**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident's call light was within reach for 1 (#R1) of 7 (#1, #2, #3, #4, #5, #6, and #R1 ) residents reviewed. Findings: A review of the facility's undated policy titled Call Light System, revealed, in part: Unless indicated in the care plan, each resident, when in their room or in bed, must have the call light placed within reach at all times, regardless of staff assessment of resident ability to use it. A review of the medical record for Resident #R1 revealed she was admitted to the facility on [DATE] with diagnoses which included, Muscle Wasting and Atrophy right shoulder, Chronic Pain Syndrome, Unsteadiness on feet, History of falling, Dementia, Lack of Coordination, and Alzheimer's Disease. A review of the current Care Plan for Resident #R1 revealed the resident was at risk for falls related to Gait/balance problems. Interventions included encourage resident to call for assist. On 04/06/2025 at 8:51 a.m., an observation was made of Resident #R1 lying in bed with her call light noted to be on the table at the foot of her bed. When Resident #R1 was asked where her call light was, she searched her bed and could not find it. Resident #R1 was unable to reach her call light. On 04/06/2025 at 10:56 a.m., an observation was made of Resident #R1 lying in bed with her call light on the table at the foot of her bed. Resident #R1 was unable to reach her call light. On 04/07/2025 at 10:57 a.m., an interview was conducted with S3CNAS. She confirmed Resident #R1's call light was on the table at the foot of her bed. She further confirmed Resident #R1's call light was out of reach and should have been within reach. On 04/08/2025 at 4:32 p.m., an interview was conducted with S2ADON. She stated she expected staff to ensure resident call lights were kept within reach.

Based on record review and interview the facility failed to have sufficient Certified Nursing Assistant (CNA) staff to provide direct care and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident based on the facility assessment. This deficiency had the potential to affect the facility's total census of 68 residents. Findings: Review of the facility's Minimum Staffing Requirements assessment revealed the following: Hall A Days: 1-2 CNA Evenings: 1 CNA Nights: 1 CNA Hall B Days: 2 CNA Evenings: 2 CNA Nights: 1 CNA Hall C Days: 2 CNA Evenings: 2 CNA Nights: 1 CNA Review of the facility's Staffing Pattern dated 03/04/2025 revealed the following: Staff assigned: Day shift - 7 CNA; Evening shift- 2-CNA; Night shift- 2 CNA On 04/06/2025 at 9:16 a.m. an interview was conducted with S8CNA. She revealed the facility was often short staffed. She further stated it was most often Hall B and Hall C that was short staffed. On 04/06/2025 at 9:35 a.m. an interview was conducted with S7CNA. She revealed the facility was often short staffed on the weekends. On 04/06/2025 at 10:00 a.m. an interview was conducted with S10CNA. She revealed she was often asked to pick up shifts. She stated the facility could use more staff. On 4/07/2025 at 8:26 a.m. an interview was conducted with S9LPN. She revealed the number of CNA staff for Hall B and Hall C was not sufficient at times. On 04/07/2025 at 3:51 p.m. an interview was conducted with S11CNA. She revealed she had to work Hall C by herself on more than one occasion. On 04/08/2025 at 12:20 p.m. An interview was conducted with S12CNA. She revealed she has worked the evening shift by herself and it was too much for one person. On 04/08/2025 at 3:30 p.m. an interview was conducted with S1ADM. She stated she would look at the facility assessment to determine the facility's staffing procedure and based on the facility's census and resident acuity she was able to determine the minimum staffing requirements. On 04/08/2025 at 3:50 p.m. an interview was conducted with S6CNA. She confirmed on 03/04/2025 she was one of two CNAs for the entire facility on the 2 p.m.-10 p.m. shift. She stated it was not enough CNA staff to be able to complete her tasks on time. On 04/08/2025 at 3:51 p.m. an interview was conducted with S5CNA. She confirmed on 03/04/2025 she was one of two CNAs for the entire facility on the 2 p.m.-10 p.m. shift. She stated it was not enough CNA staff to be able to complete her tasks on time. On 04/08/2025 at 4:05 p.m. an interview was conducted with S4CNA. She confirmed on 03/04/2025 she was one of two CNAs for the entire facility on the 10 p.m.-6 a.m. shift. She stated it was not enough CNA staff to be able to complete her tasks on time. On 04/08/2025 at 4:25 p.m. an interview was conducted with S1ADM. She confirmed on 03/04/2025 on the evening and night shifts there were only 2 CNAs for the entire facility. She confirmed 2 CNAs was not sufficient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure a resident's plan of care was revised by failing to update vision interventions for 1 (#54) of 19 residents reviewed in the final sample for Care Plans. Findings: Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Legally Blind. Review of Resident #54's Quarterly MDS, with ARD of 12/09/2024, revealed a BIMS of 12, which indicated she was moderately cognitive impaired. Further review revealed Section B: Hearing, Speech, and Vision, line B100-Vision was coded as Adequate, and Corrective Lenses was coded as No. Review of Resident #54's Care Plan dated 12/22/2023 revealed: Care Plan Description: Visual deficit related to Blindness to Bilateral Eyes Interventions: Assist resident to maintain eyeglasses. Encourage to wear glasses. Ensure adequate lighting for tasks. Keep eyeglasses within reach. Keep pathways clear. Provide assistance with ambulation as needed. On 01/08/2025 at 9:00 a.m., an interview was conducted with Resident #54. She stated she was legally blind, unable to distinguish light from dark, and does not wear corrective lenses. She confirmed she was non-ambulatory and bed bound. On 01/08/2025 at 9:10 a.m., an interview