**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure each resident's MDS (Minimum Data Set) assessment was transmitted to CMS (Centers for Medicare and Medicaid Services) within the required timeframe for 1 (#74 ) of 1 (#74 ) resident who was reviewed for Resident Assessment. Findings: Review of Resident #74's MDS assessments revealed a discharge MDS dated [DATE] with a status of in progress. During an interview on 01/07/2025 at 4:30 p.m., S3 Nurse Case Manager confirmed resident #74's discharge MDS had not been transmitted to CMS and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#15, #80) of 2 (#15, #80) residents' rooms observed for environment. The facility failed to ensure: 1. Resident #15's wheelchair was clean and sanitary 2. Resident #80's restroom was clean and sanitary. Findings: Resident #15 Review of Resident #15's medical record revealed an admit date of 01/18/2019 with diagnoses, of but not limited to, Alzheimer's disease, moderate protein calorie malnutrition, gastric reflux disease, dermatitis, dysphagia, vascular dementia, lack of coordination, cognitive communication deficit, and hypertension. Review of Resident #15's MDS (Minimum Data Set) for 11/12/2024, revealed Resident #15 was assessed as rarely understood. Observation on 01/06/2025 at 8:00 a.m. with S4 ADON (Assistant Director of Nurses) revealed Resident #15's wheelchair had dried white colored food residue on the seat, armrest and the right wheel. During an interview 01/06/2025 at 8:00 a.m. S4 ADON confirmed the white food residue on Resident #15's wheelchair was build up from Resident #15 spitting and reported the certified nursing assistants on the night shift should have cleaned Resident #15's wheelchair. Resident #80 Review of Resident #80's medical record revealed an admit date of 12/02/2022 with a diagnoses, of but not limited to atrial fib, chronic kidney disease, mild protein calorie malnutrition, osteoarthritis, hypertension, gastric reflux disease and type 2 diabetes. Review of Resident #80's Quarterly MDS dated [DATE] revealed Resident #80 had a BIMS (Brief Interview Mental Status) Score of 15 indicating intact cognition. Observation on 01/06/2025 at 8:15 a.m. revealed brown colored splash spots on the wall next to and behind Resident #80's toilet. Further observation revealed Resident #80's toilet had brown stains on the seat and inside of the toilet. Observation on 01/07/2025 at 8:00 a.m. with S5 Housekeeper revealed brown colored splash spots on the wall next to and behind Resident #80's toilet. Further observation revealed Resident #80's toilet had brown stains on the seat and inside of the toilet. During an interview on 01/07/2025 at 8:00 a.m. S5 Housekeeper reported Resident #80's restroom was supposed to be cleaned daily and confirmed it had not been cleaned. During an interview on 01/08/2025 at 8:00 a.m. S6 Housekeeping Supervisor confirmed Resident #80's restroom was not cleaned daily and should have been.

Based on record review and interview the facility failed to ensure a resident's plan of care was implemented for 1 (#15) of 1(#15) resident out of total of 34 sampled residents. The facility failed to ensure Resident #15's lab work was done as ordered. Findings: Review of Resident #15's medical record revealed an admit date of 01/18/2019 with diagnosis of but not limited to; Alzheimer's disease, moderate protein calorie malnutrition, gastric reflux disease, dermatitis, dysphagia, vascular dementia, lack of coordination, cognitive communication deficit, and hypertension. Review of Resident #15's MDS (Minimum Data Set) for 11/12/2024, revealed Resident #15 was assessed as rarely understood. Review of Resident #15's December 2024 Physician's orders revealed an order for a CBC (Complete Blood Count) dated 12/13/2024 one time for dementia until 12/16/2024. Review of Resident #15's medical record failed to reveal lab results from the CBC ordered on 12/13/2024. During an interview on 01/08/2025 at 12:48 p.m. S2 DON (Director of Nurses) reported the facility did not have the results of Resident #15's CBC because the specimen had clotted and the facility failed to follow-up and ensure the lab was re-drawn. S2 DON confirmed Resident #15's lab work was not done as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure each resident received the care and services in accordance with professional standards of practice for 1 (#2) of 1 sample resident reviewed for skin conditions (non-pressure). The