**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: 2575789, 2567564Based on interview and record review, the facility failed to prevent resident to resident sexual abuse in 1 of 3 sampled residents (Resident #102) reviewed for abuse, resulting in the potential for a decline in mental and psychosocial well-being.Findings include: Resident #102: Review of an admission Record revealed Resident #102 was a female with pertinent diagnoses which included major depressive disorder, reduced mobility, hemiplegia and hemiparesis (paralysis) following cerebral infarction affecting left non dominant side, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 6/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #102 was cognitively intact. Review of current Care Plan for Resident #102, revised on 3/19/2025, revealed the focus, .Resident has an impaired mood/psychiatric status related to major depressive do (disorder), anxiety. Has depression r/t (related to) stroke dx (diagnosis). Resident chooses to keep concern forms in her room to use as notes rather than share them with staff. with the interventions .Periodically complete the PHQ-9 (questionnaire used to screen, diagnosis, and monitor depression severity).Provide resident with quality listening time and encourage expressions of feelings.Encourage resident to share her concerns so that we can assist her. Review of Order dated 7/17/25, revealed, .Ensure stop sign is hung across bedroom doorway at night at bedtime. Review of Nurses' Notes dated 7/17/2025 at 04:15 AM, revealed, .Resident reported to nurse that resident (Resident #103) in room (Room Hallway and Number) was in her room and she called the police, asked what happened and resident states I woke up because I felt someone touching me and it was him! Then she states that he was touching her in her breasts and vaginal area so she screamed for him to leave and he did and so she called the police, the police arrived and spoke with resident who does want to press charges, writer called and notified administrator who is also the abuse coordinator, writer had seen both residents asleep in their rooms after midnight med pass. The CNA (Certified nursing assistant) reports they were both sleeping in their beds at 0300 rounds.Review of Social Services Progress Notes dated 7/17/2025 at 3:39 PM, revealed, .SS (social services) followed up with resident r/t (related to) recent incident that occurred with another resident.SS did voice that she wants to press charges in which she has been in communication with the police. Resident has a stop sign located outside her door in which order is being put in to ensure that it is put up over doorway during the night. Resident voiced that she is happy that the resident that the incident occurred with has been moved to another hall. Resident was seen by the psych NP (nurse practitioner) today 7/17 and continues to be followed by services for continued support. Review of Social Services Progress Notes dated 7/18/2025 at 3:16 PM, revealed, .SS (social services) visited with resident to see how she is doing. Resident stated I'm good and I'm feeling safer now that that guy is not on the hall anymore. Resident is referring to (Resident #103) who has entered her room the other day while she was sleeping. Resident #103: Review of an admission Record revealed Resident # 103 was a male with pertinent diagnoses which included dementia with other behavioral disturbance, major depressive disorder, and insomnia. Review of Care Plan for Resident #103, revised on 6/30/25, revealed the focus, .Resident has behaviors of sexual comments, gestures towards staff. May become intimate with other residents such as kissing. Physical and verbal aggression toward staff. Exit seeking behaviors. with the interventions .Observe and document episodes of inappropriate behaviors, explain that behavior is inappropriate.Revision on: 04/22/2025. Offer/provide activities of interest to keep resident engaged in positive interactions.Date Initiated: 04/22/2025.Review of Care Plan for Resident #103, revised on 7/25/25, revealed the focus, .Resident has behaviors of sexual comments, gestures towards staff such as grabbing at inappropriate areas. May become intimate with other residents such as kissing. At times prefers to lay naked in his bed, declining to put clothing on. Physical and verbal aggression toward staff. Exit seeking behaviors. with the interventions .1:1 at all times until further notice.Observe and document episodes of inappropriate behaviors, explain that behavior is inappropriate.Offer/provide activities of interest to keep resident engaged in positive interactions.Redirect to activity of interest- Watching Westerns, baseball games and boxing, listening to country music.Review of Nurses' Notes dated 6/22/2025 at 11:09 PM, revealed, .observed resident walking down the hallway without wheelchair multiple times during shift. redirected resident multiple times. redirection effective for a short period of times, repeated getting up ambulating down the hall. resident noted having hallucinations of seeing a person and dog in room. Resident redirected to wheelchair, spent time with nurse at nurse cart during med (medication) pass for safety, then assisted to bed. Resident denies anything wrong.message left for NP in communication book.Review of Nurses' Notes dated 6/25/2025 at 3:10 PM, revealed, .Resident noted with increase confusion, hallucination of seeing people in his room, he had attempted to pick up stuff of floor that was (sic) there, very restless today. NP wants to check UA (urinalysis) with CNS (culture and sensitivity) d/t (due to) hallucinations, increase confusion, dysuria, and urgency. Called and reported to (name of daughter) the POA of new orders as well. Resident did have recent GDR (gradual dose reduction) in Lexapro but resident was over the recommended dose. Nurse (first name) notified of the new orders. Review of Pertinent Charting-Behavior dated 6/30/2025 at 1:57 PM, revealed, .Event date: 06/25/2025: resident calm and cooperative throughout morning, blowing kisses at staff and trying to grab butts, easy to redirect, ate meals in room independently with set up assist only, appetite good, denies SOB (short of breath), prn (as needed) pain medication given and effective.Review of Nurses' Notes dated 6/30/2025 at 07:04 AM, revealed, .CNA also reported after this that CNA was trying to get him to the bathroom and he took out his penis and started goes towards her, CNA was able to redirect will continue to monitor for this behavior. Review of Pertinent Charting-Behavior dated 7/1/2025 at 06:23 AM, revealed, .Event date: 06/30/2025: Resident had quiet night. When woke up this morning for his Synthroid, became touchy wanting to hug this nurse saying, I love you, give me a hug. Was educated that this behavior was inappropriate. Seemed to accept this without any aggression.Review of Pertinent Charting-Behavior dated 7/4/2025 at 04:09 AM, revealed, .Event date: 06/30/2025.resident up ambulating on own in hallways, somewhat compliant with redirection. continues with slightly sexual inappropriate gestures.Review of Pertinent Charting-Behavior dated 7/4/2025 at 5:43 PM, revealed, .Event date: 06/30/2025:.resident restless on and off throughout shift, has intermittent episodes of exit seeking, difficult to redirect. Review of Pertinent Charting-Behavior dated 7/13/2025 at 7:37 PM, revealed, .Event Date: 07/13/2025.Behavior Displayed: resident speaking inappropriately to staff. stated you have a nice butt. when was the last time you had a blow job to male housekeeper. housekeeper reported to nurse.Precipitating factors/events: housekeeper greeted resident upon entering room for daily cleaning.Intervention(s) attempted: educated resident on appropriate conversation topics.Intervention results: no comments of sexual nature reported following intervention.Review of Nurses' Notes dated 7/17/2025 at 04:15 AM, revealed, .This resident was in resident (Hallway/Room number), the resident in her room woke to him touching her breasts and vaginal area she then started screaming and this resident then left her room and went back to his room.Review of Social Services Progress Notes dated 7/17/2025 at 3:11 PM, revealed, .SS (Social Services) followed up with resident r/t (related to) incident he had with a female resident that recently occurred. Resident had no recollection of incident during visit. Resident was seen today by (Name of Mental Health Services Provider) psych NP today 7/17. Resident has had a room move today to (Hallway/Room number) bed1in which he seems to be adjusting fine at this time. Review of Pertinent Charting-Behavior dated 7/18/2025 at 2:37 PM, revealed, .Event Date: 07/18/2025.Behavior Displayed: Increase behaviors; new orders to start zoloft and discontinue Lexapro.Precipitating factors/events: increase behaviors/agitation at times.Intervention(s) attempted: Redirection, snacks, activities.Pharmacologic Intervention required: Zoloft 50mg.Comments: Discontinue lexapro and start zoloft 50mg for depression and increase agitation and behaviors at times with increase difficulty redirecting resident. Dtr (daughter) consented to medication. Monitor for adverse effects of medication. Monitor resident's behaviors.Review of Transcribed NP/PA Progress Note dated 7/18/25 at 6:53 PM revealed, .HISTORY OF PRESENT ILLNESS: This is an [AGE] year-old male who is being seen for follow-up after patient apparently was found in a residence [sic] room and was touching her trunk area in the middle of the night-the pt's (patient's) room he was in stated that he was touching her trunk area starting from her peri-area up to her breast. Review of Pertinent Charting-Behavior dated 7/19/2025 at 4:38 PM, revealed, .Resident told cna that cna has nice breasts. Resident attempting to hug staff members while sitting in WC (wheelchair) in hallway. No aggressive behaviors observed during shift.Review of Pertinent Charting-Behavior dated 7/20/2025 at 2:40 PM, revealed, .Resident calm during shift. Attempting to hug staff members throughout day. Resident states that resident enjoys looking at CNA's breasts. Review of Nurses' Notes dated 7/20/2025 at 2:42 PM, revealed, .Nurse and staff members educated resident multiple times during day shift regarding inappropriate statements made towards staff.Review of Nurses' Notes dated 7/21/2025 at 1:19 PM, revealed, .Resident still exhibiting sexual behaviors. Resident was asking multiple staff members to allow him to perform oral sex on them. Staff members redirected resident stating this is inappropriate behavior and he needs to respect people's boundaries after staff members had told him no to holding his hand, or hugging him. Resident became frustrated and verbally aggressive after this conversation. Another staff member reports him talking about sexual interactions with other people, reportedly making the staff members feel uncomfortable.This RN reiterated that these topics are not appropriate to discuss with staff members and that he is making people uncomfortable. I requested the resident to change the topic. Able to redirect at this time. Review of Progress Note-General dated 7/22/2025 at 5:34 PM, revealed, .This writer was asked to go to the room as (Resident #103) was sexually touching the aide in his room. The aide asked him multiple times to stop, and he wouldn't. When walking into the room the nurse was standing in front of the aide, and (Resident #103) reached out and grabbed the nurse's breasts. The aide left the room, the nurse and I stayed in the room with (Resident #103). While he continued to make sexually inappropriate states including If you didn't want your p**** touched you wouldn't have come in here.Review of Nurses' Notes dated 7/22/2025 at 6:35 PM, revealed, .Entered the resident's room around lunch time to give him his meds and he grabbed my arm and pulled me to him and grabbed my vagina and told me How sweet my p**** was I told him to stop and he then grabbed my breast. I pulled away.Review of Nurses' Notes dated 7/22/2025 at 7:32 PM, revealed, .Was called into the residents room d/t (due to) him lying his head into the CNAs breast. I entered the room and the resident put his fist in my face and stated he wanted to hit the black bastard behind me and then put both hands on my breast and I told him to stop and then he grabbed my vagina. The resident then grabs my face with both hands and tells me how good my p**** is' Admin entered the room and other staff left and then he grabbed my vagina again. Stayed with the resident and the admin until he was picked up. Sent resident to (Local Hospital).Review of Pertinent Charting-Behavior dated 7/23/2025 at 4:19 PM, revealed, .Event date: 07/18/2025: Stated to the staff today.Are you sure you don't want to suck your c***, i can make your [NAME] feel real good.I really like that and I want to suck it It looks really nice please let me suck it i wish you would let me suck it.hey son I'm glad you didn't get mad and tell that i wanted to suck your d***. If you change your mind let me know.Review of Nurses' Notes 7/24/2025 at 11:56 AM, revealed, .Attempted to obtain UAx2, resident states he doesn't have to pee at this time.Resident also began pleasuring himself while staff on 1:1 was in the room. Advised staff to sit outside of resident's room to maintain the 1:1 status and pull the curtain for resident's privacy.Review of Pertinent Charting-Behavior dated 7/24/2025 at 7:46 PM, revealed, .Event date: 07/18/2025: Resident had inappropriate moments throughout the day. He at one point began to self pleasure-move 1:1 to hallway and allowed for privacy in which he stopped after staff left the room. A CNA later reported that the resident groped her butt and attempted to grab at her vagina when resident was receiving dinner tray.Review of Nurses' Notes dated 7/26/2025 at 6:50 PM, revealed, .Resident stated to this nurse the only way I would touch your butt is if I was making love to you and resident also talked about touching nurse's nipples. Resident reached at nurse attempting to touch this nurse's butt. Nurse moved away from resident and resident touched just below the butt. Resident stated, I missed I almost got your butt. Resident also kept trying to touch this nurse's face.Review of Pertinent Charting-Behavior dated 7/30/2025 at 12:30 PM, revealed, .Event date: 07/18/2025: Resident remains a 1-1. Resident making sexual comments and trying to touch staff. Education to stop this behavior was provided but resident continues. Resident noted to be masturbating this morning in his room. Privacy was provided by pulling the curtain.Review of Nurses' Notes dated 7/30/2025 at 09:16 AM, revealed, .The resident was wheeling around the hallway yelling I want fu***** pus**. The resident's eyebrows were furrowed, and he said he was fu***** angry that no one would give him pus**.He continued to ask for the person who runs this joint.He then asked 2 female staff to give him what he wants.The 1:1 sitter, (Hallway) nurse.were present.Staff were able to deescalate the resident and bring him back into his room. The resident continues to be a 1:1. The sitter is currently sitting outside the resident's room (while the resident is in sight) due to his frequent, inappropriate comments and requests. Review of Nurses' Notes dated 7/31/2025 at 06:50 AM, revealed, .resident was observed by 1:1 staff masturbating for 10 minutes in bed. privacy curtain pulled for privacy.Review of Pertinent Charting-Behavior dated 7/31/2025 at 03:17 AM, revealed, .Event date: 07/18/2025: resident continues on 1:1, resident making inappropriate comments to nurse giving resident HS (night time) meds, no further behaviors.In an interview on 08/04/25 at 2:23 PM, Resident #102 reported Resident #103 had said to her a few days prior to him coming to her room, Wouldn't it be nice if you had a blow job, she told him, No. Resident #102 reported this happened in the hallway outside of her room. Resident #102 reported a few days later she had woken up to someone touching her, she opened her eyes and saw a shadow, and then she turned on the light and it was Resident #103. Resident #102 reported she turned on the call light but no one came so she called 911 and the police came and talked to him, twice she said. Resident #102 reported he (Resident #103) had touched her in her vaginal area and moved up to her breasts. Resident #102 reported she was very frightened of him, the incident was scary to her. Resident #102 reported Resident #103 was moved to another hallway, and she was glad he was moved. Resident #102 reported the facility placed the Stop sign banner on her door after this happened. Resident #102 reported she reported it to the police so it would not happen to anyone else again and she was happy he was moved to another hallway.In an interview on 08/04/25 at 3:25 PM, Ombudsman DD reported Resident #102 was pretty upset. Ombudsman DD reported the situation had rattled Resident #102 pretty good and she expressed to her that she felt violated and the wondered if it would happen again to her. Ombudsman DD reported it was better Resident #103 had been moved from the same hallway as she was self-isolating, not wanting to leave her room, and was unsure if Resident #102 was fearful of seeing Resident #103 again. Ombudsman DD reported the staff knew Resident #103 had sexual acting out behaviors and was not managing them prior to this incident. In an interview on 08/06/25 at 4:16 PM, CNA J reported Resident #103 was a very touchy person, sexually attracted to men and women and had made sexual comments to both. CNA J reported when it came to females he had a tendency of inappropriate touching. CNA J reported she was pretty sure she was not the only person. CNA J reported it was normal for Resident #103 to ask to have kids with you and at some point, his behaviors intensified. CNA J reported Resident #103 had always acted this way since she started to work with him.In an interview on 08/06/25 at 09:15 AM, CNA R reported she had worked with Resident #103 as a one to one and noted he could not be around other residents, and staff were told to keep a close eye on him. In an interview on 08/06/25 at 09:17 AM, CNA Q reported before she became a CNA, she was a resident assistant, and she reported she worked on the hall where Resident #103 originally resided. CNA Q reported he was touchy, hugs, hold your hand, touch you in some way, tell her she was beautiful, shared he said he wanted to marry her and other staff informed her to be careful around him as he could be touchy and informed her if there was any inappropriate behavior to chart it and let someone know. CNA Q reported she did work with him on a one to one and she was surprised by his very inappropriate comments and behavior. In an interview on 08/06/25 at 09:34 AM, CNA U reported Resident #103 was touchy, he would grab your hand and hurry up and kiss it. CNA U reported he would say things like you look nice, wished he was younger, different phrases like those. CNA U reported he was flirty and then he became aggressive and would grab you in inappropriate areas on your body. CNA U reported when a resident had behaviors the staff were to document in his medical record. CNA U reported there was also paper documentation the staff could complete. CNA U reported in the medical record staff could also create an Alert for Resident #103's behaviors. In an interview on 08/06/25 at 09:59 AM, Registered Nurse (RN) BB reported she had worked with Resident #103 when he was in his previous room prior to the incident with Resident #102. RN BB reported Resident #103 was confused, alert to self and there were times he could say inappropriate things and they were graphic. In an interview on 08/06/25 at 10:11 AM, Social Services Director (SSD) CC reported the behavior management team met weekly to review residents who were on antipsychotics. SSD CC reported typically, the team would review a few residents at a time to discuss the medications, behaviors, what needs the resident may have, and whether a gradual dose reduction (GDR) was needed. SSD CC reported for those residents who were not on an antipsychotic medication and had behaviors, the clinical staff would discuss the needs in the morning meeting. As the clinical staff would be flagged when reviewing the behavior tasks, 24 hour reports, and alerts to see what the clinical staff as a team could develop for the resident as far as interventions. SSD CC reported Resident #103 was not someone the behavior management team was following. In an interview on 08/04/25 at 08:30 AM, Nursing Home Administrator (NHA) A reported Resident #103 had been on one to one since the incident on 7/17/25. NHA A reported he became more agitated, sent him to a psychiatric facility for evaluation last week (7/31/25). NHA A reported she was informed the resident had been at a local skilled nursing facility from a staff member, who had reported to the NHA the resident had been on a one to one during his stay there for inappropriate sexual behavior. NHA A reported Resident #103 did have a history of sexual crimes from 20+ years ago. NHA A reported the facility did complete a background check that doesn't prevent us from taking them as they would look at the whole person in the present. On 08/06/25 at 3:05 PM, NHA A reported when a resident was on one to one monitoring all the blanks on the 15 minute check sheet should be completed. This writer requested all behavior documentation for Resident #103 from admission. The documentation received was from 7/6/25 -7/21/25 prior to his discharge to a psychiatric facility on 7/31/25.Review of .Targeted behavior: Hallucinations such as seeing people/dogs in his room.7/17/25 Yes at 2:01 PM.Behavior: dated 7/21/25, indicated Yes.sexually inappropriate. Review of Resident #103's one to one documentation revealed, he was noted to not be monitored the following days and times, .7/20/25: 12:00 AM - 06:15 AM.7/21/25 08:30 AM - 11:45 PM.7/22/25: 12:00 AM - 07:45 AM.7/22/25: 09:00 PM to 10:15 PM.7/23/25: 1:15 PM - 2:15 PM.7/24/25: 07:00 AM - 07:45 AM.7/24/25: 2:45 PM - 3:15 PM.7/26/25: 12:00 AM - 02:15 AM.7/31/25 12:00 AM - 06:15 AM.Review of policy, Abuse, Neglect and Exploitation revised on 1/10/24, revealed, . Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual Abuse is non-consensual sexual contact of any type with a resident. B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms.