was conducted with S15CNA. She confirmed Resident # 54 is blind, does not ambulate, requires lift with 2 people, and does not have corrective glasses. On 01/08/2025 at 9:15 a.m., an interview was conducted with S6LPN. She stated Resident #54 has diagnosis of Legally Blind. She stated Resident #54 is unable to ambulate and transferred to the Geri chair daily using lift. On 01/08/2025 at 11:00 a.m., an interview was conducted with S4MDS. S4MDS reviewed the Care Plan dated 12/22/2023 for Resident #54. S4MDS confirmed the current interventions for Resident #54 related to Visual Deficit Blindness Bilateral Eyes included intervention for eye glasses, adequate lighting, glare free environment, clear pathways, and ambulation assistance did not reflect the status of Resident #54 on admission, or currently. She stated that care plan revisions should be updated as often as needed, and with 3 month assessments done by the MDS Staff and was not. 01/08/2025 at 11:30 a.m., an interview was conducted with S2DON. She confirmed Resident #54 had a diagnosis of Legal Blindness. She reviewed the Care Plan dated 12/22/2023 for Resident #54. S2DON confirmed the interventions listed for Resident #54 related to Visual Deficit Blindness Bilateral Eyes did not reflect the status of Resident #54. S2DON confirmed the care plan should be updated with each assessment conducted by MDS staff, and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, interviews, and record review, the facility failed to ensure there was a system in place for facility residents to receive routine dental care by an outside dentist as requested for 1 of 1 (#16) resident reviewed for dental services. This deficient practice had the potential to affect any of the 67 residents residing in the facility. Findings: A review of Resident #16's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Mild Protein-Calorie Malnutrition. A review of Resident #16's Quarterly MDS with an ARD of 12/26/2024 revealed he had a BIMS of 11, which indicated he was moderate cognitively impaired. A review of the In House Facility Dental notes revealed the following: 05/29/2024 Resident #16 refused dental services today. Resident #16 told S11MR he only wants to see an outside dentist. 08/29/2024 Resident #16 refused dental services today. On 01/07/2025 at 2:25 p.m., an observation and interview was conducted with Resident #16. He was observed in the dining room with multiple broken bottom teeth noted. Resident #16 stated he only wanted to see an outside dentist and did not want to see the dentist which came to the facility. On 01/08/2025 at 8:14 a.m., an interview was conducted with S12ST. She stated Resident #16 liked to attend appointments at his normal places where he was from. She stated Resident #16's last appointment with his outside dentist was on 02/07/2022. She confirmed she made all outside facility appointments and was not made aware of 05/29/2024's dental note where Resident #16 requested an appointment with the outside dentist; therefore, she did not schedule Resident #16 an appointment. On 01/08/2025 at 8:35 a.m., an interview was conducted with a representative at Resident #16's outside dental office. She confirmed Resident #16's last scheduled appointment was on 02/07/2022. On 01/08/2025 at 8:59 a.m., an interview was conducted with S11MR. She stated on 05/29/2024, Resident #16 told her he only wanted to see his outside dentist. She confirmed she did not tell the nurse because she thought S3ADON reviewed the dental notes. On 01/08/2025 at 9:06 a.m., an interview was conducted with S3ADON. She stated residents had the option to see an outside dentist if requested. She stated S13RN and S14SW reviewed the onsite dental notes when the dentist came to the facility. She confirmed S12ST was responsible for scheduling outside appointments. She reviewed the dental note dated 05/29/2024, and confirmed Resident #16 should have had an outside dental appointment scheduled. A review of Resident #16's Nurses Note, dated 06/04/2024 revealed the following: Resident #16 was to be seen by in house dentist, Resident #16 refused and stated he wanted to be seen by an outside dentist. Signed by S13RN On 01/08/2025 at 9:11 a.m., an interview was conducted with S14SW. She stated she thought she reviewed the note on 05/29/2024, an appointment was made, and Resident #16 refused to go. She was unable to provide documentation of the scheduled appointment or Resident #16's refusal. On 01/08/2025 at 4:31 p.m., an interview was conducted with S2DON. She stated she thought Resident #16 was scheduled for an appointment and refused to go. She was unable to provide documentation of the scheduled appointment or Resident #16's refusal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 2 (#14 and #65 ) of 2 (#14 and #65 ) residents reviewed for accurate documentation. The facility failed to ensure: 1. The medical record of Resident #65 contained accurate documentation of Coroner Notification with Permission to Release the Body; and 2. The medical record of Resident #14 contained a documented nurse assessment upon return from dialysis. This deficient practice had the potential to affect a current census of 67 residents. Findings: Review of the facility's undated policy, titled Documentation Guidelines: General, revealed the following: Nursing Service documentation will include, but shall not be limited to the following: 4. Baseline data such as weight, vital signs, etc. 5. Follow up care of resident's incidents and accidents Documentation in the nursing record will be made when a change in resident condition occurs. This includes all nursing interventions and follow up. Documenting information on the resident in the medical record provides: 1. A means of communication between the physician and other professionals contributing to the resident's care. 4. A way to record the care received by the resident. Review of the facility's undated policy, titled Fistula