facility failed to ensure resident #2, with a diagnosis of diabetes was provided necessary care and services for her feet. Findings: Review of resident #2's records revealed diagnoses of diabetes type 2, peripheral vascular disease, chronic kidney disease, dependence on dialysis, chronic obstructive pulmonary disease, and congestive heart failure. Review of resident #2's Annual Minimum Data Set assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. During an interview on 01/07/2025 at 09:20 a.m. resident #2 reported she had a black spot on her right foot. Resident #2 reported she had reported this to S8 Wound Care Nurse multiple times and nothing had been done. Resident #2 reported nothing had been done for her foot and she did not want to lose her foot. Observation made on 01/07/2025 at 09:30 a.m. of resident #2's right foot with S7 LPN (License Practical Nurse) revealed resident #2 had a black spot on top of her right great toe. During an interview on 01/07/2025 at 09:30 a.m. S7 LPN reported there is a foot doctor that comes to the facility that could see resident #2. S7 LPN reported she was not aware resident #2 had a black spot on her foot. During an interview on 01/08/2025 at 2:20 p.m. S9 CNA (Certified Nursing Assistant) reported she had worked with resident #2 bathing her at times. S9 CNA reported she had noticed resident #2's right toe being black yesterday and she reported it to the S8 Wound Care Nurse. During an interview at 01/08/2025 at 2:30 p.m. S10 SSD (Social Service Director) reported S11 APRN (Advanced Practice Registered Nurse) podiatrist sees all the resident at the facility for foot care. S10 SSD reported none of the facility's nurses had asked her to put resident #2 on S11 APRN podiatrist schedule. Review of S12 NP (Nurse Practitioner) notes dated 01/07/2025 revealed resident #2 had a toenail injury with toenail fungus.

Based on observations, interviews and record review the facility failed to provide preventive care, and treatment consistent with professional standards of practice, for 1 (#151) of 3 (#15. #35 and #151) residents reviewed for positioning/mobility. The facility failed to ensure residents who were at risk for development of pressure injuries was provided necessary care to avoid a pressure injury. Findings: Review of resident #151's records revealed diagnoses of non-traumatic intracerebral hemorrhage unspecified, benign neoplasm of cerebral meninges, other seizures. type 2 diabetes with hyperglycemia, diabetic polyneuropathy and essential hypertension. Review of resident #151's admit note dated 12/02/2024 S3 RN (Registered Nurse) reads in part, resident admitted to skilled facility after hospital or treatment for intracranial hemorrhaged. Resident #151 was independent prior to recent illness and did not need any assist from anyone. Resident #151 at the time of admit is total assist feeding, bed mobility, incontinent care, transfers. Review of the Skin and Wound Evaluation dated 01/01/2025 revealed resident #151's initial admission date was 12/04/2024. In facility acquired pressure ulcer to his right gluteus. Stage 2, partial-thickness skin loss with exposed dermis. Review of resident #151's MDS (Minimum Data Set) failed to reveal the entries were completed except for the entry on 12/04/2024. All other MDS entries were in progress. Review of resident #151's Plan of Care revealed the following problems and interventions: 1. Resident lifting plan Goal: Resident will have no injury/complication due to use of lift through need review. Interventions: Lift assessment quarterly and prn. 2. Resident has a stage 2 pressure ulcer to right gluteal. Goal: Pressure ulcer will heal without complication through next review. Interventions: Observe daily for sign and symptoms of infection. Observe for pain and medicate per order. Pressure relieving mattress and pressure relieving cushion to chair. Treatment to area per order. Weekly evaluation of wound healing. 