Based on observation, interview and record review, the facility failed to ensure that a urinary drainage bag was not resting on the floor to prevent the risk of urinary tract infection for 1 (Resident #101) of 3 residents reviewed for urinary catheter use, resulting in the potential for infection. Findings include:A urinary catheter is a tube placed in the body to drain and collect urine from the bladder .An indwelling catheter collects urine by attaching it to a drainage bag. The bag has a valve that can be opened to allow urine to flow out. Some of these bags can be secured to your leg. This allows you to wear the bag under your clothes. An indwelling catheter may be inserted into the bladder in 2 ways: Most often, the catheter is inserted through the urethra. This is the tube that carries urine from the bladder to the outside of the body. Sometimes, the provider will insert a catheter into your bladder through a small hole in your belly. This is done at a hospital or provider's office . A catheter is most often attached to a drainage bag. Keep the drainage bag lower than your bladder so that urine does not flow back up into your bladder. (https://medlineplus.gov > Medical Encyclopedia)Resident #101: Review of an admission Record revealed Resident #101 was a male with pertinent diagnoses which included acute kidney failure, kidney disease, retention (holding back of substances in the body that are normally excreted) of urine, and benign prostatic hyperplasia (enlarged prostate gland) with lower urinary tract symptoms. Review of current Care Plan for Resident #103, revised on 5/15/2025, revealed the focus, .Resident has a need for an indwelling catheter related to: urinary retention, mechanical complication of foley cath. with the intervention .Observe for signs and symptoms of UTI (Urinary Tract Infection) and report to the Physician: blood in urine, cloudiness, foul smell, fever, change in mental status.Document output.Report signs of peri-area redness, irritation, skin excoriation/breakdown to the Nurse.Report signs of peri-area redness, irritation, skin excoriation/breakdown to Physician/NP/PA.Assist resident with indwelling catheter care.Change catheter and drainage system as clinically indicated per order(s). Observe for signs/symptoms of obstruction (leakage, increased sediment, etc.), infection, or if closed system was compromised.Irrigate foley catheter as indicated.Maintain drainage bag below the bladder level.Privacy cover to catheter drainage bag.Review of Order dated 4/28/25 revealed, .Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify provider as needed of any changes.every day and night shift. Review of Order dated 4/28/25, revealed, .Catheter: ensure anchor secured in place.every day and night shift. Review of Order dated 4/28/25, revealed, .Change indwelling Foley catheter 16Fr; balloon 10cc as clinically indicated: s/s (signs/symptoms) of obstruction (leakage, increased sediment, etc.), infection, or if closed system was compromised.as needed.Review of Order dated 4/28/25, revealed, .Maintain indwelling foley catheter every day and night shift related to OTHER RETENTION OF URINE (R33.8).During an observation on 08/05/25 at 8:50 AM, Resident #101 was observed lying sideways in his bed. Noted his catheter bag was hanging from the left side of the bed, there was not a privacy bag which covered it, and it was lying on the floor. During an observation on 08/05/25 at 09:50 AM, Resident #101 was observed lying in his bed, his catheter bag was placed on the floor on the left side of the foot of the bed. No privacy bag/cover was over it. During an observation on 08/05/25 at 11:42 AM, Resident #101 was observed lying in his bed, his catheter bag was lying on the floor next to the right side by the privacy curtain side. During an observation on 08/05/25 at 12:58 PM, Resident #101 was observed lying in his bed. His catheter bag was lying flat on the floor, the connection to the bag/tube area was not on the floor. During an observation on 08/05/25 at 2:19 PM, Resident #101 was seated upright, and he was eating his lunch. Resident #101's catheter bag was hung at the left side of his bed, but it did not have a privacy bag/cover over it. During an observation on 08/06/2025 at 09:00 AM, Resident #101 was observed in his room, lying in his bed, he had his breakfast tray but had not begun to eat it yet. The catheter bag was hung at the side of the bed, but it did not have a privacy bag. Review of Nurse's Notes dated 7/4/2025 at 10:19 PM, revealed, .Note Text: Foley bag had milky/green foul odor urine, reported to NP (Nurse Practitioner) (Name of NP) who ordered UA C&S (culture and sensitivity).Review of Pertinent Charting-Infections/Signs Symptoms dated 7/7/2025 at 4:59 PM, revealed, .Event Date: 07/04/2025.Site of infection: UTI .Reason on antibiotics/new signs & symptoms: Foley bag had milky/green foul odor urine, reported to NP (Name of NP) who ordered UA C&S.Intervention(s): Administer medications and treatments to treat infection and/or symptoms as ordered; observe for adverse effects.Encourage fluids unless contraindicated. Observe and report to Physician/NP/PA signs/symptoms of dehydration (poor skin turgor, dry mucous membranes, increased heart rate, sunken eyes, decreased urinary output, difficulty breathing, hypotension).Evaluate for verbal and non-verbal signs of pain. Administer pain meds as ordered.Notify Physician/NP/PA of change in mentation, increased pain, decreased urinary output, sign/symptoms of infection.Observe for psychosocial changes and offer emotional support when needed.Enhanced barrier precautions.Clean peri-area well after BM (bowel movement) in order to help prevent bacteria in the urinary tract.Consult with urinary specialist as ordered.Review of Nurses' Notes dated 7/7/2025 at 5:14 PM, revealed, .New orders obtained by NP for positive UTI; Cipro 250mg BID for 7 days.In an interview on 08/06/25 at 09:36 AM, Certified Nursing Assistant (CNA) U reported for a resident who had a catheter ensure the catheter bag was closed and wear personal protective equipment (PPE) when providing care to Resident #101. CNA U reported the catheter bag should be hung on the bed rail or on the hook, should not be on the floor and should have a privacy bag. CNA U reported if the catheter bag was on the floor that could cause infection, and it would be contaminated. In an interview on 9:59 AM, Registered Nurse (RN) BB reported ensure the catheter was cleaned daily, make sure it is patent (open), draining, and with peri care it was emptied. Staff would ensure the catheter bag was secured to prevent pulling, and either a leg bag or hung on the bed below the bladder so that the urine emptied into the bag. RN BB reported the catheter bag should not be placed on the floor as this was not safe and would allow infection to get into the catheter. RN BB reported the catheter bag should've been covered with a privacy bag for the resident's dignity. In an interview on 08/06/25 at 10:25 AM, Infection Preventionist (IFP) EE reported the CNAs should ensure the catheter bag was down the line from the bladder, no loops or back up as it can grow bacteria. IFP EE reported staff should ensure the catheter drainage bag was attached to the side of the bed, beneath the catheter and secured with the securement device. IFP EE reported the catheter bag should never be on the floor as bacteria could be introduced in the bag, tubing, and up into the catheter causing a catheter associated urinary tract infection (CAUTI). IFP EE reported the catheter bag should be covered with a fig leaf bag and if the facility doesn't have any, a privacy cover bag should be used.A CAUTI (Catheter associated urinary tract infection), or a UTI associated with a catheter, is common if you have an indwelling catheter inside your urethra.Symptoms are similar to a general UTI and include bloody or cloudy urine, gritty particles or mucus in your urine, urine with a strong odor, pain in your lower back, chills and fever. (https://www.healthline.com/health/sediment-in-urine)In an interview on 08/06/25 at 3:01 PM, Unit Manager (UM) D reported the catheter bag should never be on the floor as it opened the portal for infection. Review of Resident #101's chart with UM D revealed he had a recent UTI and reported would like to prevent another one for him. Review of policy, Catheter Care Procedure - Urinary revised on 12/28/23, revealed, .It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections, while maintaining their dignity and privacy. Catheter care may be provided by the nursing assistant and/or licensed nurse. 2. Privacy bags are used to cover catheter drainage bags while in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's right to dignity with grooming of facial hair in 1 resident (Resident #101) of 5 residents reviewed for dignity resulting in the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Resident #101(R101) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R101 admitted to the facility on [DATE] with diagnoses including type 2 diabetes (body has trouble controlling blood sugar and using it for energy) and muscle weakness. Brief Interview for Mental Status (BIMS) reflected a score of 11 out of 15 which indicated R101's cognition was moderately impaired (8-12 moderately impaired). During an observation and interview on 4/7/2025 at 11:36 AM, R101 was observed to have approximately 10 long gray facial hairs on her chin. R101 stated that they used to shave her chin in the group home before she came to the facility. R101 said that she hasn't had her facial hair shaved here since she was admitted to the facility and would like it to be done. During an interview on 4/8/2025 at 9:28 AM, Resident Assistant (RA) O stated that it is standard for staff to pluck or shave residents on shower days or if they request it to be done. During an interview on 4/8/2025 at 9:31 AM, Certified Nursing Assistant (CNA) C stated that residents should be shaved on shower days. CNA C said when she notices facial hair she asks residents if they want to be shaved or they will ask her to be shaved. During an interview on 4/8/2025 at 3:49 PM, CNA S stated that on shower or bed bath days she asks residents if they want to be shaved or have hair plucked if she notices facial hair on them. During another observation and interview on 4/8/2025 at 9:39 AM, R101 was observed to still have gray facial hair on her chin. R101 stated that she had a shower the day before (4/7/2025) and the staff were supposed to shave her chin but they didn't. R101 said she would still like it done. Review of the task list for staff revealed that R101's bathing schedule was on Mondays and Thursday on 1st shift. It was noted that R101 received a bed bath or shower 9 times since admission. The shower sheets only indicated whether skin checks were done and did not display any grooming check off. During an interview on 4/8/2025 at 3:56 PM, Nursing Home Administrator A stated that it is an expectation for staff to groom and ask residents if they want facial hair removed on their shower days. Review of the Expectation and Documentation of Resident's Shower sheet in each hall's CNA book revealed .4. Facial hair for both men and women need to be attended to with each shower. If facial hair is present, please shave. If the resident refuses to allow shaving, please inform the nurse responsible for that resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement ordered restorative program services provided to maintain, increase, or improve range of motion for 1 resident (Resident #41) of 2 residents reviewed for positioning/mobility, resulting in the potential for decreased range of motion and related complications such as development/worsening of contractures (shortening and hardening of muscles, tendons or tissue leading to deformity and rigidity of joints) and pain. Findings include: Resident #41(R41) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R41 originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes (body has trouble controlling blood sugar and using it for energy), reduced mobility, depression and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R41 was cognitively intact (13 to 15 cognitively intact). During an interview on 4/7/2025 at 11:02 AM, R41 stated that he was supposed to be on a restorative program for range of motion and the facility staff hadn't done anything with him. R41 said he was on a restorative program in the past and really liked it and would like to receive it again. Review of R41's physician order revealed an order date of 3/11/2025 and Resident will benefit from level 2 restorative ADL (Activities of Daily Living)/HYGIENE and ROM (Range of Motion) program as resident tolerates and is willing. During an interview on 4/8/2025 at 9:42 AM, Restorative Aide (RA) LL stated that he worked with R41 in the past and he was on the caseload again. RA LL said that that he should work with R41 2-3 times a week if R41 was available since he likes to go outside a lot. RA LL stated that he was just on vacation for 10 days and he wasn't sure if the other RA (RA KK) saw him when he was on vacation. During an interview on 4/8/2025 at 9:47 AM, Minimum Data Set (MDS) Licensed Practical Nurse (LPN) who was also the Restorative Director (RD) II stated that R41 was on restorative caseload for ROM and hygiene but he hasn't really been seen since he spends a lot of time outside. RD II said they like to see residents 2-3 times a week but the time isn't set since it's PRN (as needed). Review of R41's care plan revealed Focus: Resident would benefit from a restorative range of motion program related to decreased strength in lower extremities, decreased strength in upper extremities. Date initiated 1/24/2024, Revision on 3/11/2025 Review of R41's task documentation revealed the following restorative tasks: Right upper extremity active Range of Motion, shoulder and elbow all planes, manual resistance 2-3 sets/15-20 reps (repetitions); Restorative Nursing: Dressing/Grooming: Hand hygiene- Set up soapy water with washcloth and orange sticks; set up/supervision assist. The questions How well did resident tolerate, amount of minutes spent proving range of motion and why did the restorative program not occur? each area displayed no data found for the last 30 days. When discussing the lack of restorative documentation on 4/8/2025 at 10:00 AM, RD II stated that she doesn't do a good job documenting for the restorative program and making sure the RA's document under the task tab. RD II said that she doesn't have any other documentation anywhere and it's my fault. Review of the Restorative Nursing Programs Policy with an implementation date of 10/30/2020 and a review date of 1/1/2022 revealed Level II Restorative Nursing - A reasonable expectation that improvement will continue to occur with resident participation and goal setting . The following types of residents could benefit from a Restorative Program(s) but limited to: Contracture prevention and/or management . Skills practice/training in Activities of Daily Living Contracture Prevention and Management . Once determined that the resident would benefit from a restorative nursing program, implement the following: Determine if the resident is willing and able to participate. Document refusal in the medical record with education regarding risks and benefits. Re-visit at least quarterly to determine if the resident would still benefit. Determine willingness and ability and document refusals as previously completed Each facility should establish a monitoring program to assure success. The following have been identified as best practices . Establishment of a daily review of rehabilitation documentation to discern delivery of care or need to schedule on another shift .Implementation of program review by nursing staff, therapy, and others as appropriate to monitor program including additions of new residents and removal of programs Documentation of implementation should be completed on the Restorative Service Delivery Record or EMR as applicable. This includes each description of the intervention or modality to be provided, Time in minutes each time provided, Staff initials each time provided