Maintenance: Post Dialysis Care, revealed the following: B. Documentation: 1. Documentation in the medical record regarding the fistula site may occur on the MAR, flowsheets, in the nurses' notes or any other part of the medical record. The following are examples of items to include in the documentation: b. condition of site; c. Presence/absence of bleeding and/or any other abnormalities noted; and d. Complaints from resident regarding the site. 1. A review of Resident #65's Clinical Record revealed he was admitted to the facility on [DATE], with diagnosis, which included Chronic Obstructive Pulmonary Disease and Neoplasm of the Digestive System. Further review revealed he expired in the facility on [DATE]. A review of Resident #65's Physician Orders revealed the following: [DATE] at 11:00 a.m. by S3ADON - Ok to call Coroner, [DATE] at 10:30 a.m. by S3ADON - Ok to release body to a local funeral home. A review of Resident #65's MDS, with an ARD of [DATE], revealed the following: Section F: Entry/Discharge Reporting: 12. Death in Facility; and A2105: Discharge Status: 13. deceased A review of Resident #65's Nurse's Note revealed in part, [DATE] at 12:15 p.m. by S7LPN - Resident found at 8:12 a.m. in his wheelchair unresponsive, skin cold to touch, and had no pulse or respiration. Cardiopulmonary Resuscitation (CPR) was started at 8:15 a.m. and continued until 8:58 a.m. Local paramedics were called and arrived at 8:26 a.m. and placed a call to the Emergency Physician at 8:56 a.m. obtaining permission to stop CPR. On [DATE] at 9:00 a.m., an interview was conducted with S7LPN. S7LPN confirmed she was working day shift on [DATE]. S7LPN stated Resident #65 was found unresponsive in his wheel chair in the dining room, and CPR was started. She stated she was the scribe for the incident, and did not place any of the notification phone calls following his death. On [DATE] at 9:30 a.m., an interview was conducted with S3ADON. S3ADON confirmed she was working on [DATE]. S3ADON stated when the paramedics arrived, they worked on Resident #65 until they called the local emergency department physician and received an order for OK to stop CPR. S3ADON stated the facility's procedure for notification of the coroner was for a nurse to call. S3ADON stated she initiated a medical order, ok to call the coroner at [DATE] at 11:00 a.m. S3ADON stated she called the Coroner's Office to notify them Resident #65 had expired. S3ADON stated she spoke to a female on the phone, but was unable to recall her name. S3ADON stated the female on the phone said OK. She stated the Coroner's Office did not come to the facility prior to the body being released to the funeral home. S3ADON confirmed she did not document the time she called the coroner, who she spoke with, and permission to release the body was obtained. On [DATE] at 11:00 a.m., an interview was conducted with the Chief of Investigations for the local Coroner's office. He confirmed when a resident expired in a nursing home, even if EMS was present on the scene at the time of death, the funeral home was required to contact the coroner's office to report the death. He confirmed his office was open on [DATE] and if the nursing home had called to report a death, a staff member would have taken the call, written a report, and due to the circumstances of a sudden unexpected death in the facility, an investigator would have been sent out to the facility. He confirmed the Coroner's office did not receive a phone call regarding Resident #65's death until the funeral home called to request permission to cremate his body. He confirmed when the funeral home called, there was no active case for Resident #65 because they were never made aware of his passing and should have been. On [DATE] at 1:00 p.m., an interview was conducted with S2DON. S2DON confirmed she was present in the building on [DATE] when Resident #65 expired. S2DON confirmed the facility was responsible for notifying the coroner's office when a resident expired in the facility. S2DON confirmed an order to call the coroner was initiated by S3ADON on [DATE] at 11:00 a.m., and there was no further documentation regarding his death notification to the coroner or obtaining permission to release the body present in Resident #65's medical record and should be. 2. A review of Resident #14's Clinical Record revealed he was admitted on [DATE] with diagnoses, which included Dependence of Renal Dialysis. A review of Resident #14's current Physician Orders revealed the following: 11//2024- Dialysis Schedule: Resident #14 to have dialysis 3 times a week on Tuesday, Thursday and Saturday at local Dialysis Center. A review of Resident #14's Nurse's Notes, dated [DATE] through [DATE], revealed no documented evidence of his nurse conducting an assessment upon his return to the facility from the local Dialysis Clinic on Tuesday [DATE], Thursday [DATE], and Saturday [DATE]. A review of Resident #14's Dialysis Communication Binder, dated [DATE] through [DATE], revealed no documented evidence of his nurse conducting an assessment upon his return to the facility from the local Dialysis Clinic on Tuesday [DATE], Thursday [DATE], and Saturday [DATE]. A review of Resident #14's MAR/TAR, dated [DATE] through [DATE], revealed no documented evidence of his nurse conducting an assessment upon his return to the facility from the local Dialysis Clinic on Tuesday [DATE], Thursday [DATE], and Saturday [DATE]. On [DATE] at 3:40 p.m., an interview was conducted with S16LPN. She stated she conducted an assessment of Resident #14 upon his return to the facility from the Dialysis Clinic and it should have been documented in her nurse's notes. She confirmed it was not documented in the nurse's notes. On [DATE] at 4:01 p.m., an interview was conducted with S5MDS. She stated it was a standard practice to assess a resident upon their return to the facility from the Dialysis Clinic and the assessment should be documented in