3. Resident needs assist with ADL's (Activity of Daily Living) and late loss ADL's. Resident requires extensive assist with repositioning and bed mobility. Chair/Bed to chair transfer. Resident is dependent on staff to transfer to and from a bed to a chair/wheelchair. Roll left to right: Resident needs substantial/maximal assist to roll left to right. Observation on 01/06/2025 at 09:30 a.m. resident #151 awake and alert positioned on his back with his head elevated. Further observation revealed a turning schedule a clock posted on the wall at the head of the bed to be turned every 2 hours to the door, window, and ceiling. Observation on 01/06/2025 at 12:15 p.m. resident #151 was still positioned on his back in bed Observation on 01/06/2025 at 2:00 p.m. resident #151 was still in the same position in bed. During an interview at this time resident #151 reported he had not been out of bed, he had not been turning or repositioned Observation on 01/07/2024 at 8:18 a.m. resident #151 in bed at this time positioned on his back. Observation on 01/07/2024 at 2:15 p.m. revealed resident #151 in bed asleep. Resident #151 easily aroused, he reported he had not been out of bed today. During an interview on 01/06/2025 at 9:30 a.m. resident #151 reported he had been at the facility for a month and had never been gotten out of bed. Resident further reported he was unable to turn or reposition himself and unable to get out of bed without assistance. During an interview on 01/07/2024 at 2:35 p.m. S8 Wound Care Nurse reported there is no reason resident #151 should not be up and out of bed. S8 Wound Care Nurse reported resident #151 has very little control of his upper body and can get up with 2 person assist by a lift to a Geri chair. S8 Wound Care Nurse reported resident #151's had a stage 2 pressure ulcer that occurred in the facility. During an interview on 01/08/2025 at 10:00 a.m. S7 LPN reported resident #151 had not been up and out of bed. Review of resident #151's records failed to reveal any documentation he had refused to be turned or repositioned or got up out of bed. . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure dependent residents were provided Activities of Daily Living for 2 (#2, #5) out of 5 (#2, #3, #4, #5, #6) residents observed. The facility failed to trim Resident #2 and Resident #5's fingernails. Findings: Review of Resident #2's medical records revealed an admit date of 01/07/2022 with the following diagnoses, in part: cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of persistent vegetative state/no discernible consciousness. Further review of functional status revealed Resident #2 requires total assistance. Observation on 12/09/2024 at 9:30 a.m. revealed Resident #2's fingernails were long on both hands. During an interview on 12/09/2024 at 9:30 a.m. S1 LPN (Licensed Practical Nurse) acknowledged Resident #2's fingernails were long and should be trimmed. Review of Resident #5's medical records revealed an admit date of 07/15/2021 with the following diagnoses, in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and cognitive communication deficit. Observation on 12/09/2024 at 9:00 a.m. revealed Resident #5's fingernails long on both hands. During an interview on 12/09/2024 at 9:00 a.m. S3 LPN acknowledged Resident 5's fingernails were long and should be trimmed.

Based on record reviews, observations, and interviews, and the facility failed to ensure appropriate treatment and services to prevent potential complications from enteral feeding for 3 (#2, #4, #5) out of 6 (#1, #2, #3, #4, #5) residents reviewed. The facility failed to change enteral feeding bags at appropriate interval and label the enteral feeding bag and syringe. Findings: Review of Facility's Tube Feedings Policy (12/15) revealed: 1. All tube feedings will be administered in accordance with verified medical necessity, established infection control policies and procedures and physician's orders . 3. Procedures for administering tube feedings are in place and address: e. labeling of container Resident #2 Review of Resident #2's medical records revealed an admit date of 01/07/2022 with the following diagnoses, in part: mild protein calorie malnutrition and gastrostomy status. Review of Resident #2's Physician's Orders revealed an order dated 09/24/2024 - off at 5a.m./on at 9a.m. tube feeding formula: Isosource 1.5 at 70ml/hr (milliliter/hour) x 20 hours. Observation on 12/09/2024 at 9:30 a.m. failed to reveal Resident #2's enteral feeding bag labeled with resident name, date, time, formula and nurse initials. During an interview on 12/09/2024 at 9:30 a.m. S1 LPN (Licensed Practical Nurse) acknowledged the enteral feeding bag had no label and should. Resident #4 Review of Resident #4's medical records revealed an admit date of 02/02/2024 with the following diagnoses, in part: dysphagia oropharyngeal phase, moderate protein-calorie malnutrition, and gastrostomy status. Review of Resident #4's Physician's Orders revealed an order dated 