses including: Hemiplegia and Hemiparesis following a Cerebral Infarction, Type 2 Diabetes Mellitus, Dysphagia following a Cerebral Infarction, Coronary Artery Disease and Hypertension. Review of Resident #79's Weight summary from 08/10/2022 to 01/11/2022 revealed a significant weight loss of -16.9%. Weight Summary: 08/10/20222- 206.0 lbs 09/09/2022- 202.0 lbs 10/10/2022- 197.0 lbs 11/07/2022- 192.0 lbs 12/05/2022- 182.8 lbs 12/14/2022- 175.4 lbs 12/28/2022- 174.8 lbs 01/11/2023- 171.8 lbs Review of Registered Dieticians notes dated 12/18/2022 read Triggered for significant weight loss: >5% in 1 month. Current weight: 175.4 lbs (12/14) -16.6 lb weight loss in 1 month; 21.6 lb weight loss in 3 months. Resident stated that he is a picky eater. Receiving a regular diet. Resident open to receiving a Mighty shake with meals. Recommend: Add mighty shake three times a day with meals. Review of the Resident #79's care plan with a review completed date of 11/22/2022 revealed the care plan did not address the Resident's significant weight loss with interventions. Staff Interview on 02/08/2023 at 09:52 a.m. with S5 RN revealed she is responsible for Resident #79's care planning with revisions. She confirmed that there were no updates to the current care plan regarding the Resident's significant weight loss with interventions, and there should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that a resident with an indwelling urinary catheter received the appropriate care and services to prevent urinary tract infections to the extent possible for 1(#13) of 1 Resident who was reviewed for urinary catheter, or urinary tract infection out of a total of 34 sampled Residents. The facility failed to ensure Resident #13's indwelling urinary catheter was placed off of floor, covered, and secured with a leg strap. Findings: Review of Resident #13's Electronic Medical Record revealed an admit date of 09/21/2021 with diagnoses including in part: Neuromuscular Dysfunction of Bladder, and Urinary Tract Infection. Review of Resident #13's Quarterly MDS with an ARD of 12/26/2022 revealed in part: Section C - Cognitive Pattern - The Resident had a BIMS of 14. Section G- Functional Status- The Resident required extensive assistance with 2 person assist for bed mobility, toileting, and transfers. Section H - Bowel and Bladder-The Resident had an indwelling catheter. Review of Resident #13's Comprehensive Person Centered Care Plan with review date of 11/14/2022 revealed in part: I have an Indwelling catheter. Approaches included in part: Assess urine color, consistence, and odor every shift. Catheter care every shift with warm water and soap. Position catheter bag and tubing below the level of the bladder and away from entrance room door, or apply bag cover to maintain dignity. Monitor leg strap. Monitor and document intake and output as per facility policy. Keep water pitcher at bedside and encourage fluids. Secure Foley Catheter tubing with leg strap at all times and check for kinks in tubing. Review of Resident #13's 02/2023 MD Orders revealed in part: 02/07/2023 Cipro 500mg tablet every morning and every night for Urinary Tract Infection for 7 days. Stop date: 02/14/2023 10/24/2022 Catheter Care every shift with warm water and soap. 10/24/2022 Secure Foley Cath tubing with leg strap at all times. 08/10/2022 Flush Foley Cath with 60ml Normal Saline if no urine. Change Foley Cath as needed for no urine or distended bladder. 11/15/2021 Describe urine color and consistency every shift, and document. Review of Resident #13's 02/2023 Progress Notes and Interview with S4 LPN on 02/07/2023 at 11:04 a.m. revealed the Resident was sent to emergency room on [DATE] for decreased urinary output, and confusion. Resident was diagnosed with Urinary Tract Infection, placed on antibiotics, and sent back to nursing home. Observation on 02/07/2023 at 10:57 a.m. revealed Resident # 13 lying in bed. Resident #13's indwelling urinary catheter bag was observed uncovered, lying on floor, next to the Resident's bed. Interview and observation on 02/07/2023 at 10:57 a.m. with S2 DON confirmed Resident #13's catheter bag was on the floor, uncovered, and it should not be. Observation on 02/07/2023 at 02:05 p.m. revealed Resident #13 was without catheter leg strap in place as ordered to keep catheter secure. Interview and observation on 02/07/2023 at 02:05 p.m. with S4 LPN confirmed Resident #13 did not have a catheter leg strap in place as ordered and should have.

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