Based on interview and record review the facility failed to ensure that grievances were promptly documented, investigated and resolved for 9 of 9 residents that participated in the Resident Council (RC) meeting. Findings include: Review of RC minutes dated 3/14/25 revealed old business included a concern that call lights on 3 rd shift were not answered timely and light turned off before need was met and that water was not passed consistently. The section of Actions taken was left blank. RC minutes dated 2/7/25 RC revealed old business that call light response time on 3rd shift slow to respond, and water pass was not consistent. New business identified concerns of 1. Call light on 3rd shift long wait time. 2. Turning off call light before addressing issues. 3. Ice water not passed out consistently Action taken changing hours to support third shift RC minutes dated 1/10/25 reflected under old business that call light response time was ongoing actions taken section of the minutes was left blank. New Business concerns were 1. Water not passed consistently 2. Call light response time 3rd shift weekends RC minutes dated 12/06/24 identified old business as call light response time status update ongoing Action taken will be added to all shift. New business call lights not being answered timely on 3rd shift will be added to all staff RC minutes dated 11/08/24 identified old business was call light response time Status update ongoing New Business - Call light response time early morning/night Action taken was ongoing. RC minutes dated 10/11/24 revealed new Business was a concern with call light response time- Action taken Was that the Director of Nursing would do spot checks on 2nd and 3rd shift. During the RC meeting on 4/8/25 at 10:00 am, 9 of the 9 participants reported they do not receive assistance in a timely manner on third shift. One participant reported he turned on his call light last night at 3:30 am and did not receive assistance until the day shift came in at 7:00 am. All 9 participants stated they complain about call light response time, staff turning off the call light prior to meeting their need and staff not consistently passing out water. RC participants stated these issues come up every month and will get better for a few days, then revert back. Five of the 9 RC participants reported they no longer voice concerns to Nursing Home Administrator A or Director of Nursing (DON) Bbecause they felt like their concerns were not taken seriously and fall on deaf ears. Three participants stated there was a canned response of We will take care of it. or Will see. On 04/09/25 at 10:10 AM, during an interview with NHA A she reported she stated she was aware of the concerns and had altered the staff development nurses schedule to work 4 -10 hour days in attempts to correct issues. When queried what time the staff development nurse got off duty , NHA A stated 9:00 pm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During the RC meeting on 4/8/25 at 10:00 am, 9 of the 9 participants reported the food was always , always cold with overcooked vegetables that were mushy. The RC participants reported items were missing of trays at every meal either a tea bag, salad, bread, dessert, food requests/preferences not honored. RC participants stated the facility had food committee in place, but all 9 RC participants unanimously agreed there had been no improvement. Resident 91 Review of the clinical record including the Minimum Data Set (MDS) dated [DATE], reflected Resident 91 (R91) was admitted to the facility with diagnoses that included sepsis due to escherichia Coli (E. Coli). R91 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 04/07/25 at 02:27 PM during an interview R91 reported food was terrible, had no flavor and always cold. R91 reported making multiple complaints to staff and had missed several meals due to palatability. Based on observation, interview, and record review, the facility failed to serve food at a palatable temperature in 2 of 4 residents (Resident #66 & #91) reviewed for food palatability, and 9 of 9 residents from the confidential group interview, resulting in dissatisfaction with meals and the potential for nutritional decline. Findings include: Resident #66 Review of an admission Record revealed Resident #66 was a female with pertinent diagnoses which included anemia, diabetes, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #66, with a reference date of 2/22/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact. In an interview on 4/7/25 at 11:49 AM, Resident #66 reported she eats her meals in her room, and hot foods at the facility are often cold by the time they are served. In an interview on 4/8/25 at 3:48 PM, Registered Dietitian (RD) M reported they have talked with Resident #66 about her food concerns, which include hot foods being served cold. In an interview on 4/8/25 at 3:58 PM, Resident #66 reported the dinner served last night (pork chop) was cold by the time it was delivered to her room. An interview with [NAME] SS, at 11:59 AM on 4/7/25, found that she likes hot food on the steam table to be around 175F. At this time, temperatures of hot food items were taken and found to be over 175F. An interview with Certified Dietary Manager RR at 12:21 PM on 4/7/25, found that the order of food being delivered goes C hall cart, B hall cart , Dining room service , A hall cart, and then D hall cart. During lunch service, at 1:15 PM on 4/7/25, a test tray was plated and placed as the first meal tray on the D hall cart. No observations of additional food temperatures were found to have been taken since the start of service. At 1:29 PM on 4/7/25, the D hall cart, with the test tray and roughly 16 resident trays, was delivered to D hall. At 1:35 PM on 4/7/25, all of the resident trays on D hall had been delivered and the test tray was back in the conference room. The following temperatures were found with a rapid read digital thermometer: Mash potatoes 119F, Salisbury steak 109F, and carrots 118F.

Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During the initial tour of the kitchen, at 10:10 AM on 4/7/25, it was observed that the kitchens only hand sink was being blocked by a large dietary cart full of dirty dishes from breakfast. With no other hand sink in the kitchen, the cart had to be repositioned and moved over so that the hand sink could be accessible. An interview with Regional Dietitian VV found that facility staff have thought about adding another hand sink in the kitchen but are not sure of the best location. An interview with Maintenance Director Z, at 11:20 AM on 4/7/25, found that the original location suggested for an additional hand sink was too close to an electrical panel. When asked about adding a sink between the cook line and the three compartment sink, Maintenance Director Z stated one could possibly fit and more easily tie into the plumbing. An interview with Director of Operations WW, at 4:02 PM on 4/7/25, found that where its easiest to place the dietary carts for dishes is not convenient for regular access to the only hand sink. According to the 2022 FDA Food Code section 5-203.11 Handwashing Sinks. (A) Except as specified in (B) and (C) of this section, at least 1 HANDWASHING SINK, a number of HANDWASHING SINKS necessary for their convenient use by EMPLOYEES in areas specified under § 5-204.11, and not fewer than the number of HANDWASHING SINKS required by LAW shall be provided. According to the 2022 FDA Food Code section 5-204.11 Handwashing Sinks. A HANDWASHING SINK shall be located: (A) To allow convenient use by EMPLOYEES in FOOD preparation, FOOD dispensing, and WAREWASHING areas . According to the 2022 FDA Food Code section 5-205.11 Using a Handwashing Sink. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use . During a tour of lunch service, starting at 12:08 PM on 4/7/25, it was observed that Dietary Aide TT and Dietary Aide UU were found with artificial fingernails on the service-line. The dietary aids were helping add drinks, silverware, desserts, and plates of food to trays. At this time, no gloves were observed being worn by staff with artificial fingernails and Dietary Aide TT was observed wearing four bracelets. According to the 2022 FDA Food Code section 2-302.11 Maintenance of Fingernails (A) FOOD EMPLOYEES shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. (B) Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD. According to the 2022 FDA Food Code section 2-303.11 Prohibition Jewelry Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands. During an observation of lunch service, at 12:31 PM on 4/7/25, it was observed that Certified Dietary Manager (CDM) RR was helping check resident meal tickets and completed trays before being delivered. [NAME] SS stated she needed assistance with a food item. CDM RR was observed coming into the kitchen from outside the service window and assisting [NAME] SS with getting what looked to be parmesan cheese and then going back outside of the service window to continue her work with the trays. No hand washing was observed upon entering the kitchen and working with food. During an observation of lunch service, at 12:35 PM on 4/7/25, was observed that Dietary Aid UU, was placing utensils, desserts, and drinks onto resident trays. At this time, Dietary Aide UU was observed stepping off the tray line and exiting the kitchen to grab the next halls meal tickets located in the dining room. Dietary Aide UU was observed checking her phone upon leaving the kitchen and before grabbing the next halls meal tickets. After getting the meal tickets, Dietary Aid UU walked back into the kitchen and got back onto the service-line without washing her hands. During an observation of lunch service, at 12:43 PM on 4/7/25, it was observed that CDM RR was helping check resident meal tickets and completed trays before being delivered to residents. [NAME] SS stated she needed assistance with a food item. CDM RR was observed coming into the kitchen and getting chips for [NAME] SS without washing her hands. According to the 2022 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and:(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview, and record review the facility failed to revise a person-centered care plan for 1 (Resident #106) of 7 residents reviewed for person-centered care plan revisions resulting in an inaccurate reflection of the resident's current care needs. Findings include: Review of an admission Record revealed Resident #106 had pertinent diagnoses which included: adult failure to thrive, restlessness and agitation, and severe protein calorie malnutrition. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 12/20/2024 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #106 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). Review of Order Summary for Resident #106 revealed Adaptive equipment: plate guard, built-up utensils (a piece of foam with a slit in the center for the handle of eating utensils to be inserted to create a greater gripping surface area), 2-handled cup with straw with a start date of 8/26/2024. Review of Care Plan for Resident #106 revealed Focus/Interventions Resident has an ADL (activity of daily living) self-care performance deficit related to physical debility, generalized muscle weakness .adult failure to thrive; Intervention eating: 1 person assist; utilize plate guard, built-up utensils, 2-handled cup with straw with meals with an initiation date of 8/26/2024. Review of Therapy to Nursing Communication Form for Resident #106 dated 8/26/24 revealed plate guard, built-up utensils, 2-handled cup w/ straw (with). During an observation on 2/5/25 at 8:40 AM Resident #106 was sitting his high back wheelchair, in the dining room, with his legs pulled up and his knees bent. Resident #106 had a breakfast tray on the table in front of him, that included 2 coffee cups with lids and straws and Resident #106 was holding and drinking from a coffee cup with a lid and a straw in it. Restorative Aide (RA) AA was observed scraping Resident #106's scrambled eggs into a bowl and handing the bowl and a built-up utensil to Resident #106 to eat. In an interview on 2/5/25 at 10:20 AM, Occupational Therapist (OT) GG reported Resident #106 did not use built up utensils anymore. OT GG reported she had upgraded Resident #106 to regular silverware, and she had communicated the changes to nursing and dietary departments. OT GG reported that Resident #106 did not always need a 2-handeld cup, but she had not changed that yet. OT GG reviewed the care plan for Resident #106 with this surveyor and confirmed the care plan indicated plate guard, built-up utensils, and 2-handled cups for liquids and it had not been revised to reflect the changed OT GG had communicated. Review of Therapy to Nursing Communication Form for Resident #106 dated 12/11/24 revealed Return to regular utensils-D/C (discontinue) built-up. The form was signed by nursing and dated 12/11/24 as acknowledged. In an interview on 2/5/25 at 10:31 AM, Dietary Manager (DM) JJ reported that Resident #106 was to have coffee cups with lids and straws, built up utensils, and a plate guard. DM JJreported that dietary staff knew the resident's needs because they were listed on the Resident's meal ticket. Review of meal tickets for Resident #106 dated 2/5/25 revealed Breakfast- Coffee cups w/lids for all liquids, built up utensils, plate guard; Lunch - built up utensils, coffee cups w/lids for all liquids, plate guard; Dinner- Built up utensils, coffee cup w/lids for all liquids, plate guard. During an observation on 2/5/25 at 12:40 PM Resident #106 was sitting in his wheelchair in the dining room, up to a table, drinking from a coffee cup with a lid and a straw that he was holding. Review of Order Summary for Resident #106 dated 2/5/25 at 11:02 AM, revealed adaptive equipment: plate guard, 2-handled cup with straw In an interview on 2/5/25 at 12:43 PM, Unit Manager/Licensed Practical Nurse (UM/LPN) O reported she had made updates today to Resident #106's orders for adaptive equipment because she was given a communication that was signed in December and the changes had not yet been made. UM/LPN O reported the nursing department communicates changes to the dietary department. UM/LPN reported when the changes did not happen in the nursing department, they did not happen in the dietary department either. In an observation on 2/5/25 at 12:53 PM, Resident #106 was sitting in his wheelchair, in the dining room, drinking from a coffee cup with a lid and straw that he was holding. OT GG was present, observing and interacting with Resident #106. In an observation on 2/5/25 at 12:56 PM, Resident #106 was sitting in his wheelchair, in the dining room, up to the table, with his meal tray present in front of him. Resident #106 meal tray included built-up utensils, a plate guard, and 3 2-handled cups of liquids. OT GG joined Resident #106 and replaced his built-up utensils with regular ones.