11/15/2024 for tube feeding formula: Peptamen 1.5 bolus/carton daily at 1p.m and an order dated 10/16/2024 for on at 7p.m./off at 9a.m. tube feeding formula: Peptamen 1.5 at 50ml/hr for 14 hours. Observation on 12/09/2024 at 9:40 a.m. revealed Resident #4's enteral feeding bag with a torn label showing a date of 12/06/2024 and a date of 12/07/2024 written on bag. Further observation revealed enteral feeding bag was not labeled with resident name, formula, time, nurse initials. During an interview on 12/09/2024 at 9:40 a.m. S2 LPN acknowledged the enteral tube feeding bag had been reused and not been changed since 12/07/2024 and should have. S2 LPN further acknowledged there was no label with resident name, date, time, formula and nurse initials. Resident #5 Review of Resident #5's medical records revealed an admit date of 07/15/2021 with the following diagnoses, in part: dysphagia following unspecified cerebrovascular disease, moderate protein-calorie malnutrition, and gastrostomy status. Review of Resident #5's Physician's Orders revealed an order dated 09/24/24 for on at 7p.m./off at 9a.m. tube feeding formula: Nutren 2.0 at 50ml/hr for 14 hours and tube feeding formula: Nutren 2.0 bolus give one carton per PEG (Percutaneous Endoscopic Gastrostomy) tube twice daily. Observation on 12/09/2024 at 9:00 a.m. failed to reveal Resident #5's enteral feeding bag labeled with resident name, date, time, formula and nurse initials. During an interview on 12/09/2024 at 9:00 a.m. S3 LPN acknowledged the enteral feeding bag was not labeled with resident name, time, and nurse initials and should be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practiced for 2 (#14, #55) of 3 (# 14, #55, #62) residents reviewed for respiratory care. The facility failed to ensure the oxygen tubing and humidification bottles were changed and dated weekly and oxygen and nebulizer tubings were bagged when not in use. Findings: Review of the facility Infection Control Oxygen Equipment Cleaning policy dated 03/2018 revealed in part: 6. Refillable humidifiers should be washed and refilled every 72 hours with distilled or sterile water and dated. 7. Tubing should be replaced every 7 days 8. Masks should be replaced every 7 days 9. Cannulas should be replaced every 7 days 10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. Resident #14 Observation on 01/08/2024 at 8:22 a.m. revealed resident #14's oxygen tubing dated 12/15/2023 and humidification bottle dated 07/02/2023. Observation on 01/09/2024 at 3:00 p.m. revealed resident #14's nasal cannula tubing on the floor unbagged dated 12/15/2023, and humidification bottle with no date. Review of resident #14's record revealed an admit date of 06/18/2012 with diagnoses that include in part chronic obstructive pulmonary disease, chronic pulmonary edema, and anxiety. Review of resident #14's January 2024 Physician orders revealed an order dated 07/20/2023 for oxygen at 2 liters/minute per nasal cannula continuously. Review of resident #14's MDS (minimum data set) dated 11/14/2023 revealed in part: Health Conditions: Shortness of breath/trouble breathing. Special treatments: Oxygen therapy Resident #55 Observation on 01/08/2024 at 9:30 a.m. revealed resident #55's nasal cannula on the floor unbagged and no date, and nebulizer mask dated 12/09/2023. Observation on 01/09/2024 at 3:45 p.m. revealed resident #55's nasal cannula on the floor unbagged and no date, and nebulizer mask dated 12/09/2023. Review of resident #55's record revealed an admit date of 06/05/2022 with diagnoses that include in part supraventricular tachycardia, acute and chronic respiratory failure, chronic systolic congestive heart failure, and obstructive sleep apnea. Review of resident #55's January 2024 Physician orders dated: 12/19/2023 Iprat-Albut 0.5-3 (2.5) milligram/3 milliliters. Give one unit dose via inhalation per nebulizer every 6 hours as needed for shortness of breath/wheezing 12/19/2023 Change oxygen & nebulizer tubing weekly. 12/19/2023 Oxygen at 3 liters via nasal cannula at night. Review of resident #55's MDS dated [DATE] revealed in part: Health Conditions: Shortness of breath/trouble breathing. Special treatment: Oxygen therapy During an interview on 01/09/2024 at 3:48 p.m. S3 LPN (Licensed Practical Nurse) reported the evening shift should change the tubing out for oxygen and nebulizers weekly and the tubing and mask should be bagged. S3 LPN acknowledged it had not been done and should have been.