the resident's medical record. She confirmed Resident #14 attended dialysis three times per week and the medical record did not have any documented evidence of his nurse conducting an assessment upon his return to the facility from the Dialysis Clinic. On [DATE] at 4:31 p.m., an interview was conducted with the S2DON. She stated the nurse should complete a resident assessment upon return to the facility from dialysis, which included an assessment of their dialysis access site. She stated the assessment should be documented on the resident's MAR/TAR. She confirmed there was no documented evidence of a completed assessment upon return from the Dialysis Clinic in Resident #14's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of infection for 1 (#167) of 19 resident's reviewed in the final sample. The facility failed to ensure: 1. Staff wore proper Personal Protective Equipment (PPE) while providing catheter care; and 2. Staff performed proper hand hygiene while providing catheter care. Findings: Review of Resident #167's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Urinary Tract Infection. Review of Resident #167's current Physician Orders revealed the following, in part: Enhanced Barrier Precautions utilized when performing high-contact resident care activities related to Urinary Catheter; and Catheter care with soap and water. One time every shift. On 01/07/2025 at 9:20 a.m., an observation of the Enhanced Barrier Precautions sign posted on Resident #167's door revealed the following, in part: Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities: Providing hygiene, changing briefs, device care or use: urinary catheter. On 01/07/2025 at 9:24 a.m., an observation was made of S8CNA performing catheter care for Resident #167 with no gown in use. S8CNA cleansed Resident #167's genitalia and catheter tubing, then applied a clean brief without changing gloves or performing hand hygiene. On 01/07/2025 at 9:42 a.m., an interview was conducted with S8CNA. She confirmed she did not wear a gown while performing catheter care for Resident #167. She confirmed she did not change gloves or perform hand hygiene between cleansing Resident #167's genitalia, catheter tubing, and applying a new, clean brief. On 01/07/2025 at 11:12 a.m., an interview was conducted with S2DON. She confirmed S8CNA should have worn a gown during catheter care. She confirmed S8CNA should have changed gloves and performed hand hygiene after cleansing the resident's genitalia and catheter tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 3 (#12, #54 and #66) residents out of a total of 21 sampled residents. The facility failed to ensure: 1. Resident #12 was coded correctly for PASRR (Pre-admission Screening and Resident Review); 2. Resident #54 was coded correctly for vision; and 3. Resident #66 was coded correctly for discharge. Findings: Resident #12 Review of Resident #12's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #12's OBH-Level II Evaluation Summary & Determination Notice dated 08/02/2024 revealed under recommendations: The individual has a serious mental illness and nursing home admission was recommended. Review of Resident #12's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2024 revealed Section A1500 PASRR: Is the resident currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as 0. No. On 01/07/2025 at 1:02 p.m., an interview was conducted with S4MDS. She stated she was responsible for completing resident's MDS assessments. She reviewed Resident #12's PASRR Level II dated 08/02/2024 indicating she had a serious mental illness. She reviewed Resident #12's Annual MDS with an ARD of 09/04/2024. She confirmed Resident #12 was not coded accurately for having a serious mental illness and should have been. On 01/07/2025 at 1:13 p.m., an interview was conducted with S2DON. She reviewed Resident #12's information listed above. She confirmed Resident #12 was not coded accurately for having a serious mental illness and should have been. Resident #54 Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Legal Blindness. Review of Resident #54's Quarterly MDS with an ARD of 12/09/2024 revealed she had a BIMS of 12, which indicated she was moderately cognitively impaired. Further review revealed Section B1000 Vision was coded as Adequate. On 01/08/2025 at 9:00 a.m., an interview was conducted with Resident #54. She stated she was legally blind. On 01/08/2025 at 10:00 a.m., an interview was conducted with S4MDS. S4MDS reviewed Resident #54's Quarterly MDS with an ADR of 12/09/2024 and verified Section B1000 was coded for Adequate Vision. S4MDS confirmed Resident #54 was legally blind, which made the entry incorrect. On 01/08/2025 at 11:30 a.m., an interview was conducted with S2DON. She confirmed Resident #54 had a diagnosis of legal blindness. She reviewed the Quarterly MDS with an ADR 12/09/2024 and confirmed Section B1000 Vision was coded as Adequate, which was not correct. Resident #66 Review of Resident #66's Clinical Record revealed she was admitted to the facility on [DATE] and transferred to a local hospital for shortness of breath on 11/02/2024. Review of Resident #66's Discharge MDS with an ARD of 11/02/2024 revealed Section A2105 Discharge Status: Inpatient Rehabilitation Facility. Review of Resident #66's Nurse's Note dated 11/02/2024 at 2:49 p.m. revealed the following, in part: Resident was complaining of shortness of breath and coughing up mucous, wheezing was heard upon auscultation, contacted doctor. Order given to send to emergency room for evaluation and treatment. Signed, S9LPN. Review of Resident #66's Physician Order dated 11/02/2024 revealed the following, in part: Send to ER. On 01/08/2025 at 2:00 p.m., an interview was conducted with S5MDS and S2DON. They reviewed the above documentation and confirmed Resident #66 should have been coded as having a discharge location for a Short Term General Hospital and not an Inpatient Rehabilitation Facility.