This citation pertains to intake #MI00146503 Based on interview and record review the facility failed to ensure that professional standards of nursing practice were maintained related to physician orders for 1 (Resident #100) of 1 resident reviewed for professional nursing standards and physician orders resulting in inaccurate physician orders and the potential for medication error. Findings include: Review of an admission Record revealed Resident #100 had pertinent diagnoses which included: pain, muscle spasm, contracture of the left foot, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 12/16/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #100 was cognitively intact. (BIMS score 12-15 indicates little or no cognitive impairment). Review of Medication Administration Record (MAR) for Resident #100 for the month of December 2024 revealed Oxycodone-acetaminophen (Percocet) Oral Tablet 10-325 mg (milligrams) (Oxycodone w/ (with) acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain until 12/11/24 at 23:59 (11:59pm) with a start date of 12/10/2024 at 17:30 (5:30 pm). Documentation was noted on the MAR indicating at 17:30 pm on 12/10/24 this medication was administered to Resident #100. In a telephone interview on 1/30/25 at 2:25 PM, Family Member (FM) DD reported the facility did not dispense Resident #100's pain medication as her physician was ordering/prescribing it. FM DD reported the facility had given Resident #100 Percocet, and Resident #100 never had an order for Percocet. FM DD reported Resident #100 should have had an order for Norco. FM DD reported he was told this was a near miss (a serious error or mishap that has the potential to cause an adverse event but fails to do so because of chance or because it is intercepted) and not a medication error. Review of Nurses' Notes for Resident #100 dated 12/10/2024 at 19:20 (7:20 PM) and authored by Registered Nurse/Supervisor (RN/S) K revealed Resident's PCP (primary care physician) was in to visit resident and gave verbal order for Norco 10-325mg q8 (every 8 hours) PRN (as needed) until 12-11 at 23:59 . In a telephone interview on 1/30/25 at 3:33 PM., Resident #100 reported she remembered she was supposed to take Norco for pain and the facility tried to give her something else. In an interview on 2/4/25 at 12:10 PM., Director of Nursing (DON) B reported the order for Percocet was entered inaccurately, the order should have been for Norco. In an interview on 2/4/25 at 12:10 PM., Nursing Home Administrator (NHA) A reported the order for Percocet for Resident #100 was entered into the computer (Electronic Health Record/EHR) inaccurately, it should have been an order for Norco. In an interview on 2/4/25 at 3:24 PM., Education Training Director/RN (ETD/RN) W reported Resident #100's order for Percocet was a clerical error, the order was inputted into the EHR wrong. ETD/RN W reported there was no written prescription and no verbal order for Resident #100 to have Percocet. ETD/RN W reported there was never a delivery of Percocet for Resident #100 to the facility. In an interview on 2/5/25 at 10:49 AM., RN/S K reported on 12/10/24 Resident #100's doctor gave her a verbal order and she wrote it down wrong. RN/S K reported the actual verbal order was for hydrocodone (Norco), not Percocet. RN/S K reported she entered the order into Resident #100's EHR as Percocet. RN/S K did not recall if she documented she had administered Percocet to Resident #100 on that day. RN/S K reported Percocet was never available in the medication cart for Resident #100 and she did not administer Percocet to Resident #100 when her doctor gave her a verbal order. RN/S K stated I gave her what was available in the medication cart and that was Norco. Review of Controlled Substance Record for Resident #100 revealed Hydrocodone-APAP (acetaminophen) (Norco) 10-325 mg tab (tablet). On 12/10/24 at 17:30 (5:30pm) RN/S K initialed for the removal of one tablet for administration to Resident #100. Review of MAR for Resident #100 for the month of December revealed no active order for Hydrocodone-Acetaminophen (Norco) Tablet 10-325 mg give one tablet by mouth every 8 hours as needed for pain on 12/10/2024. Review of Quality Assistance Form dated 1/16/25, completed by NHA A and reviewed by DON B, concerning Resident #100 revealed The order for Norco (hydrocodone) was written for oxycodone (Percocet). Findings: orders only written for Norco; Plan/Action: reordered the next day; resolved, yes, correct order written. In an interview on 2/5/25 at 12:16 PM., RN Q reported the medication given should match the order in the EHR. In an interview on 2/5/25 at 12:18 PM., Licensed Practical Nurse (LPN) BB reported verifying the medication order and the medication available was part of the 5 rights to medication administration. In an interview on 2/5/25 at 12:36 PM., DON B reported her expectations were when a medication was administred the order EHR and the medication given should match.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure proper placement of an aspen collar (immobilization brace for the neck) was in place during a transfer for 1 (Resident #105) of 1 resident reviewed for aspen collar use resulting in the potential for re-fracturing, delayed healing and/or potential re-injury. Findings include: Review of an admission Record revealed Resident #105 had pertinent diagnoses which included: unspecified nondisplaced fracture of the second cervical vertebra (a break in a bone in the neck near the base of the skull). Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 11/6/24 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #105 was severely cognitively impaired (BIMS score 0-7 indicates severe cognitive impairment). Review of Order Summary for Resident #105 revealed Apply Aspen collar prior to rising in the morning with a start date of 5/30/2023; Aspen collar to be worn when up in w/c (wheelchair) (even with showers), Okay to remove while in bed; monitor skin under and surrounding collar for s/sx (signs and symptoms) of breakdown with a start date of 5/26/2023; Remove Aspen Collar at HS (evening) at bedtime with a start date of 11/10/2024; Remove Aspen collar to monitor skin under collar and surround skin for any s/sx of breakdown and notify MD/NP (medical doctor/nurse practitioner) with a start date of 11/10/2024 Review of Care Plan for Resident #105 revealed Focus/Interventions Resident has an ADL (activity of daily living) self-care performance deficit related to .fx (fracture) of base of skull right side .fx of 2nd cervical vertebra .Transfers: 1 person assist to stand and pivot. Leave cervical collar on when transferring from chair to bed, initiated on 9/27/23 with a revision date of 1/30/25. In an interview on 1/30/25 at 9:30 AM, Resident #105 was sitting in the doorway of her room in her wheelchair with her aspen collar in place on her neck. Resident #105 asked this surveyor if I would put her to bed. Certified Nursing Assistant (CNA) L overheard Resident #105 ask to lay down and approached Resident #105 to assist her. During an observation on 1/30/25 at 9:35 AM, CNA L positioned Resident #105 in her wheelchair next to her bed, removed Resident #105's aspen collar and placed it onto the dresser. CNA L then retrieved a gait belt (belt used during a transfer to provide a place to hold on to a person), applied it around Resident #105's waist and assisted Resident #105 to stand and pivot transfer from her wheelchair into her bed. In an interview on 1/30/25 at 9:45 AM, CNA L reported Resident #105 wears her aspen collar only when she was up. CNA L asked Registered Nurse (RN) Q who was walking by to confirm that Resident #105 needed her aspen collar when she was up. RN Q agreed, Resident #105 wore her aspen collar when up and not when she was in bed. When queried, RN Q reported that Resident #105's aspen collar should be removed after she was transferred to bed, as she has a fracture in her neck. RN Q reported Resident #105 should wear her aspen collar during transfers. CNA L reported she had no idea it mattered if the aspen collar was removed before or after the transfer because it did not specify in the [NAME] (a condensed report of the care plan for the staff to access specific information about the resident's care needs), which was where she got resident specific information. In an interview on 2/3/25 at 2:46 PM, Unit Manager/Licensed Practical Nurse (UM/LPN) O reported Resident #105 was to wear an aspen collar when up out of bed and the collar should not be removed before a transfer, it should be removed after the transfer, as Resident #105 was still at risk for a fracture. UM/LPN O reported Resident #105's care plan was updated to include wearing the aspen collar duirng transfers. Review of Nurses' Notes for Resident #105 dated 4/22/24 at 17:53 (5:53 pm) revealed Received phone call back form (Name Omitted) doctor's office and spoke with (Name Omitted) whom stated that (Name Omitted) doctor is going to recommend the aspen collar for life at this time .

This citation pertains to intake #MI00146503 Based on interview and record review the facility failed to maintain clear, concise, and accurate medical records for 1 (Resident #100) of 7 residents reviewed for clear, concise, and accurate medical records resulting in inaccurate documentation of medication orders and the potential for a diminished medical outcome. Findings include: Review of an admission Record revealed Resident #100 had pertinent diagnoses which included: pain, muscle spasm, contracture of the left foot, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 12/16/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #100 was cognitively intact. (BIMS score 12-15 indicates little or no cognitive impairment). Review of Order Summary for Resident #100 revealed Oxycodone-acetaminophen (Percocet) Oral Tablet 10-325 mg (milligrams) (Oxycodone w/ (with) acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain until 12/11/24 at 23:59 (11:59pm) with a start date of 12/10/2024 at 17:30 (5:30 pm). In a telephone interview on 1/30/25 at 2:25 PM, Family Member (FM) DD reported Resident #100 never had an order for Percocet. FM DD reported Resident #100 had an order for Norco. Review of Nurses' Notes for Resident #100 dated 12/10/2024 at 19:20 (7:20 PM) and authored by Registered Nurse/Supervisor (RN/S) K revealed Resident's PCP (primary care physician) was in to visit resident and gave verbal order for Norco 10-325mg q8 (every 8 hours) PRN (as needed) until 12-11 at 23:59 . In an interview on 2/4/25 at 12:10 PM., Director of Nursing (DON) B reported the order for Percocet was entered inaccurately, the order should have been for Norco. In an interview on 2/4/25 at 3:24 PM., Education Training Director/RN (ETD/RN) W reported Resident #100's order for Percocet was a clerical error, the order was inputted into the electronic health record (EHR) wrong. ETD/RN W reported there was no written prescription and no verbal order for Resident #100 to have Percocet. In an interview on 2/5/25 at 10:49 AM., RN/S K reported on 12/10/24 Resident #100's doctor gave her a verbal order and she wrote it down wrong. RN/S K reported the actual verbal order was for hydrocodone (Norco), not Percocet. RN/S K reported she entered the order into Resident #100's EHR as Percocet, not Norco.

Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) specifically face masks, was worn correctly by staff throughout the facility during a covid outbreak, resulting in the potential for the spread of infection and disease transmission for residents residing in the facility. Findings include: On 1/30/25 at 8:19 AM., signage on the entry door to the facility revealed a Covid outbreak and that face masks were required to be worn in the building. On 1/30/25 at 8:22 AM., Office Receptionist (OR) SS unlocked the facility door and when queried, she responded that face masks were required to be worn by staff, but per the Infection Preventionist, visitors could not be forced to wear face masks. On 1/30/25 at 10:30 AM Dietary Aide (DA) LL was observed in the main dining room with his face mask under his nose. On 1/30/25 at 11:23 AM., Registered Nurse (RN) C was observed on the A Hall, moving between the medication cart, supply closet, and resident's rooms with her face mask positioned under her chin and not covering her mouth and nose. During an observation and interview on 1/30/25 at 11:34 AM., RN C was observed preparing medications for a resident at the medication cart on A Hall with her mask under her chin. RN C reported when the facility experiences a Covid outbreak the Infection Preventionist initiates masks to be worn by staff throughout the building. When queried, RN C confirmed that her mask was under her chin and the correct way to wear a face mask was to have it cover her nose and mouth. RN C stated I am not approaching residents with my mask below my chin, I do it at the cart. This surveyor noted droplet isolation and airborne precaution signage posted on the wall next to the room behind where RN C's medication cart was located on A Hall. On 1/30/25 at 11:40 AM., Certified Nurse Assistant (CNA) P was observed exiting a resident's room on A Hall with her face mask below her chin. When CNA P made eye contact with this surveyor, she adjusted her face mask to cover her nose and mouth. On 1/30/25 at 1:38 PM., DA LL was observed in the dining room without a face mask on, interacting with residents in the dining room, and providing requested items from the cabinet to residents. On 2/4/25 at 10:27 AM., Housekeeper (H) QQ was observed exiting a resident room on C Hall with her face mask positioned below her nose. When queried, H QQ reported facemask were to be worn over the nose and mouth. On 2/4/25 at 10:29 AM Floor Tech (FT) OO was observed pushing a floor cleaning machine down B Hall with his face mask below his nose. On 2/4/25 at 10:32 AM., CNA R was observed in a resident's room, at the bedside, assisting with the resident's blankets, with her face mask below her nose. On 2/4/25 at 10:33 AM H RR was observed on B Hall with her face mask below her nose. In an interview on 2/4/25 at 10:39 AM., CNA R reported that face masks were required to be worn by the staff throughout the facility and that proper placement of a face mask was covering the nose and mouth. CNA R reported the droplet precautions and airborne precautions signage indicated the room had a Covid positive resident in it. During an observation and interview on 2/4/25 at 11:01 AM., DA MM was sitting in the dining room preparing silverware at a table without a face mask on, a face mask was noted to be laying on the table. Residents were present in the dining room. When queried, DA MM reported that infection control practices for the dietary staff included wearing a face mask (DA MM) reached for the discarded face mask on the table and applied it to his face) and hand washing when in the kitchen. When queried, DA MM reported proper wearing of a face mask included covering the nose and mouth. On 2/4/25 at 11:10 AM., Dietary Manager (DM) JJ was observed in the kitchen through the serving window with her face mask below her chin. DA LL was observed exiting the kitchen though the door next to the serving window without a face mask on. In an interview on 2/4/25 at 2:48 PM., Unit Manager/Licensed Practical Nurse (UM/LPN) O reported during a Covid outbreak face masks were required to be worn by all staff and should cover the nose and mouth. In an interview on 2/4/25 at 4:10 PM., Infection Preventionist (IP) T reported one positive Covid resident was considered a Covid outbreak. IP T reported staff was required to wear a face mask throughout the building during an outbreak. IP T reported the proper way to wear a face mask was to ensure the nose and mouth were covered. IP T had a laminated picture of a face with a face mask covering their mouth and nose, and a log of employee signatures, when queried, he reported he was re-educating all staff on the proper way to wear a face mask as it was an ongoing problem.