Based on record reviews and interviews, the facility failed to ensure residents on dialysis received services consistent with professional standards of practice for 1 (#62) of 3 (#44, #55, #62) sampled residents receiving dialysis. The facility failed to monitor dialysis access site for Resident #62. Findings: Review of Facility's Hemodialysis - Care of Resident Policy revealed: Document the following: 2. Condition of cannula site. Review of Resident #62's Medical Record revealed an admit date of 07/01/2021 with the following diagnoses, in part: end stage renal disease, dependence on renal dialysis, essential (primary) hypertension and type 2 diabetes mellitus with hyperglycemia. Review of Resident #62's Comprehensive Care Plan revealed included the problem of receives dialysis with approaches that included check shunt site daily bruit or thrill, pain, swelling, redness, warmth, drainage .notify MD (Medical Director) of any complications. Review of Resident #62's December 2023 and January 2024 MAR (Medication Administration Record)/TAR (Treatment Administration Record) failed to reveal left chest wall dialysis access site was monitored. During an interview on 01/10/2024 at 2:20 p.m. S1 DON (Director of Nursing) reviewed Resident #62's December 2023 and January 2024 MARs (Medication Administration Records)/TARs (Treatment Administration Records) and acknowledged they failed to reveal documentation of left chest wall dialysis access site monitoring

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of needs for 1 (#74) of 33 sampled residents in the facility. The facility failed to ensure resident #74's call light/button was in reach to call for assistance. Findings: Review of the facility's Call light/Bell Policy revealed the following; Purpose: To provide the resident a means of communication with staff members To provide staff members a means of summoning assistance when they are with the resident 1. Ensure resident has call light in reach when in resident room or in bathroom. Review of resident #74's medical record revealed an admit date of 6/14/2022 with a diagnosis of but not limited to cerebral vascular accident, type 2 diabetes, anxiety disorder, Alzheimer's disease, and major depressive disorder. Review of resident #74's Minimum Data Set, dated [DATE] revealed resident #74 had a BIMS (Brief Interview Mental Status) score of 10 indicating moderately impaired cognition. Observation on 1/23/2023 at 9:06 a.m. revealed resident #74's call light/button on the floor next to the bed out of resident #74's reach. During an interview on 1/23/2023 at 9:06 a.m. S7 CNA (certified nurse assistant) confirmed resident #74's call light/button was out of resident #74's reach and should have been placed on the wheelchair within the resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure resident's medical records reflected the resident's advance directive wishes for 1 (#295) of 7 (#3, #13, #16, #31, #59, #82, #295) residents investigated for Advance directives out of a total of 33 sampled residents. The facility failed to ensure physician orders were consistent with the resident's wishes for advance directives. Findings: Review of resident #295's physician orders revealed [DATE] order type: Full Code. Review of resident #295's baseline care plan dated [DATE] completed by S5 Medicare Case Manager, resident #295's wife and interdisciplinary team revealed code status - Full Code. Review of resident #295's LA Post (Louisiana Physician Order for Scope of Treatment) dated [DATE] signed by resident #295's wife and physician is marked for: Do Not Resuscitate (DNR). Review of resident #295's medical record face sheet revealed code status DNR. Review of resident #295's medical record revealed document Resident/Family consent for Cardiopulmonary Resuscitation (CPR) statement: I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on this resident. However I wish that other interventions be performed unless specifically noted in advance directives this not be done. Form signed by resident #295's wife and witnessed by S6 Admissions coordinator and physician on [DATE]. During an interview on [DATE] at 3:00 p.m. S8 Corporate Nurse acknowledged the code status did not match the face sheet and the MD (medical director) orders for resident #295 and did not reflect the resident's wishes.