Based on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. This deficient practice had the potential to affect any of the 67 residents residing in the facility. Findings: Review of the PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year 2024 Quarter 4 (July 1- September 30) revealed the following: -One star staffing rating, triggered. -Excessively low weekend staffing, triggered. -No Registered Nurse hours, triggered. -Failed to have licensed nursing coverage 24 hours/day, triggered. An interview was conducted on 01/08/2025 at 10:40 a.m. with S10CHR. She stated she was responsible for submitting payroll data to a contract company who was hired to submit the facility's payroll data. She stated on 01/08/2025, the contract company identified inaccurately submitted September 2024 payroll data for direct care staffing. She stated all quarters for payroll data submission for direct care staffing should be complete and accurate. An interview was conducted on 01/08/2025 at 10:52 a.m. with S1ADM. She stated all quarters for payroll data submission for direct care staffing should be complete and accurate.

Based on observation, record review and interview, the provider failed to ensure the care plan was implemented for 1 ( #2) of 3 (#1, #2, and #3) residents sampled for ADL care had incontinence care provided with the required amount of staff assistance. Findings: Review of the document titled CNA Skill Acknowledgement of Resident Wall Care Plan Sheet and Turning Schedule revealed the following, in part: Resident Wall Care Plan Sheets and Turning Schedules are used by this facility to relay important individualized information about the residents to the CNA caring for that person. Each resident should have a Resident Wall Care Plan Sheet located in their room either above the bed, on the bulletin board or in another prominent location easily seen by direct care staff . The Resident Wall Care Plan Sheet should include information including but not limited to: Transfer status (including use of lift (type) and size of sling, if lift is used) . It is the responsibility of the CNA to read and follow the wall care plan instructions to care for each resident. Review of the undated policy titled, Positioning (Movement in Bed), revealed the following, in part: Procedure: 3. Obtain assistance needed based on assessment of resident's ability to move in bed and type of positioning required. Review of Resident #2's clinical record revealed an admission date of 05/26/2021. Resident #3 had diagnoses which included Lack of Coordination, Muscle Wasting and Atrophy, and Hemiplegia and Hemiparesis. Review of Resident #2's Optional State Assessment MDS with an ARD revealed Resident #2 had a BIMS of 13 which indicated intact cognition. Resident #2 required extensive Two + persons physical assistance with bed mobility, toileting, and transfers. Review of Resident #2's Care Plan revealed the following in part: Self-Care ADL deficit: resident will receive person centered care. Resident is extensive 2 person assistance for transfers, bed mobility and toileting. Review of the Resident's wall care plan sheet revealed the following, in part: Bed mobility x2 person assist. On 07/29/2024 at 1:51 p.m., an observation was made of S4CNA performing incontinence care to Resident #2. S4CNA did not have assistance from another staff member. S4CNA was observed to roll Resident #2 from one side to the other during the removal of the wet brief, incontinence care and the placement of the new brief. On 07/29/2024 at 2:02 p.m., an interview was conducted with S4CNA. S4CNA reviewed Resident #2's wall care plan and confirmed Resident #2 was a 2 person assistance. S4CNA confirmed she had performed incontinence care on Resident #2 by herself. S4CNA confirmed she should have had another staff member present during Resident #2's incontinence care. On 07/30/2024 at 12:25 p.m., an interview was conducted with S2DON. S2DON was made aware of the aforementioned findings for Residents #2. S2DON confirmed peri-care/incontinence care was included in bed mobility. S2DON confirmed Resident #2 should have had two staff present during incontinence care. On 07/30/2024 at 2:55 p.m., an interview was conducted with S1ADM. S1ADM was made aware of the aforementioned findings. S1ADM confirmed peri-care/incontinence care is encompassed in bed mobility. S1ADM confirmed the wall communication sheet contains information from the resident's care plan and transfers and care should be followed in accordance with the care plan.