Based on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity for 1 resident (Resident #6) of 3 reviewed for dignity, resulting in the potential of feelings of embarrassment, loss of self-worth, and decreased quality of life. Findings include: Resident #6: Review of an admission Record revealed Resident #6 was a male with pertinent diagnoses which included dementia, dysphagia (difficulty swallowing foods or liquids), stroke, muscle weakness, diabetes, nutritional anemia (the body does not get enough iron or a few other nutrients from their diet), contracture of left hand, acute subdural hemorrhage (traumatic head injury, such as a blow to the head or a fall), idiopathic orofacial dystonia (involuntary, spasmodic movements of the muscles of the orofacial (mouth and face), masticatory (chewing muscles), and lingual (tongue) region and torticollis (rare condition which the neck muscles contract, causing the head to twist to one side). Review of current Care Plan for Resident #6, revised on 9/9/23, revealed the focus, .Resident has an ADL self care performance deficit related to: Adult failure to thrive, tardive dyskinesia, to thrive, chronic pain, T2DM, prostate CA, schizophrenia, left hand contracture, muscle cramps, BPH (enlarged prostate gland), restless leg syndrome, incontinence, traumatic subdural hemorrhage, anxiety, anemia, GERD, IBS, vascular dementia, dysphasia . with the interventions .EATING: Feeds self with set up assistance .DRESSING: 1 person assist . During an observation on 2/28/24 at 3:20 PM, Resident #6 was observed seated in his wheelchair by the nurse's station between the station and the wall heading towards the hallway entrance. He was observed leaning to the left side, moving his feet but was not self-propelling or ambulating anywhere. Resident #6 was observed to have 5-6 whole peas on the left chest area of his shirt with various dried food and liquids spilled on the left chest area of his shirt running down the front of his shirt. Resident #6's shorts were observed to have dried food scattered all over the front of his shorts, in his lap, and down the legs of the short. During an observation on 2/28/24 at 3:26 PM, Certified Nursing Assistant (CNA) AA walked passed him and did not speak to him, offer assistance to propel him to his destination or make note of his soiled shirt and shorts and offer to get him cleaned up. CNA X walked passed him as well and did not greet him, offer assistance to propel him in his wheelchair, or make note of his dirty shirt and shorts and offer to get him cleaned up. During an observation on 2/29/24 at 9:26 AM, Resident #6 was observed in his room seated in his wheelchair with his tray table and breakfast in front of him. He had the spoon in his right hand and was holding it in a bowl of oatmeal, he held the spoon in the bowl for a few moments and slowly brought it up to his mouth with his hand shaking and large pieces of oatmeal were falling of the spoon. It appeared his right hand was twisted to the inside of his wrist. Resident #6 leaned to the left while sitting in his wheelchair, head tilted forward appearing as if his left side of his jaw and chin were resting on his left shoulder/chest area. Resident #6 did not drool out the side of his mouth. During an observation on 2/29/24 at 09:28 AM, Resident #6 lifted the spoon slowly bringing it to his mouth with his hand shaking and spilled some on his pant leg on the left side. In an interview on 2/29/24 at 9:29 AM, Licensed Practical Nurse (LPN) CC reported he normally eats in the dining room but he woke up late today. LPN CC reported the staff don't bring clothing protectors to the rooms. They only have them in the dining room. Usually they would grab a towel and cover the resident. LPN CC reported if Resident #6 soiled his clothing while eating the staff would change his clothes. During an observation on 2/29/24 at 9:33 AM, Resident #6 had chunks of oatmeal down the left side of his shirt into his vest down into the chest area. During an observation on at 2/29/24 at 12:22 PM, Resident #6 was sitting in his room in his wheelchair with oatmeal down the left front of the vest he was wearing. As he leans to the left, his clothing gathers on that side creating a concave space where food gathers. In an interview on 2/29/24 at 10:40 AM, CNA E reported she would assist the resident with ambulation if they wanted, remove the larger food items on their clothing. In an interview on 2/29/24 at 10:53 AM, CNA O reported she would assist the resident with ambulation if they needed assistance; she would not just leave them in the middle of the hallway. CNA O reported she would offer to clean the resident up and change their shirt if it had food on it or food dried on it. In an interview on 2/29/24 at 2:30 PM, Director of Nursing (DON) B reported she would expect the facility staff to assist the resident with ambulation if they were struggling and needed assistance. She reported she would have expected the staff, if the resident's clothing was soiled, to talk with the resident and change the resident's clothing. Review of policy, Resident Rights revised on 1/1/22, revealed, .11. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a call light was accessible to two residents (R89 and R93) of 22 residents reviewed for accommodations of needs, resulting in the potential of unmeet care needs. Findings include: R89 According to the Minimum Data Set (MDS) dated [DATE], R89 scored 2/15 on her BIMS (Brief Interview Mental Status) indicating the resident was severely cognitively impaired. The resident had no impairment in her arms or legs with diagnoses that included Alzheimer's disease. Observed on 2/27/24 at 10:40 AM, R89 was in bed with her eyes closed. The bed was against the wall on the resident's right side with the call light on the floor under the bed out of sight and reach of the resident. R93 According to the Minimum Data Set (MDS) dated [DATE], R93 did not have a BIMS score indicating her cognition. Her functional abilities in Section GG reported her as having an impairment on one side of her body affecting her arm and leg. Diagnoses included a stroke with partial paralysis. During an observation on 2/27/24 at 10:45 AM, a call light was clipped to the privacy curtain behind R93's head-of-bed, out of sight and reach of the resident. During an observation and interview on 2/27/24 at 10:49 AM, Certified Nursing Assistant (CNA) W stated, (R93) has a push type call light. The CNA then turned around and looked at the call light clipped to the privacy curtain and stated, I did not see the call light there. The last time I checked on her was 8:30 this morning when I was feeding her. I did not notice the call light then either. During an interview on 2/27/24 at 1:41 PM, CNA DD stated, Call lights should be kept within reach of residents; any resident no matter if they can use it or not. During an observation and interview on 2/28/24 at 12:42 PM, while touring R93's room, Licensed Practical Nurse (LPN) TT observed with surveyor, resident's soft touch call light clipped to resident's left side below the left edge of the perimeter mattress out of sight and reach of resident. LPN stated, The call light should be available to the resident. During an interview on 2/28/24 sat 1:27 PM, Unit Manager TT stated, Call lights should be accessible to all residents when in their rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessments in 1 of 22 residents (Resident #80) reviewed for accuracy of assessments, resulting in an inaccurate reflection of the resident's status. Findings include: Resident #80 Review of an admission Record revealed Resident #80 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: adult failure to thrive. Review of a MDS assessment for Resident #80, with a reference date of 12/14/23 indicated 0 unhealed pressure ulcers, 2 venous and arterial ulcers, and was checked for diabetic foot ulcers. Review of a Significant Change of Condition MDS assessment for Resident #80, with a reference date of 9/23/23 indicated 0 unhealed pressure ulcers, 0 venous and arterial ulcers, and was checked for diabetic foot ulcers. In an interview on 02/29/24 at 02:18 PM, MDS Nurse QQ reported that the information used to complete the MDS assessment was taken from actual observation of the resident's skin, nursing skin/wound assessments, treatment administration records, progress notes, medical diagnoses, and wound doctor notes. MDS Nurse QQ reported that the physician noted on 8/16/23 that Resident #80 had an unstageable pressure ulcer and the wound clinic notes indicated a Stage 3 pressure ulcer on 8/30/23. MDS Nurse QQ reported that Resident #80's Significant Change of Condition MDS assessment on 9/15/23 should have indicated a new unhealed pressure ulcer. Review of Resident #80's Physician Progress Note dated 8/16/2023 revealed, .recently treated in the hospital for aspiration pneumonia sepsis .work-up in the hospital showed old multiple pelvic fractures, she was found to have a left heel pressure ulcer unstageable .Documentation reviewed .Plan: .Unstageable left heel ulcer with discharge-continue calcium alginate dressing . Review of Resident #80's Wound Doctor Consultation Note dated 8/30/23 revealed, .Assessment/Findings: Stage 3 pressure ulcer with possible arterial insufficiency .New Orders: 1. left foot/heel xray: r/o (rule out) osteomyelitis (inflammation in the bone that is caused by a skin infection) . In an interview on 02/29/24 at 10:33 AM, Wound Nurse (WN) Y reported that Resident #80 acquired wounds on both heels while in the facility; the left heel wound was identified on 6/21/23, and the right heel wound in September 2023. WN Y reported that both wounds are located over a bony prominence, and the interventions put in place were to offload pressure to promote healing. WN Y reported that she assessed the wounds weekly and the facility provider called them diabetic wounds, therefore, that is how they were documented. During an observation and interview on 02/29/24 at 11:04 AM, Resident #80 was sitting in her wheelchair in her room, wearing blue protective boots and her feet were laying turned outward. RN T reported that the wounds on Resident #80's heels have came a long way. Observation of Resident #80's right lateral (side) heel was an area of dark thickened skin approximately the size of a quarter. Observation of Resident #80's left lateral (side) heel was a thick dark brown scab approximately the size of a quarter. In an interview on 02/29/24 at 11:43 AM, Nurse Practitioner (NP) RR reported that Resident #80's heel wounds were classified as diabetic ulcers due to her history of diabetes, regardless of the location of the wound being over a bony prominence. NP RR reported that Resident #80 was not eating well and was not getting out of bed as much when the wounds started. NP RR reported that she does not always physically assess wounds, but she reviews the photos that the wound nurse takes, and was not able to recall when the last physical assessment was performed. NP RR reported that the bone scan and/or vascular work-up that was recommended by the wound clinic was not obtained due to the resident's general health at that time. In an interview on 02/29/24 at 01:10 PM, Unit Manager-Registered Nurse (UM-RN) Q reported that Resident #80 had developed areas of softness and redness on both heels in April of 2023, and that the facility implemented skin prep (protective skin treatment) and repositioning. UM-RN Q reported that Resident #80's left heel wound was discovered in June 2023 and then in September 2023 an additional wound was discovered on her right heel. UM-RN Q reported that Resident #80 was a diabetic and that any wound below the waist would have been diagnosed as a diabetic ulcer, and not a pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop person centered, comprehensive care plans for 2 residents (Resident #408 and Resident #82) of 22 sample residents reviewed for care planning, resulting in a potential for re-traumatization of a Resident with PTSD (post-traumatic stress disorder), and a potential for unmet care needs for a resident with an implanted medical device. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident 's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident 's written plan of care . Resident #408 Review of an admission Record dated 2/25/23 revealed Resident #408 was admitted to the facility with pertinent diagnoses that included: depression. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Inventory for Mental Status (BIMS) score of 15/15 which indicated Resident #408 was cognitively intact. Review of a current Care Plan for Resident #408 dated 9/14/23 revealed the focus, .Resident is at risk for/has an impaired mood/psychiatric status related to depression .with intervention the intervention .observe for signs of mood changes or distress . Review of a Social Services Progress Review dated 11/17/23 revealed section E (Trauma Informed Care, question 1, Does resident have a diagnosis of Post-Traumatic Stress Disorder (PTSD) .the documented answer: No. Review of a Nursing Progress Note documented on 12/31/23 at 7:23pm revealed Resident #408 sought out a nurse following an encounter with his roommate and stated, I have PTSD and I've had thoughts of hurting that son of a b*tch. The nurse documented Nursing Home Administrator (NHA) A was immediately informed. In an interview on 2/28/24 at 1:53pm, Registered Nurse (RN) L reported Resident #408 had several roommates in the past that he was not comfortable with, and that she learned the resident had PTSD (Post Traumatic Stress Disorder) from his military service when she talked with him. RN L reported Resident #408 told her that he had the urge to hit his former roommate when he awoke and saw his roommate standing over him. RN L reported the facility had several residents who received services from a governmental agency because they were disabled from military service. RN L confirmed that a resident with PTSD required person centered care to maintain their psychosocial wellness. In an interview on 2/28/24 at 3:36pm, Resident #408 sat on the edge of his bed, his eyes were directed downward throughout the interview and when asked, he confirmed was diagnosed with PTSD related to his service in the military. Resident #408 reported the roommate he had in December frequently invaded his personal space, sorted through his personal belongings, and appeared manipulative. Resident #408 reported on the evening of 12/31/23, he awoke and saw the roommate standing over him. Resident #408 stated it really upset me when I woke up and that guy was standing over me. It triggered me from my time in the service. Resident #408 reported he worried he would get another roommate that did similar things that would cause him to relapse with symptoms of PTSD. Resident #408 gestured toward his current roommate and stated I worry what kind of roommate I'll get when he leaves. I don't want to go through that situation again. In an interview on 2/29/24 at 9:34am, Care Coordinator (CC) II from the government agency that services to military veterans, reported Resident #408 should have person-centered interventions in place for his diagnosis of PTSD and without a proper care plan, the resident's psychosocial wellness may not be maintained. CC II reported it was likely Resident #408 would experience re-traumatization if he was placed with a roommate that exhibited the behaviors that had triggered his distress in December of 2023. In an interview on 2/29/24 at 2:01pm, Nursing Home Administrator (NHA) A confirmed she was notified that Resident #408 was upset with his roommate. NHA A reported the information the staff member reported did not clearly explain that Resident #408 was experiencing symptoms of PTSD and as a result, it was acted upon immediately or shared with social services. In an interview on 2/29/24 at 10:28am, Social Services Director (SSD) D reported she had reached out to the governmental agency involved in Resident #408's care and learned he had a diagnosis of PTSD. SSD D reported Resident #408 should have a care plan in place to outline interventions that would avoid further re-traumatization because without a care plan, Resident #408 could be assigned a roommate with the same types of behaviors that caused his distress in December. Review of an Active Problems list dated 2/28/24, generated by the governmental agency for military veterans, revealed Resident #408 had a diagnosis of chronic PTSD. R82 According to the Minimum Data Set (MDS) dated 1.17.24, R82 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) with diagnoses that included urinary tract infections within the last 30 days. During an interview on 2/27/24 at 2:13 PM, R82 reported she had been seen the day prior by an urologist regarding her InterStim (InterStim therapy implantable device for overactive bladder and urinary retention). During an interview on 2/28/2023 at 1:27 PM Licensed Practical Nurse (LPN) N stated, (R82) has a bladder stimulator. She came to the facility with it. She has been seeing a urologist while here and has another appointment in April (2024). Review of R82's Hospital Summary, 10/20/23 reported bladder stimulator. Review of R82's Nursing admission Evaluation 10/22/23 reported the resident was incontinent of bladder with no mention of a Interstim. Review of R82's Care Plan, 10/24/2023, reported the resident had impaired genitourinary status related to overactive bladder, urge incontinence, incontinence, and polyuria (abnormal large amounts of urine). The goal was to be free of altered genitourinary status. An internal bladder stimulator was not included in the resident's specific plan of care. Review of R82's Progress Note 1/3/2024 14:36 (4:36 PM) reported the resident has a bladder stimulator that per resident was non-functioning. Review of R82's Progress Note 1/4/2024 09:41 (AM), reported the facility received a phone call back from urology related to the bladder stimulator not functioning. Review of R82's 1/26/24 Urology Report reported the resident presented with urinary urgency and InterStim check that was not helping her with urinary symptoms. The resident had a prior history of InterStim stage I and II on 10/20/2018, InterStim lead removal and replacement on 9/25/2019, with InterStim battery pocket revision on 4/14/2021. Review of R82's Progress Note 1/29/2024 12:09 (PM) reported the resident went to follow up with urology; they did adjust her bladder stimulator and follow up in one month. Review of R82's Progress Note 2/28/2024 09:43 reported the resident went to follow up with urology on 2/27/24 to recheck her Interstim with talk of getting the device replaced. During an interview and record review on 2/29/24 at 10:29 PM, Director of Nursing (DON) B reviewed R82's medical record stating, There is no care plan for (R82's) InterStim in her bladder. That should be in the care plan to direct resident care. Every morning during the IDT (interdisciplinary team) meeting, if something is discussed that needs to be put in a care plan it is done then. If, outside of that meeting, something comes up any nurse can create or revise a care plan. It should be done. Review of facility policy Baseline Care Plan revised 1/1/2022, reported Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care . Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan . The facility may develop a comprehensive care plan in place of the baseline care plan . Review of facility policy Comprehensive Care Plan revised 6/30/2022, reported, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment (Minimum Data Set) . Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives . The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care . The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL) care was provided for 1 (Resident #6 ) of 2 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's dependent on staff for assistance. Findings include: Resident #6: Review of an admission Record revealed Resident #6 was a male with pertinent diagnoses which included dementia, dysphagia (difficulty swallowing foods or liquids), stroke, muscle weakness, diabetes, nutritional anemia (the body does not get enough iron or a few other nutrients from their diet), contracture of left hand, acute subdural hemorrhage (traumatic head injury, such as a blow to the head or a fall), idiopathic orofacial dystonia (involuntary, spasmodic movements of the muscles of the orofacial (mouth and face), masticatory (chewing muscles), and lingual (tongue) region and torticollis (rare condition which the neck muscles contract, causing the head to twist to one side). Review of current Care Plan for Resident #6, revised on 9/9/23, revealed the focus, .Resident has an ADL self-care performance deficit related to: Adult failure to thrive, tardive dyskinesia, to thrive, chronic pain, T2DM, prostate CA, schizophrenia, left hand contracture, muscle cramps, BPH (enlarged prostate gland), restless leg syndrome, incontinence, traumatic subdural hemorrhage, anxiety, anemia, GERD, IBS, vascular dementia, dysphasia . with the interventions .DRESSING: 1 person assist .PERSONAL HYGIENE: 1 person assist . Review of Minimum Data Set (MDS) dated [DATE], revealed, .A. Eating: Setup or clean-up assistance - Helper SETS UP or CLEANS UP; resident completes activity .F. Upper body dressing: ability to dress and undress above the waist .Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity . During an observation and interview on 2/27/24 at 2:35 PM, Resident #6 was self-ambulating in a wheelchair by using a hand railing on D Hall. Caught under his wheelchair was a yellow plastic Caution sign. His facial hair appeared to be unshaven with several days of growth for a reasonable person. His head was tilted towards his left shoulder. Housekeeping observed the caution sign and removed the sign. Resident #6 who was in his wheelchair next to his bed was observed with food on resident's face and in the folds of his sweatshirt on his chest. During an observation on 2/28/24 at 3:20 PM, Resident #6 was observed seated in his wheelchair by the nurse's station between the station and the wall heading towards the hallway entrance. He was observed leaning to the left side, moving his feet but was not self-propelling or ambulating anywhere. Resident #6 was observed to have 5-6 whole peas on the left chest area of his shirt with various dried food and liquids spilled on the left chest area of his shirt running down the front of his shirt. Resident #6's shorts were observed to have dried food scattered all over the front of his shorts, in his lap, and down the legs of the short. During and observation at 2/28/24 at 3:26 PM, Certified Nursing Assistant (CNA) AA walked past him and did not speak to him, offer assistance to propel him to his destination or make note of his soiled shirt and shorts and offer to get him cleaned up. CNA X walked past him as well and did not greet him, offer assistance to propel him in his wheelchair, or make note of his dirty shirt and short and offer to get him cleaned up. During an observation on 2/29/24 at 9:26 AM, Resident #6 was observed in his room seated in his wheelchair with his tray table and breakfast in front of him. He had the spoon in his right hand and was holding it in a bowl of oatmeal, he held the spoon in the bowl for a few moments and slowly brought it up to his mouth with his hand shaking and large pieces of oatmeal were falling of the spoon. It appeared his right hand was twisted to the inside of his wrist. Resident #6 leaned to the left while sitting in his wheelchair, head tilted forward appearing as if his left side of his jaw and chin were resting on his left shoulder/chest area. Resident #6 did not drool out the side of his mouth. In an interview on 2/29/24 at 9:29 AM, Licensed Practical Nurse (LPN) CC reported if Resident #6 soiled his clothing while eating, the staff would change his clothes. During an observation on 2/29/24 at 9:33 AM, this writer observed Resident #6 with chunks of oatmeal down the left side of his shirt into his vest down into the chest area. During an observation on at 2/29/24 at 12:22 PM, Resident #6 was observed sitting in his room in his wheelchair with oatmeal down the left front of the vest he was wearing. As he leans to the left, his clothing gathers on that side creating a concave space where food gathers. In an interview on 2/29/23 at 2:53 PM, Certified Nursing Assistant (CNA) OO reported Resident #6 when he needed cleaned up, never denied any care from him. CNA OO reported if you talk to him, explained what you wanted to do, he did not have any problems from Resident #6. CNA OO reported if he needed his shirt changed, he would let me change his shirt. In an interview on 2/29/23 at 2:54 AM, CNA NN reported she didn't have any problems with Resident #6. She reported if you approached him respectfully and let him know what you were doing, he wouldn't give her any problems, just need to explain to him and he would be receptive of care as she knows others have had issues with him. CNA NN reported Resident #6 allowed her to clean him up and to change his clothes as needed. In an interview on 2/29/24 at 02:37 PM, Director of Nursing (DON) B reported she would expect the nursing staff to assist Resident #6 with any personal hygiene he needed completed and if he had a soiled shirt and/or pants, she would expect the staff to assist him in cleaning up and changing the shirt and/or pants. Review of policy, Activities of Daily Living (ADLs) revised on 1/1/2022, revealed, .3. 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 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that a resident who was a trauma survivor received care and services that addressed their psychosocial needs in 1 of 3 residents reviewed (Resident #408) for trauma-informed care, resulting in Resident #408 experiencing emotional distress, and thoughts of physical aggression toward others. Findings include: Review of Key ingredients for Successful Trauma Informed Care published by the Substance Abuse and Mental Health Services Administration (SAMHSA), 2021, revealed trauma informed care acknowledges the need to understand a patient's life experiences to deliver effective care . Resident #408 Review of an admission Record dated 2/25/23 revealed Resident #408 was admitted to the facility with pertinent diagnoses that included: depression. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Inventory for Mental Status (BIMS) score of 15/15 which indicated Resident #408 was cognitively intact. Review of a current Care Plan for Resident #408 dated 9/14/23 revealed the focus, .Resident is at risk for/has an impaired mood/psychiatric status related to depression .with intervention .observe for signs of mood changes or distress . Review of a Social Services Progress Review dated 11/17/23 revealed section E (Trauma Informed Care, question 1, Does resident have a diagnosis of Post-Traumatic Stress Disorder (PTSD) .the documented answer: No. Review of a Nursing Progress Note documented on 12/31/23 at 7:23pm revealed Resident #408 sought out a nurse following an encounter with his roommate and stated, I have PTSD and I've had thoughts of hurting that son of a b*tch. The nurse documented Nursing Home Administrator (NHA) A was immediately informed. In an interview on 2/28/24 at 1:53pm, Registered Nurse (RN) L reported Resident #408 had several roommates in the past that he was not comfortable with. RN L reported she learned from the resident that he had PTSD (Post Traumatic Stress Disorder- a mental health condition triggered by a terrifying event with symptoms that may include flashbacks, uncontrollable thoughts, and anxiety) from his military service. RN L reported Resident #408 told her that he had the urge to hit his former roommate when he awoke and saw someone standing over him. RN L reported Resident #408 appeared upset about having thoughts of hurting someone. RN L reported the facility had several residents with prior military service, and all received services from a governmental agency because they were disabled from military service. In an interview on 2/29/24 at 11:29am, Registered Nurse (RN) L reported she did not know what trauma informed care was. RN L reviewed her education record and reported she completed computer-based learning for Trauma Informed Care within the last twelve months but did not recall any information from the training. In an interview on 2/28/24 at 2:41pm, Social Services Director (SSD) D reported Resident #408's only psychiatric diagnosis was depression. SSD D reported Resident #408 was a recipient of services from a government organization that cares for veterans who had a service-related disability, and the resident had a care coordinator from that organization. SSD D reported she had not communicated with the care coordinator to determine if Resident #408 had a diagnosis of PTSD. SSD D also reported she was not aware of the situation that arose between Resident #408 and his roommate on 12/31/23. In an interview on 2/28/24 at 3:36pm, Resident sat on the edge of his bed, with his eyes directed downward and when asked, he confirmed he had a diagnosis of PTSD related to his service in the military. Resident #408 reported the roommate he had in December frequently entered his personal space, sorted through his personal belongings, and appeared manipulative. Resident #408 reported on the evening of 12/31/23, he awoke and saw the roommate standing over him. Resident #408 stated it really upset me when I woke up and that guy was standing over me. It triggered me from my time in the service. Resident #408 reported he worried he would get another roommate that did similar things and that would cause him to relapse with symptoms of PTSD. Resident #408 gestured toward his current roommate and stated I worry what kind of roommate I'll get when he leaves. I don't want to go through that situation again. In an interview on 2/29/24 at 9:34am, Resident #408's Care Coordinator (CC) II from the government agency, reported Resident #408 had a diagnosis of chronic PTSD related to war-time combat. CC II reported Resident #408's PTSD was significant and caused 50% of his status of being disabled. CC II reported her agency provided a diagnosis list for each resident at the time of their admission, and that a thorough assessment of a resident by the facility was important to provide adequate care. CC II reported the facility was responsible for the resident's care, should have known if a resident had a diagnosis of PTSD, and should have implemented interventions to avoid re-traumatization. CC II stated implementation of interventions to avoid re-traumatization would minimize the risk of (Resident #408) experiencing a psychosocial decline. Review of an Active Problems list dated 2/28/24, generated by the governmental agency for military veterans, revealed Resident #408 had a diagnosis of chronic PTSD. In an interview on 2/29/24 at 10:28am, Social Services Director (SSD) D reported she had reached out to the government agency involved in Resident #408's care and learned he had a diagnosis of PTSD. SSD D reported it was her responsibility to ensure residents were paired with roommates that would be the most compatible, and that she should have been informed of the situation that arose between Resident #408 and his previous roommate. SSD D reported Resident #408 should also have a care plan in place to provide interventions that would mitigate his PTSD triggers, including roommates with certain behaviors. Review of Room Change Record revealed Resident #408 moved to another room on 1/3/24, 2 days after he voiced concern that he might harm his roommate because his PTSD was triggered by the roommate's actions. Review of a facility policy titled Trauma Informed Care with a reference date of 10/24/22 revealed .Potential causes of re-traumatization by staff may include .being unaware of the resident's traumatic history .failing to provide adequate safety . Review of a facility policy titled Trauma Informed Care with a reference date of 10/24/22 revealed .Potential causes of re-traumatization by staff may include .being unaware of the resident's traumatic history .failing to provide adequate safety .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to discontinue psychotropic medications prescribed as needed (PRN), after 14 days and/or document rationale to extend prn psychotropic medication use in 1 of 5 residents (Resident #80) reviewed for unnecessary medications, resulting in the potential for adverse side effects and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: Resident #80 Review of an admission Record revealed Resident #80 was originally admitted to the facility on [DATE], with pertinent diagnoses which included, alzheimer's disease. In an interview on 02/28/24 at 10:26 AM, Family Member (FM) SS reported that Resident #80 had anxiety in the afternoon, and that the facility applied a cream to calm her down. FM SS reported that it was her understanding that the cream had not been working, and that was why the resident was being prescribed an new antidepressant medication. Review of Resident #80's Medication Orders revealed, Ativan gel 0.5mg/1 ml .every 4 hours as needed for agitation/aggression related to Alzheimer's disease . Start date 8/15/2023. There was no end date on the order. In an interview on 02/29/24 at 10:21 AM, Unit Manager (UM) Q reported that Resident #80 had frequent behaviors, and had a current order for PRN Ativan, that had been in place for greater than 14 days, with no end date. UM Q reported that Resident #80 had used the PRN Ativan 12 times in the month of February. UM Q did not know the physician's rationale for writing the PRN Ativan order. In an interview on 02/29/24 at 11:36 AM, Nurse Practitioner (NP) RR reported that the facility should be writing PRN orders for Ativan for 14 days and then reevaluating the need. NP RR reported that she wrote Resident #80's order for the PRN Ativan and did not document a rationale or duration for the medication. NP RR reported that she did not know when Resident #80 was last evaluated, and did not regularly document about Ativan, because the resident saw psychiatry and behavioral health services to manage the medication. Review of Resident #80's Psychiatry Progress Notes from 7/10/23 through 1/8/24 did not list Ativan in the past, current and/or recommended medication lists. There were no notes related to Ativan. Review of Resident #80's Behavioral Health Notes from 8/7/23 through 1/23/24 did not list Ativan in the past, current and/or recommended medication lists. There were no notes related to Ativan. Review of Resident #80's Monthly Medication Regimen Reviews since August 2023 did not indicate any irregularities related to the PRN Ativan orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** In an interview on 2/27/24 at 9:17am, Nursing Home Administrator (NHA) A reported one resident (Resident #408) tested positive for Influenza A that morning and he and his roommate (Resident #409) were in quarantine. The residents in quarantine were in Room C13. NHA A reported droplet precautions were in effect for those residents. During an observation on 2/27/24 at 11:05am, a 9x11 brightly colored sign that stated :Special Droplet Precautions, Everyone must clean hands when entering, wear mask, wear eye protection, gown and glove at the door hung on the door frame of room C13. A personal protective equipment (PPE) cart was in the hallway under the sign. During an observation on 2/27/24 at 11:14am, Occupational Therapist (OT) FF and Certified Nursing Assistant (CNA) J entered room C13 without donning any PPE. The staff members assisted Resident #409 out of bed and into a standing position. Resident #409 then walked into the hallway as OT FF walked alongside and held on to a gait belt that was wrapped around Resident #409's waist. Neither Resident #409 or OT FF wore any PPE until they had walked at a slow pace, approximately 50' down the hallway. CNA J then donned a surgical mask onto the resident's face. The resident pulled the mask below his nose, exposing his nostrils throughout the remainder of the time he was in the hallway, approximately 7 minutes. Several residents and staff nearby in the hallway at the time. In an interview on 2/27/24 at 11:19am, CNA J reported one of the residents in room C13 had tested positive for Influenza A that morning and as a result, both residents were in quarantine. CNA J reported she should have donned a mask, eye protection, gloves, and a gown prior to entering the room. In an interview on 2/27/24 at 11:21am, OT FF reported she overlooked the infection control precautions sign on the door frame of room C13 and that she should have donned a mask, gloves, eye protection, and gown prior to entering the room. OT FF reported Resident #409 should have worn a mask during the time that he was in the common area/hallway to reduce the risk of other resident's contracting influenza. OT FF confirmed that her lack of use of PPE for herself, and lack of proper use of PPE for Resident #409 were breaches of the facility's infection control process and could result in further spread of illness. In an interview on 2/29/24 at 12:47pm, Infection Preventionist (IP) Y reported both residents in Room C13 were under droplet precautions effect approximately 9:00am on 2/27/24. When queried about how staff were informed when infection control precautions were implemented, IP Y reported staff were educated via word of mouth although therapy staff may not have been informed and it was difficult to educate everyone in this manner. IP Y reported it was the expectation that staff would look for infection control signage posted near resident doors before they entered a room. IP Y confirmed that the lack of use of PPE by OT FF and CNA J, as well as taking an unmasked resident under droplet precautions into a common area, were breaches of the facility's infection control processes. Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed to ensure 1). proper hand hygiene was performed during brief change for one resident (R89), 2). adequate condition for cleanliness of personal equipment (R89), and 3). appropriate PPE (Personal Protection Equipment) use in a Transmission-Based Precautions Isolation room, of 22 residents reviewed for infection control, resulting in the potential for bacterial harborage, cross contamination, and the spread of disease to a vulnerable population. Findings include: R89 According to the Minimum Data Set (MDS) dated [DATE], R89 scored 2/15 on her BIMS (Brief Interview Mental Status) indicating the resident was severely cognitively impaired. The resident had no impairment in her arms or legs with diagnoses that included Alzheimer's disease. Hand Hygiene During an observation and interview on 2/27/24 at 10:49 AM, Certified Nursing Assistant (CNA) DD entered R89's room with CNA W to perform a brief change. CNA DD donned (applied) gloves without performing hand hygiene. R89 had a small bowel movement (BM) in her brief along with urine. CNA DD used wipes to clean the resident's BM and private area with CNA W assisting. Without changing gloves after cleaning the soiled areas, CNA DD applied a clean brief, clean clothes, and a mechanical lift sling to R89. CNA DD then doffed (removed) gloves, touched the resident's privacy curtain and moved a bedside table to the hall. CNA W removed her gloves, and without performing hand hygiene, took the bag of soiled items to the soiled utility room. CNA DD and W then transferred R89 from her bed to a wheelchair. Both CNAs searched R89's dresser and bed area for geri-sleeves (slide on protection against skin tears). CNA DD found the geri-sleeves on the floor and put them on the resident reporting the sleeves should be put in the wash after using them that day and finding them on the floor. During an interview on 2/27/24 at 10:49 AM, CNA W stated, Hand hygiene should be done when entering and leaving a resident's room, and when gloves become soiled during a brief change. During an interview on 2/27/24 at 1:41 PM, CNA DD stated, Hand hygiene should be done after changing a soiled brief and putting residents in clothing. During an interview on 2/29/24 at 2:02 PM, Nursing Home Administrator (NHA) A and Director of Nursing (DON) B stated, Hand hygiene should be done when staff enter and exit a resident room. During soiled brief changing, hand hygiene and changing out gloves should be done after the dirty brief is handled. Hands should be cleaned and new gloves put on before touching a clean brief, clothing, bedding; anything. Staff have been educated on hand hygiene. NHA A stated, Hand hygiene should be done during brief changing for infection control purposes. PERSONAL EQUIPMENT Observed on 2/27/24 at 10:40 AM, R89 was in bed with the right side against the wall. A recliner positioned to the left side of the resident's bed was torn and tattered on the footrest underneath where the resident would place her feet with foam exposed across the entire end of it. The right arm of the chair was also torn and tattered with exposed foam. Observed on 2/27/24 at 1:42 PM, R89 was in bed with the right side against the wall. A recliner positioned to the left side of the resident's bed was torn and tattered on the footrest underneath where the resident would place her feet with foam exposed across the entire end of it. The right arm of the chair was also torn and tattered with exposed foam. During an observation and interview on 2/29/24 at 11:30 AM, Nursing Home Administrator (NHA) A stated while touring R89's room with surveyor, I was told by a nurse yesterday that (R89's) recliner was torn with the foam coming out of it. I think when she sits up in it her feet rub on the bar in the footrest and has put the tear in it. Observed R89 sitting in the chair with the footrest extended. The resident's feet were not in the same area of the tear and protruding foam. The right arm of the chair was torn at the end with foam exposed and sticking out. The left arm of the chair was tattered. The NHA stated, The footrest has been repaired before either with staples or sewn. It would be an infection control concern if something was spilled on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation on 2/28/24 at 2:57 PM, outside of room A15 there was a Sit to stand and the handles the residents grabbed had soiling in the grooves of the bumps for grips on the handles. The footrest had dirt and debris on it and there were bunches of brown hair wrapped in the back wheel on left side. Resident #91: Review of an admission Record revealed Resident #91 was a male with pertinent diagnoses which included cerebral infarction (disrupted blood flow to the brain cells deprives them of oxygen), traumatic brain injury with loss of consciousness (Note: pedestrian struck by vehicle), contracture right ankle, oral cancer, and fracture of thoracic vertebrae (bone in the spine collapses creating a compression fracture). Review of current Care Plan for Resident #91, revised on 12/17/23, revealed the focus, .Resident has an ADL self-care performance deficit related to: cerebral infarction, hx of intracerebral hemorrhage . with the intervention .Resident dependent on broda chair for locomotion throughout facility with staff assistance . During an observation of the resident equipment storage area across from the nurse's station on 2/28/24 at 2:58 PM, there was a sit to stand with the letter A on the base on the right side which had white dried liquid streaking down the sides of the base with dirt and the extended piece which held the handles had the dried white liquid on it, and debris on the footrest. There were purple wipes hanging from the side of the machine in a clear plastic bag with drawstring. A broda chair had dried brown dirt appearing material on the headrest where the head layed, the padding on both sides of the head rest area, the armrest had dried brown material appearing like dirt. There was dried white/pinkish material on the outside of the cloth in the hip area on the left side. It had a tag on the bag which indicated it was Resident #91. Resident #78: Review of an admission Record revealed Resident #78 was a female with pertinent diagnoses which included history of traumatic fracture, dependence on wheelchair, muscle weakness, and need for assistance with personal care. During an observation of the resident equipment storage area across from the nurse's station on 2/28/23 at 2:59 PM, observed a high back wheelchair with a black pad on the seat which which had splatters of white speckles spread about the seat, the back of the head area had white dried speckles as well. A tag revealed it was for Resident # 78. Resident #76: Review of an admission Record revealed Resident #76 was a female with pertinent diagnoses which included reduced mobility, muscle weakness, contracture of left foot, disorders of tendon right ankle and foot, disorders of tendon left ankle and foot, and wernicke's encephalopathy (neurological condition, life threatening illness caused by thiamine deficiency which primarily affects the peripheral and central nervous system). During an observation of the resident equipment storage area across from the nurse's station on 2/28/24 at 3:03 PM, observed a broda chair had white dried food material on the seat pad. There was a blue/black foot boot lying in the seat. The wheelchair frame had dust, dirt, and debris on the entirety of the frame. The black foam on the handles were coated in a brown/tan material. The tag on the broda chair indicated it was for Resident #76. Resident #48: Review of an admission Record revealed Resident #48 was a female with pertinent diagnoses which included paralysis on right side following a cerebral infarction, adult failure to thrive, dependence on wheelchair, contracture of right knee, contracture of left knee, monoplegia of upper right limb (type of paralysis that impacts one limb). During an observation of the resident equipment storage area across from the nurse's stationon 2/28/24 at 3:05 PM, observed a broda chair with dried dirt and debris on the left side of the chair with dried liquid running down the side of the chair. The footrest area had dried brown material on the outside padding on the left side. There was dirt and debris on the frame of the chair. The tag on the handle revealed the chair belonged to Resident #48. Resident #42: Review of an admission Record revealed Resident #42 was a male with pertinent diagnoses which included paralysis on left side following cerebral infarction, charcot's joint, right ankle and foot (chronic devastating and destructive disease of the bone structure and joints in patients with neuropathy), neuropathy (weakness, numbness, and pain from nerve damage), muscle spasm, reduced mobility, and dependence on wheelchair. During an observation on 2/28/24 at 3:10 PM, observed a wheelchair in the hallway outside of Resident #42's room which had a black pad on the seat with crumbs, dirt, and debris on it with those located under the black seat pad as well. The padded arm rests also had scattered pieces of white debris on them. The band on the wheelchair indicated it was Resident #42's chair. Resident #63: Review of an admission Record revealed Resident #63 was a male with pertinent diagnoses which included reduced mobility, chronic pain, muscle spasm, sciatica nerve pain (lower back area), carpal tunnel syndrome, pain in right arm, stroke, muscle weakness, paralysis affecting right side, and spina bifida (birth defect spinal cord failed to develop properly). During an observation on 2/28/24 at 3:11 PM, observed the wheelchair for Resident #63 in the hallway outside of his room and it had dust/ dirt on the frame of his power chair behind the seat pad there was dust, dirt, and white specks. The entire frame was covered in dirt and debris. On the front of the black seat pad there was dried orange/red liquid/food material. During an observation on 2/28/24 at 3:07 PM Outside of Room B1 there were dried brownish/dark grey liquid streaks down the lower wall. There was noted to be no hand sanitizer dispenser at this location. In an interview on 2/29/24 at 10:45 AM, Certified Nursing Assistant (CNA) J reported the resident wheelchairs were cleaned by third shift CNAs. She reported there was a schedule at the nurse's station which would indicate what the schedule was. In an interview on 2/29/24 at 2:30 PM, Director of Nursing (DON) B reported the third shift CNAs were responsible for cleaning the resident equipment. Review of the 3rd Shift CNAs to do list on 2/29/24 revealed, .Clean all lifts .Wash wheelchairs and walkers as assigned . Review of policy, Routine Cleaning and Disinfection revised on 2/1/22, revealed, .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible . In an observation on 02/27/24 12:05 PM, in room B-10 noted the wall on the right side of the room near the head of the beds, the rubber trim at the bottom of the wall was not attached and hanging off of the wall, which revealed crumbled paint and dirt. During a tour of the facility, starting at 2:05 PM on 2/27/24, observation of the C hall linen closet floor found excess accumulation of debris, used gloves, trash, and dust. An interview with Housekeeping Manager HH found that her staff did not know the code to the closets in order to clean them. During a tour of the D hall, at 2:17 PM on 2/27/24, found that the linen closet floor was found with an excess accumulation of debris, including trash, used gloves, and dust. During a tour of the A hall medical supply closet, at 2:39 PM on 2/27/24, found an excess accumulation of debris on the floor, including paper wrappers, used gloves, and dust. During a tour of the Beauty Shop, at 2:43 PM on 2/27/24, it was observed that the sprayer used for washing and rinsing hair was hanging below the overflow rim of the sink and was found to not have a proper backflow prevention device, such as an atmospheric vacuum breaker. During a tour of the B hall spa room, at 2:47 PM on 2/27/24, it was observed that no shower head was located on the shower and excess black rubber and plastic debris was observed in the corner of the shower, on the walls, and on the shower ledge next to the sink. Observation of the shower floor found some missing tiles and grout. Further observation of the spa room found the cabinet to the left of the sink was observed with heavy deterioration of the surface inside of the cabinet allowing for flaking of wood particles and not allowing for a smooth and easily cleanable surface. An interview with Maintenance Director S found that staff use this area to pressure wash wheel chairs and give resident showers. R89 According to the Minimum Data Set (MDS) dated [DATE], R89 scored 2/15 on her BIMS (Brief Interview Mental Status) indicating the resident was severely cognitively impaired. The resident had no impairment in her arms or legs with diagnoses that included Alzheimer's disease. Observed on 2/27/24 at 10:40 AM, R89 was in bed with the right side against the wall. The walls next to the bed were in disrepair as evidenced by gouges in the wall and large pieces of missing sheetrock material, and holes covered with patches painted in a different color. A recliner positioned to the left side of the resident's bed was torn and tattered on the footrest underneath where the resident would place her feet with foam exposed across the entire end of it. The right arm of the chair was also torn and tattered with exposed foam. Observed on 2/27/24 at 1:42 PM, R89 was in bed with eyes open with the right side of the bed against the wall. The wall was in disrepair missing sheetrock material with large gouges. Higher on the wall were multiple holes covered with patches in different colors. The recliner next to her bed was torn and tattered on the footrest with foam exposed and hanging out of it. The tear was on the bottom of the footrest and not where the resident places her feet. The right arm of the chair had a hole at the end with foam exposed and sticking out. The left arm of the chair was tattered. Observed on 2/29/24 at 11:00 AM, R89 was in bed with eyes open with the right side of the bed against the wall. The wall was in disrepair missing sheetrock material with large gouges. Higher on the wall were multiple holes covered with patches in different colors. The recliner next to her bed was torn and tattered on the footrest with foam exposed and hanging out of it. The tear was on the bottom of the footrest and not where the resident places her feet. The right arm of the chair had a hole at the end with foam exposed and sticking out. The left arm of the chair was tattered. During an observation and interview on 2/29/24 at 11:30 AM, Nursing Home Administrator (NHA) A stated while touring R89's room with surveyor, I was told by a nurse yesterday that (R89's) recliner was torn with the foam coming out of it. I think when she sits up in it her feet rub on the bar in the footrest and has put the tear in it. Observed R89 sitting in the chair with the footrest extended. The resident's feet were not in the same area of the tear and protruding foam. The right arm of the chair was torn at the end with foam exposed and sticking out. The left arm of the chair was tattered. The NHA stated, The footrest has been repaired before either with staples or sewn. Observed with NHA R89's wall next to her bed. NHA stated, Oh, I had no idea that wall was like that. That is bad. I will tell Maintenance about it. Based on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting residents in following areas: Findings include: In an observation on 2/27/24 at 11:01 AM., noted both privacy curtains in room A-3 were visibly soiled in various areas with dark stains, and an overall soiled/dirty appearance. Bed 1 had multiple missing hanging hooks where the privacy curtain was not attached to the ceiling slide runner, which left the privacy curtain unattached and hanging down. In an observation on 2/27/24 at 11:13 AM., noted both privacy curtains in room A-8 were visibly soiled in various areas with dark stains, and an overall soiled/dirty appearance. In an observation on 2/27/24 at 11:39 AM., noted the floor in room A-11 bed 2 had multiple random medical supply items scattered underneath and next to the bed. The top of a nebulizer-machine was noted on the floor, multiple single use normal saline (NS) tubes also on the floor and underneath bed 2. The floor in A-11 had multiple areas dried liquid spillage, food crumbs, random pieces of paper-wrappers. While walking and observing room A-11 the floor was noted to be sticky on the soles of this surveyors shoes. In an observation on 2/28/24 at 2:42 PM., noted a sit to stand lift in an alcove between the C/D halls. The base of the lift was noted to be soiled with dust, debris and food crumbs. The knee pad (where resident legs are stabilized) was noted to have a dried white substance stuck on the surface in various areas of the knee pad. In an observation on 2/28/24 at 3:01 PM., noted a hoyer lift parked next to room D-11 The mechanical portion of the lift was noted to have multiple areas of dried stuck on substances that resembled dried food. The base of the lift had an area of what appeared to be a substance which resembled yellow dried stuck on urine. During an interview on 2/28/24 at 3:04 PM., Certified Nurse Aide (CNA) PP reported CNA staff and or any nursing staff are to sanitize all resident shared equipment before and after each use. CNA PP reported she was unsure if the resident lifts, wheelchairs, walkers and canes get deep cleaned on a regular basis. CNA PP reported there was no log book or audit type documentation that staff use to document these resident shared items, and or who would be responsible for the deep cleaning. During an interview on 2/28/24 at 3:18 PM., Registered Nurse (RN) L reported nursing staff (both CNA/Nurses) were responsible for ensuring resident shared equipment was sanitized before and after each use. RN L reported whenever a staff member notices something soiled or not working properly staff are responsible to clean up anything they made a mess of, and or if time was an issue the staff should be requesting assistance from housekeeping/maintenance. RN L reported she was unaware of any audit tool, deep cleaning documentation or log book of resident shared equipment, wheelchairs and any other deep cleaning schedule for those items. RN L reported when assisting residents with care, meals, and Activity of Daily Living (ADL's) that specific staff was expected to clean up after themselves, and the resident. In an observation on 2/28/24 at 3:21 PM., noted in room D-3 bed 1 (which was positioned against the wall) had large gouges out of the drywall/sheet-rock. The paint was chipped off from what appeared to be from the bed being raised and lowered coming into contact with the wall. Noted near bed 1 was what appeared to be a dark substance smeared on the wall, the substance appeared to be dried food or fecal matter. In an observation on 2/28/24 at 3:36 PM., noted the hand rails on the D hall were heavily soiled with dried stuck on substances. The hand rails were noted to be painted with the tan paint which was chipping off (along the entire hallway both sides of the walls) exposing the old original color of deep purple. Noted the handrail on the right hand side of the D hall near room D-10 was missing the end cap exposing sharp edges. In an observation on 2/28/24 at 3:55 PM., noted the floor in room A-11 bed 2 had multiple random medical supply items scattered underneath and next to the bed. The top of a nebulizer-machine was noted on the floor, multiple single use normal saline (NS) tubes also on the floor and underneath bed 2. The floor in A-11 had multiple areas dried liquid spillage, food crumbs, random pieces of paper-wrappers. While walking and observing room A-11 the floor was noted to be sticky on the soles of this surveyors shoes. During an interview on 2/29/24 at 10:24 AM., Housekeeper (Hsk) JJ reported resident rooms are suppose to be cleaned/sanitized daily including all commonly used equipment, bed side tables, night stands, windowsills, remote controls for call lights, beds and TV's. Hsk JJ reported resident room floors should be swept and mopped daily, and and the entire bathroom.