Based on observation, interview, and record review, the facility failed to ensure proper infection control technique was practiced for 1 (#74) of 1 (#74) residents observed for perineal care. The facility failed to ensure staff provided proper perineal care consistent with accepted standards of practice to prevent infection. This failed practice had the chance to effect a total of 36 female residents that receive perineal care in the facility. Findings: Observation on 1/24/23 at 9:45 a.m. revealed S3 CNA (Certified Nursing Assistant) wiping Resident # 74 from back to front when performing perineal care. During an interview on 1/24/23 at 9:55 a.m. S3 CNA confirmed she performed perineal care wrong by wiping resident #74 from back to front. S3 CNA further reported she should have wiped from front to back. Review of the facility's Perineal Care procedure guide revealed: 9. With a new washcloth or pre-moistened wash wipe, clean the anal area from front to back using a clean area of the washcloth or pre-moistened wash wipe after each stroke.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure appropriate care and services had been provided for 1 of 1 (#18) residents reviewed for Dialysis out of a total of 33 sampled residents. The facility failed to ensure resident #18's dialysis shunt was monitored. Findings: Review of resident #18's record revealed an admit date of 11/23/2022 with diagnoses that include chronic kidney disease and dependence on renal dialysis. Review of resident #18's current physician orders revealed and order dated 12/22/22: local dialysis center, Tuesday, Thursday, Saturday. Review of resident #18's comprehensive care plan revealed risk for malnutrition, diagnoses of renal insufficiency/renal failure/End stage renal disease: Review of interventions failed to reveal shunt site monitoring. Review of resident #18's 5 day Minimum Data Set, dated [DATE] revealed a cognitive score of 14=cognitively intact. Special treatment: dialysis Review of resident #18's January 2023 Medication Administration Record failed to reveal shunt site monitoring. During an interview on 1/24/22 at 1:30 p.m. resident's #18's daughter reported she visits daily for several hours and has never seen staff check resident #18's chest wall shunt site. During an interview on 1/24/2023 at 2:00 p.m. S2 Director of Nursing acknowledged there was no documentation resident #18's dialysis site was monitored and should have been. During an interview on 1/24/2022 at 3:00 p.m. S8 Corporate Nurse acknowledged resident #18's shunt site had not been monitored and should have been.

Based on record review, observation and interview, the facility failed to ensure that a resident receiving psychotropic medications was monitored for target behaviors for 1 (#294) of 5 (#3, #4, #17, #74, #294) residents reviewed for unnecessary medications. Findings: Review of resident #294's medical record revealed and admit date of 1/19/2023 with diagnoses that include in part cerebrovascular disease, chronic kidney disease, thyrotoxicosis, and Dementia. Review of resident #294's baseline care plan revealed in part: psychotropic drug use: Monitor for target behaviors. Review of resident #294's current physician orders included an order dated 1/19/2023 for Alprazolam 0.25 mg (milligram) tablet, give one tablet by mouth every 8 hours as needed (PRN). Target behaviors; anxiousness. Review of resident #294's January 2023 MAR (Medication Administration Record) failed to reveal monitoring for target behaviors. During an interview on 1/25/2023 at 12:50 p.m. S9 LPN (Licensed Practical Nurse) acknowledged resident #294 received Alprazolam 0.25 mg but was unable to provide documentation of monitoring for target behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3 Review of resident #3's revealed admit date [DATE]. Review of resident #3's clinical records failed to reveal an Advanced Directive Acknowledgement form. Based on record reviews, the facility failed to ensure documentation of resident rights regarding Advance Directives had been presented and/or explained to the residents or their responsible party for 2 (#3, #17) of 33 sample residents. Findings: Review of resident #17's revealed admit date of 11/1/2014. Review of resident #17's clinical records failed to reveal an Advanced Directive Acknowledgement form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to develop and implement a person centered care plan for 1 (#1) out of 2 (#1, #50) residents reviewed for position and mobility. The facility failed to address Resident #1's contracture to right hand. The facility had a total of 33 residents with contractures according to the Census and Conditions of Residents dated 1/23/23. Findings: Review of Resident #1's Medical Records revealed admit date of 7/09/21 with the following diagnoses, in part: muscle wasting and atrophy/multiple sites, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed: Section G: Functional Status - bed mobility, locomotion, toilet use, bathing