Based on interviews and record review, the facility failed to ensure residents remained free of accident hazards by failing to ensure residents were transferred with proper transfer assistance and devices for 2 (#2 and #3) of 3 (#1, #2, and #3) residents reviewed for transfer assistance. The facility failed to ensure: 1. Resident #2 was transferred with 2 person assistance; and 2. Resident #3 was transferred with a mechanical lift. Findings: Review of the document titled CNA Skill Acknowledgement of Resident Wall Care Plan Sheet and Turning Schedule revealed the following, in part: Resident Wall Care Plan Sheets and Turning Schedules are used by this facility to relay important individualized information about the residents to the CNA caring for that person. Each resident should have a Resident Wall Care Plan Sheet located in their room either above the bed, on the bulletin board or in another prominent location easily seen by direct care staff. The Resident Wall Care Plan Sheet should include information including but not limited to: Transfer status (including use of lift (type) and size of sling, if lift is used). It is the responsibility of the CNA to read and follow the wall care plan instructions to care for each resident. Review of the undated policy titled, Transfer: Wheelchair or Geri Chair Policy, revealed the following, in part: The procedures involve various degrees of assistance depending on the strength and capabilities of the resident. Conditions in which assistance is usually necessary are paralysis or weakness of one or both sides. The techniques involved in transfer to and from bed and chair require that the nurse obtain extra staff to assist, if needed, and use correct body mechanics to prevent injury. Essential Points to Remember: 2. Obtain assistance from another staff member if resident is unable to assist. Resident #2 Review of Resident #2's clinical record revealed an admission date of 05/26/2021. Resident #3 had diagnoses which included Lack of Coordination; Muscle Wasting and Atrophy; Hemiplegia and Hemiparesis. Review of Resident #2's MDS with an ARD dated 06/12/2024, revealed Resident #2 had a BIMS of 13, which indicated intact cognition. Resident #2 required extensive Two + persons physical assistance with bed mobility, toileting, and transfers. Review of Resident #2's Care Plan revealed the following, in part: High Risk for falls related to left sided hemiplegia secondary to Cerebral Vascular Accident on 05/31/2024 fall no injury. Required 2 person assistance for transfers. Review of Resident #2's wall care plan sheet revealed the following, in part: Transfer x2 person assist Review of Resident #2's current Physician Orders revealed the following, in part: 05/26/2021 Resident requires 2 person assistance with transfer Review of the Resident #2's Incident Report dated 05/31/2024 revealed the following, in part: Incident Type- lying on floor Date/time: 05/31/2024 6:15 p.m. Incident reported by S3CNA Narrative: Resident lying on floor in supine position. Aide states while trying to transfer from WC to bed resident's foot got caught and they both began to fall to the floor. On 07/29/2024 at 2:07 p.m., an interview was conducted with Resident #2. Resident #2 stated they normally transferred her with 2 people. Resident #2 stated S3CNA transferred her by herself. On 07/30/2024 at 10:02 a.m., an interview was conducted with S3CNA. S3CNA stated they were educated to review communication sheets on the wall to know what care and assistance the residents need. S3CNA confirmed she did not check the communication sheet on the wall for Resident #2. S3CNA stated she transferred Resident #2 by herself and should have had another CNA assist her. Resident #3 Review of Resident #3's clinical record revealed an admission date of 08/07/2019 with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Muscle Wasting and Atrophy, History of Falling, and Other Lack of Coordination. Review Resident #3's Care Plan revealed the following, in part: At high risk for falls related to diagnoses of hemiplegia, osteoarthritis, Cerebral Vascular Accident and debility 07/18/2024 lowered to floor; no injuries Self-Care Deficit: resident requires Extensive x2 person assist with bed mobility, transfers, toilet use, locomotion. Transfer x2 with mechanical lift A review of the current Physician's Orders revealed the following, in part: 12/05/2023 Transfer assist x2 with mechanical lift Review of the resident's Wall Care Plan Sheet revealed the following in part: Transfer x2 person assist with mechanical lift Review of Resident #3's Incident Report dated 07/18/2024 at 7:00 a.m. revealed the following, in part: Incident Type: Lowered to the floor Narrative: CNA staff stated Resident #3 was being transferred with staff assistance x 2 when his legs began to give out. CNA stated we lowered Resident #3 to the floor so the resident did not fall. Resident #3 did not hit his head. There were no apparent injuries upon assessment. On 07/29/2024 at 3:34 p.m., an interview was conducted with S6CNA. S6CNA stated she and S5CNA were transferring Resident #3 from the bed to chair and he started sliding down. S6CNA stated she and S5CNA were lifting Resident #3 under his arms. S6CNA confirmed a mechanical lift was not being used during the transfer. S6CNA confirmed she did not check the wall communication sheet for the resident's transfer status before transferring Resident #3. On 07/30/2024 at 9:14 a.m., an interview was conducted with S5CNA. S5CNA stated Resident #3 is dependent and requires 2 aides with a mechanical lift for transfers. S5CNA confirmed a mechanical lift was not used for Resident #3 during the transfer on 07/18/2024. On 07/30/2024 at 12:25 p.m., an interview was conducted with S2DON. S2DON stated CNAs are trained to look at the wall care plans for the resident's transfer needs. S2DON confirmed Resident #2 was a 2 person assistance with transfers. S2DON confirmed S3CNA transferred Resident #2 by herself on 05/31/2024. S2DON confirmed Resident #3 required two person mechanical lift for transfers. S2DON confirmed S5CNA and S6CNA transferred Resident #3 without a mechanical lift. S2DON confirmed if Residents #2 and #3 had received the transfer assistance as listed on the wall care plan both incidents could have been prevented. On 07/30/2024 at 2:55 p.m., an interview was conducted with S1ADM. S1ADM confirmed the wall communication sheet contains information from the resident's care plan and transfers and care should be followed in accordance with the care plan.