total dependence/2 person assist; transfer 2 person assist; dressing, personal hygiene total dependence/1 person assist; eating supervision/1 person assist. Impairment - both lower extremities. Mobility device - wheelchair. Review of Resident #1's Care Plan failed to reveal a problem and approach to address contracture to right hand. Observation on 1/23/23 at 8:50 a.m revealed Resident #1 with contracture to right hand and fingers folded in towards palm. Observation on 1/23/23 at 12:00 p.m. revealed Resident #1 with contracture to right hand and fingers folded in towards palm. Observation on 1/23/23 at 3:05 p.m. revealed Resident #1 with contracture to right hand and fingers folded in towards palm. Observation on 1/24/23 at 9:30 a.m. revealed Resident #1 with contracture to right hand and fingers folded in towards palm. Observation on 1/25/23 at 8:30am revealed Resident #1 with right hand contracted and fingers folded in towards palm. Observation on 1/25/23 at 11:00 a.m. revealed Resident #1 with contracture to right hand and fingers folded in towards palm. During an interview on 1/25/23 at 10:30 a.m. S2 DON (Director of Nursing) was informed Resident #1's care plan did not address contractured right hand with approaches in place. S2 DON acknowledged Resident #1's contractured right hand should have been addressed and wasn't. During an interview on 1/25/23 at 11:00 a.m. Resident #1 was asked if they put a splint on her right hand and she nodded no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1 Review of Resident #1's Medical Records revealed admit date of 7/09/21 with the following diagnoses, in part: muscle wasting and atrophy/multiple sites, other lack of coordination, cerebellar stroke syndrome, aphasia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, bilateral primary osteoarthritis of knees, shortness of breath, type 2 diabetes mellitus with diabetic neuropathy/unspecified, and major depressive disorder/recurrent/unspecified. Review of Resident #1's Comprehensive Care Plan revealed: needs staff assistance with late loss activities of daily living - bed mobility, transfers, eating, toileting. Observation on 1/23/22 at 2:00 p.m. revealed Resident #1 lying in bed. Resident #1 is unable to verbalize but can by nodding yes or no or using her hand. During an interview on 1/23/23 at 2:00 p.m. Resident #1 when asked if the staff gets her out of bed daily she nodded no and when asked if she would like to get up she nodded yes. Observation on 1/24/23 at 10:00 a.m. revealed Resident #1 lying in bed. Observation on 1/24/23 at 3:15 p.m. revealed Resident #1 lying in bed. Observation on 1/25/23 at 8:50 a.m. revealed Resident #1 lying in bed. Further observation revealed gerichair in bathroom. During an interview on 1/25/23 at 8:50 a.m. Resident #1's roommate Resident #24 reported the staff never get Resident #1 up in the gerichair and she feels sorry for her because she lays in the bed all day. During an interview on 1/25/23 at 9:05 a.m. S4 CNA(Certified Nurse Assistant) reported has never assisted Resident #1 out of bed. Observation on 1/25/23 at 10:00 a.m. revealed Resident #1 lying in bed. Further observation revealed gerichair in bathroom. During an interview on 1/25/23 at 10:30 a.m. S2 DON was informed Resident #1 had not been assisted out of bed throughout the survey. S2 DON acknowledged this should not be occurring. Resident #81 Review of Resident #81's Medical Records revealed admit date of 3/16/22 with the following diagnoses, in part: major depressive disorder/recurrent/unspecified, gastrostomy status, dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction and cognitive communication deficit. Review of Resident #81's MDS assessment dated [DATE] revealed: Section G: Functional Status - bed mobility, transfer, toilet use extensive assist with 2 person; eating extensive assist with 1 person; locomotion, dressing, personal hygiene. Impairment - one side upper and lower extremity. Review of Resident #81's Comprehensive Care Plan revealed: Needs staff assistance with activities of daily living - assist with bed mobility, transfers, eating, and toileting. Observation on 1/23/23 at 8:50 a.m revealed Resident #81 lying in bed in the dark. Further observation revealed gerichair in corner of room. Observation on 1/23/23 at 12:00 p.m. revealed Resident #81 lying in bed in dark. Further observation revealed gerichair in corner of room. Observation on 1/23/23 at 3:05 p.m. revealed Resident #81 lying in bed in dark. Further observation revealed gerichair in corner of room. During an interview on 1/23/23 at 3:05 p.m. Resident 81 unable to speak but nodded no when asked if the staff gets him out of bed and yes when asked if he would like to get up. Observation on 1/24/23 at 9:30 a.m. revealed Resident #81 lying in bed in dark. Further observation revealed gerichair in corner of room. During an interview on 1/24/23 at 3:30 p.m. with Resident # 81's brother, he reported the staff never get him out of bed in the gerichair. Observation on 1/25/23 at 8:30 a.m. revealed Resident #81 lying in bed in dark. Further observation revealed gerichair in corner of room. During an interview on 1/25/23 at 10:30 a.m. S2 DON was informed Resident #81 had not been assisted out of bed throughout the survey and has been lying in the dark. S2 DON acknowledged staff should be assisting Resident #81 out of bed and they should have. Observation on 1/25/23 at 11:00 a.m. revealed Resident #81 lying in dark in bed. Further observation revealed gerichair in corner of room. Based on observations, interviews and record reviews the facility failed to ensure residents who were unable to complete activities of daily living received the necessary services to maintain good grooming and hygiene for 4 (#1, #31, #51 , #81) of 5 (#1, #31, #50, #51, #81) residents reviewed for activities of daily living. The facility failed to: 1. Provide nail care for Resident #31 and #51 2. Provide assistance out of bed for Resident #1 and #81 Findings: Resident #31 Review of the facility nail care policy revealed the following: 8. Trim the nails straight across, and even with the end of the finger or toe. For fingers, remove any sharp edges with the file or emery board. Review of resident #31's medical record revealed an admit date of 11/18/2022 with a diagnosis of but not limited to cardiovascular accident with left sided weakness, lack of coordination, muscle weakness, cognitive communication deficit, and essential hypertension. Review of resident #31's Minimum Data Set (MDS) dated [DATE] revealed Resident #31 was assessed to have a BIMS (Brief Interview Mental Status) score of 15 indicating intact cognition. Further review revealed Resident #31 was assessed to require limited one person physical assistance with personal hygiene. During an interview on 1/25/2023 at 8:15 a.m. Resident #31 stated, Yes I want my fingernails trimmed, some lady told me yesterday they were going to cut them but she never came back. Observation on 1/25/2023 at 8:15 a.m. revealed Resident #31 had long fingernails on both hands which had grown past the nailbeds. During an interview on 1/25/2023 at 8:30 a.m. S2 DON (Director of Nurses) confirmed Resident #31's fingernails should have been trimmed as the resident requested. Resident #51 Review of resident #51's medical record revealed an admit date of 10/20/2020 with a diagnosis of but not limited to dementia, sciatica, gout, major depressive disorder, and type 2 diabetes. Review of resident #51's Minimum Data Set revealed Resident #51 was assessed to have a BIMS of 6 indicating severely impaired cognition. Further review revealed Resident #51 required supervision with personal hygiene. Observation on 1/23/2023 at 10:10 a.m. revealed Resident #51 had long untrimmed fingernails protruding past nail on both hands with dark brown residue underneath fingernails. Observation on 1/24/2023 at 8:19 a.m. revealed Resident #51 had long untrimmed fingernails protruding past nail on both hands with dark brown residue underneath fingernails. During an interview on 1/23/2023 at 10:10 a.m. Resident #51 answered, yes when asked, would you like your fingernails cleaned and trimmed? Observation on 01/25/2023 at 8:30 a.m. with S2 DON revealed Resident #51 had untrimmed fingernails protruding past nail on both hands with dark brown residue underneath fingernails. During an interview on 1/25/2023 at 8:30 a.m. S2 DON confirmed Resident #51's fingernails should have been trimmed and cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure there was a functioning call system to allow residents to call for staff assistance for 1 (#22) of 33 sampled residents. Findings: Review of the facilities Call Light/Bell Policy revealed the following: 8. If the call light is defective, immediately report this information to the unit supervisor. Discuss with the charge nurse a rounding schedule to ensure that resident's needs are met until the call light is in working order again. Review of resident #22's medical record revealed an admit date of 8/26/2015 with a diagnosis of but not limited to essential hypertension, cerebral infarct, type 2 diabetes, pseudobulbar affect, major depressive disorder, cognitive communication deficit, and anxiety disorder. Review of resident #22's Minimum Data Set, dated [DATE] revealed resident #22 had a BIMS (Brief Interview Mental Status) score of 12 indicating moderately impaired cognition. During an interview on 1/23/2023 at 8:00 a.m. resident # 22 reported her call light/button did not work. Observation on 1/23/2023 at 8:00 a.m. of resident #22 attempted use of the call light/button to call for assistance revealed the call light/button was not functioning and there was no response to resident #22's use of the call light/button. Observation on 1/25/2022 at 8:35 a.m. with S2 DON (Director of Nurses) revealed resident #22's call light/button was not functioning. During an interview on 1/23/2023 at 8:35 a.m. S2 DON confirmed resident #22's call light/button was not functioning.