Based on record reviews and interviews, the facility failed to ensure resident rights by failing to initiate resident grievances received during monthly resident council meetings for 1 (#53) of 8 (#31, #46, #51, #52, #53, #58, #61, and #62) residents present for the resident council meeting. Findings: Review of the facility's policy titled Resident Council revealed, in part, the following: Policy: It is the policy of this facility that a Resident Council be supported by the administration. Procedure: 7. Written follow-up to resident concerns identified at each meeting will be identified in writing regardless of whether or not the issue is resolved. 9. Minutes of the Meetings: a. Documentation of meetings, findings and recommendations shall be maintained by the committee and are to be filed in the Administrator's office. c. Minutes of Meetings shall contain at least the following information: 4. Findings, recommendation and corrective action taken. 10. Responsibilities: h. Maintaining minutes of all meetings and submitting a copy to the Administrator for his/her review. Review of the facility's policy titled Resident Rights revealed, in part, the following: Policy: A facility must protect and promote the rights of each resident, including each of the following rights: (f) Grievances. A resident has the right to- (2) Prompt efforts by the facility to resolve grievances the resident may have (6) When a resident or family group exists, the facility must listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility. Review of the facility's Resident Council Meeting Minutes, dated November 2023 through January 2024, revealed typed meeting minutes written by S8AD on 11/30/2023, 02/27/2023 and 01/30/2024. Further review revealed a handwritten note attached to the 01/30/2024 meeting minutes indicating Resident #53 reported missing property during the meeting; one skull hat and one pair of black pants. Review of the facility's Grievance Log, dated October 2023 to January 2024, revealed no grievances had been filed for Resident #53's missing property. Review of Resident #53's Quarterly MDS with ARD of 11/22/2023 revealed a BIMS of 11, which indicated moderate cognitive impairment. On 02/19/2024 at 10:45 a.m., an interview was conducted with Resident #53. He stated he attended resident council meetings regularly. He stated he reported some missing belongings to S8AD four months ago during a resident council meeting and they were still missing. He stated he had never received an update from anyone at the facility about the status of his missing items. On 02/20/2024 at 11:31 a.m., an interview was conducted with S8AD. She stated she was responsible for documenting Resident Council Meeting minutes. S8AD stated after the meeting, she takes the Resident Council Meeting minutes to the Administrator for her to review. She stated if multiple residents voiced a concern, she would file a grievance but she would not if only one person voiced the issue. S8AD confirmed if an individual resident had a concern she would not put it in her meeting minutes. She stated she would write that information in her hand written notes and verbally inform S1ADM without filing a formal grievance. On 02/21/2024 at 10:00 a.m., an interview was conducted with S1ADM. She confirmed she was responsible for investigating and completing the facility's grievance process once a grievance was filed. She stated she would not file a grievance for issues brought up during Resident Council meetings. She confirmed there was not a grievance on file for Resident #53's missing property nor was she aware he had anything missing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure the oxygen tubing and humidification bottles were properly labeled for 3 (#23, #266, and #267) of 3 (#23, #266, and #267) residents reviewed for oxygen therapy. Findings: Resident #23 Review of the Clinical Record for Resident #23 revealed she was admitted to the facility on [DATE] and had diagnoses which included Shortness of Breath. Review of Resident #23's Quarterly MDS with an ARD of 11/08/2023 revealed she had a BIMS of 10, which indicated she had moderate cognitive impairment. Further review revealed she received oxygen therapy. Review of the current Physician Orders for Resident #23 revealed the following, in part: Start date: 03/06/2022 Oxygen at 2 Liters via nasal cannula continuously Start date: 11/01/2022 Change 02 tubing/humidifier bottle and clean filter q week on Thursdays. Review of the current Care Plan for Resident #23 revealed, in part: Respiratory Care Intervention: Change 02 tubing/humidifier bottle and clean filter q week (11/08/2023) An observation was made of Resident #23 on 02/19/2024 at 8:45 a.m. using oxygen via nasal cannula. The oxygen tubing and humidification bottle were dated 02/08/2024. An interview was conducted with Resident #23 on 02/20/2024 at 3:00 p.m. She stated she wore oxygen via nasal cannula at all times. An interview was conducted with S5LPN on 02/19/2024 at 8:50 a.m. She stated Resident #23 utilized her oxygen via nasal cannula at all times. She stated the oxygen tubing and humidification bottle should be changed and labeled every 7 days. She confirmed Resident #23's oxygen tubing and humidifier bottle was dated 02/08/2024. Resident #266 Review of the Clinical Record for Resident #266 revealed he was admitted to the facility on [DATE] and had diagnoses which included Chronic Respiratory Failure with Hypoxia. Review of the current Physician Orders for Resident #266 revealed the following, in part: Start date: 02/14/2024 Oxygen at 2 Liters via nasal cannula continuously Start date: 02/15/2024 Change 02 tubing/humidifier bottle and clean filter q week on Thursdays. Review of the Current Care Plan for Resident #266 revealed, in part: Respiratory Therapy Intervention: Administer oxygen therapy as ordered (02/14/2024) An observation was made of Resident #266 on 02/19/2024 at 9:39 a.m. using oxygen via nasal cannula. The oxygen tubing was not labeled with a date. An interview was conducted with S6LPN on 02/19/2024 at 10:00 a.m. She stated Resident #266 utilized his oxygen via nasal cannula at all times. She confirmed oxygen tubing was not labeled with a date and should have been. Resident #267 Review of the Clinical Record for Resident #267 revealed she was admitted to the facility on [DATE] and had diagnoses which included Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea, and Dependence on Supplemental Oxygen. Review of Resident #267's admission MDS with an ARD of 02/18/2024 revealed she had a BIMS of 12, which indicated she had moderate cognitive impairment. Further review revealed she received oxygen therapy. Review of the current Physician Orders for Resident #267 revealed the following, in part: Start date: 02/13/2024 Apply BiPap at setting of 16/6 when asleep. O2@2l with sterile water in chamber Start date: 02/13/2024 O2 at 2 liters/Nasal Cannula continuously Start date: 02/15/2024 Change 02 tubing/humidifier bottle and clean filter q week on Thursdays. Review of current Care Plan for Resident #267, revealed, in part: Respiratory Therapy Intervention: Administer oxygen therapy as ordered (02/13/2024) Intervention: Bipap as ordered with settings of 16/6 at 40%. (02/13/2024) An observation was made of Resident #267 on 02/29/2024 at 9:45 a.m. using her Bipap machine with oxygen connected. The oxygen tubing did not have a date labeled on it. An interview was conducted with S6LPN on 02/19/2024 at 12:02 p.m. She confirmed Resident #267's oxygen tubing was not labeled with a date and should have been. An interview was conducted with S2DON on 02/20/2024 at 12:08 p.m. She stated nursing staff should change oxygen tubing, humidification bottles and label them every seven days.

Based on observations, interviews, and record review, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was properly sealed and dated after opening; and 2. Dietary staff wore a hair restraint while the kitchen. There were a total of 56 out of 60 facility residents who were provided meals and beverages from the facility's kitchen. Findings: 1. Review of the facility's Appearance and Dress Code Policy revealed, in part, the following: Each employee will be expected to adhere to the dress code established by this facility. Dietary Personnel must wear a hairnet large enough to cover all the hair. On 02/19/2024 at 8:35 a.m., an initial tour of the facility's kitchen was conducted with the following observations made within the facility's refrigerator: -1 package of deli sliced white American cheese opened and undated; and -1 package of deli sliced cheddar American cheese opened, undated, and unsealed. On 02/19/2024 at 8:40 a.m., an interview was conducted with S3PM. She verified the above observations and confirmed the facility failed to store foods properly. She confirmed she would expect all opened food products to be sealed and labeled with the date opened and they were not. 2. On 02/19/2024 at 8:35 a.m., an observation was made of S7DW inside the kitchen standing near the serving and dishwashing area with her ponytail protruding through the back of her baseball hat with hair exposed and no hairnet in use. On 02/19/2024 at 11:15 a.m., an observation was made of S7DW inside the kitchen with her ponytail protruding through back of her baseball hat with hair exposed and no hairnet in use. On 02/19/2024 at 11:20 a.m., an interview was conducted with S3PM. She confirmed hairnets were required for all kitchen staff when inside of the kitchen. She confirmed S7DW did not have her exposed hair covered with a hairnet and should have. On 02/21/2024 at 3:07 p.m., an interview was conducted with S1ADM. She confirmed she would expect kitchen staff to ensure all open foods were dated and sealed. S1ADM confirmed she would expect kitchen staff to have exposed hair covered with a hairnet when inside of the kitchen.