Based on observation and interview, the facility failed to provide a safe hand railing on Dogwood Trail, resulting in the potential of injury, affecting all residents with the need of handrail assistance while on that hall, a safe way to stabilize or propel themselves. Findings include: Observed on 2/27/24 at 2:48 PM, the metal hand railing ending at room D10 on Dogwood Trail with a broken and sharp end. During an observation and interview on 2/29/24 at 10:00 AM, Maintenance Director S stated, I have three other buildings besides this one. Observed the hand railing outside of room D10 on Dogwood Trail. Maintenance Director stated, There is no end cap. I would expect the nurses to tell me about this one. It has exposed metal edges. All that needs is an end cap.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report and injury of unknown origin in 1 of 1 residents (Resident #100) reviewed for abuse reporting resulting in the potential for further injuries to go undetected , and not reported and/or thoroughly investigated. Findings include: Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic respiratory failure. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 11/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #100 was cognitively intact. Review of Resident #100's Incident/Accident: report dated 8/29/23 at 10:00 AM., revealed: Nursing Description: Resident complained of left leg pain On 08/28/23 a tib/fib x-ray was ordered with results noting Obliquely oriented fracture through the mid distal tibial shaft Resident Description: -Do you remember anything happening to your leg? No-Did something hurt your leg? No Do someone hurt your leg? No, .It hurts when they turn me. Injuries Observed at Time of Incident . Location Injury Left lower leg (front) . Type Injury Bruise Fracture .Location Left lower leg (front) In an interview/observation on 12/5/23 at 12:10 PM., Resident #100 reported she broke her left leg somehow. Resident #100 reported she is unsure how it happened, but it hurt and she had to wear a boot like cast for a while Resident #100 reported she does not walk, and needs to be transferred to and from her bed, to the shower, her wheelchair and activities when she attends them. In an interview on 12/5/23 at 12:35 PM., Certified Nurse Aide (CNA) G reported (Resident #100) had some kind of injury to her left leg about 3-4 months ago. CNA G reported no one knows exactly what happened, but staff and management think her leg possibly was twisted or hit during a hoyer lift. CNA G reported she (Resident #100)had an X-ray done, and it revealed a fracture in her lower left leg/ankle. CNA G reported (Resident #100) had to wear a hard boot for a while, she (Resident #100) did not have a normal type hard cast. here was an injury to her left leg, in about September, the doctor order a hard boot. In an interivew on 12/7/23 at 1:45 PM., Nursing Home Administrator (NHA) A reported she did not report the injury of unknown origin to the State Agency. NHA A reported she and the staff were unsure of exactly what happened to (Resident #100's) lower left leg back in late August 2020. NHA A reported there was a possibility that when she (Resident #100) attended an activity, she was lifted with a hoyer lift into her wheelchair, and later that week started to report her (Resident #100's) leg was in pain. NHA A reported an X-ray indicated a spiral fracture. NHA A reported she was unsure that an injury of unknown origin needed to reported. Review of a facility Policy with a revision date of 1/1/22 revealed: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. B .Possible indicators of abuse include, but are not limited to:1. Resident, staff or family report of abuse . 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident ' s body .3 .Physical injury of a resident, of unknown source .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to perform an assessment or obtain a physician order for self-administration of medication for 3 residents (Resident #41, #42, and #59), of 30 Residents reviewed for self-administration of medications, resulting in the mismanagement of medications with a likelihood for adverse side effects. Findings include: Resident #41: Review of an admission Record revealed Resident #41 was a female with pertinent diagnoses which included intellectual disabilities, dementia with behavioral disturbances, and Alzheimer's disease. Review of a Minimum Data Set (MDS) assessment for Resident #41, with a reference date of 2/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated Resident #41 was severely cognitively impaired. Review of current Care Plan for Resident #41, revised on 2/26/23, revealed the focus, .The resident has yeast under bilateral breasts, a blanchable reddened area to the middle back .10/11/22 . with the intervention .Administer treatments as ordered by MD/NP (physician/nurse practitioner) . Review of Order dated 2/10/23, revealed, .Apply antifungal powder to left underarm .every 8 hours as needed for Rash . Review of Resident #41's record revealed, Resident #41 did not have an assessment on record indicating the resident was safe to self-administer medications. Review of Nursing readmission Evaluation dated 8/1/22, revealed, .Does the resident wish to self- administer medications .No . During an observation on 2/27/23 at 2:03 PM, observed antifungal powder on Resident #41's window ledge next to her bed. During an observation on 2/27/23 at 3:25 PM, observed antifungal powder on Resident #41's window ledge next to her bed. Resident #42: Review of an admission Record revealed Resident #42 was a male with pertinent diagnoses which included chronic obstructive pulmonary disease (COPD), respiratory failure, diabetes, schizophrenia, and bipolar disorder. Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 1/5/23 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated Resident #42 was severely cognitively impaired. Review of Orders dated 2/12/23, revealed, .Breo Ellipta Aerosol Powder Breath Activated 100-25 MCG/INH (Fluticasone Furoate-Vilanterol) .1 puff inhale orally in the morning related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED . Review of Nursing readmission Evaluation dated 2/11/23, revealed, .Does the resident wish to self- administer medications .No . Review of Resident #42's record revealed, Resident #42 did not have an assessment on record indicating the resident was safe to self-administer medications. During an observation on 3/2/23 at 9:30 AM, Resident #42 was lying in his bed, head covered with a blanket, leaning against the wall on his left side. Observed the Breo Ellipta Aerosol Powder Breath Activated, dialed to 1.9 with his name on it, lying on the rolling bedside table which was pulled over the top of the bed with no nurse present in the room. During an observation on 3/02/23 at 10:16 AM, Resident #42 was leaning to the left side covered his head with the blanket, head was on the wall, his Breo Ellipta Aerosol Power Breath Activated, dialed to 1.9 name on it, it was on his rolling table in front of him with no nurse present in the room. In an interview on 3/7/23 at 1:20 PM, Licensed Practical Nurse (LPN) EE reported on the resident's admission the admitting nurse would make note in the Admissions Assessment on whether the resident would like to self-administer medications as well as an additional assessment would be completed to determine if the resident was competent to self-administer medications. Resident #59 Review of an admission Record revealed Resident #59 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic obstructive pulmonary disease (COPD) (lung disease that blocks airflow and makes it difficult to breathe.) Review of a Minimum Data Set (MDS) assessment for Resident #59, with a reference date of 12/10/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #59 was cognitively intact. During an observation and interview on 02/28/23 at 01:18 P.M. Resident #59 was lying in her bed and there was an Albuterol (medication that increases flow of air through the lungs) Inhaler observed on the over the bed table, an oxygen concentration machine set at 2L (liters) running at the bedside, and Resident #59 was observed receiving oxygen via nasal cannula (device used to deliver oxygen). Resident #59 reported that she did not know if she was supposed to have oxygen all the time, but that she always used it when she was in her room and stated, .and I have my inhalers right here .they (facility) want me to do that myself .I use it 3 times a day or more .whenever I want . Resident #59 presented the Albuterol Inhaler to this surveyor, and it was observed almost empty, and with no open date. Resident #59 then presented a second Albuterol Inhaler to this surveyor, it was also observed used, and without an open date. Resident #59 held up the second Albuterol inhaler and stated, .I keep this one on me when I go outside . Resident #59 reported that facility staff had taken her oxygen away, but that they had to give it back due to her oxygen levels dropping recently. Review of Resident #59's Medication Administration Record (MAR) for the month of February 2023, indicated orders for Ventolin (Albuterol) inhaler 2 puffs every 6 hours as needed for SOB (shortness of breath)/wheezing related to COPD with a start date of 2/1/23. There were no checks or staff initials to indicate that the inhaler was used for the entire month of February, and did not indicate self-administration. Review of Resident #59's Care Plan revealed, The resident has alteration in respiratory status related to COPD, and a history of COVID-19, chronic cough, nose, bleeds, history of oxygen dependence. Date initiated, 3/23/2022. Revision on 2/14/2023. Interventions: administer medication as ordered by MD/NP (physician/nurse practitioner), See MAR (medication administration record). Date initiated 09/27/2022. Monitor for difficulty breathing (dyspnea) on exertion. Remind resident not to push beyond endurance. Monitor for s/sx (signs and symptoms) of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest, somnolence. Monitor/Document report PRN (as needed) to MD/NP any s/sx of respiratory infection .Date initiated 03/23/2022. Review of current care plan on 2/28/2023 did not include self administration use of inhalers. In an interview on 03/01/23 at 11:31 A.M., Registered Nurse (RN) DD reported that Resident #59 self administers Albuterol inhaler and stated, I don't know how often she uses it .she regulates it herself .it's ordered PRN (as needed) . RN DD reported that she would only document administration of Resident #59's Albuterol inhaler if the resident reported to have used it. RN DD reported that Resident #59 did not have an assessment on record indicating that she is safe to self administer medications, the order did not include self administration, and her care plan does not indicate self administration of her Albuterol/Ventolin inhaler. Review of Nurse's Note dated 3/1/2023 at 19:22 (7:22 P.M.) revealed, (NP YYY) notified of the Resident's (Resident #59) request to use her inhaler at bedside and is in agreement at this time. Review of Self Administration of Medications Evaluation of Resident's Ability dated 3/1/2023 at 21:37 (9:37 P.M.) revealed, .Initial Evaluation .Ventolin .Able to safely self-administer . In an interview on 03/06/23 at 12:37 P.M., CNA X reported that Resident #59 is not supposed to have her inhalers and stated, .the nurses leave them in her room and the resident is supposed to call and let us know when she uses it, then we take them to the nurse .sometimes I find a few inhalers in the room at a time . In an interview on 03/06/23 at 01:42 P.M. Resident #59 reported that the facility removed her Albuterol/Ventolin inhalers that she had last week in her room and gave her a new one to use on her own and stated, .they talked to me about how to use it . Review of an anonymous complaint to the State Agency received on 10/30/22 indicated that facility staff were refusing to administer an inhaler to Resident #59.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure the Resident Council group was afforded a private space to meet, resulting in a reluctance to voice concerns and grievances not being discussed confidentally. Findings include: In a confidential Resident Council meeting on 3/1/23 at 3:00pm, 6 of 8 Residents in attendance voiced concern that the meetings are not held in a private space. The Residents reported the meetings are always held in the dining room and as a result, dietary staff come through the area during their meetings. 2 of 8 Residents reported they did not feel comfortable sharing concerns at the meetings due to the lack of privacy. During an observation of the Resident Council meeting on 3/1/23 at 3:00pm, dietary staff walked through the room [ROOM NUMBER] times. Some Residents stopped speaking about their concerns when staff arrived.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00133261. Based on interview and record review, the facility failed to perform a complete assessment after a fall, and notify the physician and emergency contact for 1 resident (Resident #304) of 7 residents reviewed for notifications, resulting in the lack of pain management and a delay in care of a thoracic spine (mid-back) fracture. Findings include: Resident #304 Review of an admission Record revealed Resident #304 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: history of falling and fracture of left femur (upper leg). Resident #304 discharged on 12/3/22. Review of a Minimum Data Set (MDS) assessment for Resident #304, with a reference date of 11/16/22 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #304 was cognitively intact. In an interview on 2/27/22 at 10:02 A.M., Family Member (FM) IIII reported that Resident #304 sustained a fall with major injury on 11/28/22, and the facility failed to notify her of the fall. FM IIII reported that she was told by the Director of Nursing (DON) that Resident #304 was aware and therefore FM IIII did not need to be contacted. FM IIII was frustrated because the facility required her to sign all the paperwork upon admission, and require her authorization about immunizations, but yet the facility didn't notify her about Resident #304's fall. Review of Nurse's Note dated 11/29/2022 at 13:54 (1:54 P.M.) revealed, resident awoke for breakfast and stated she has severe pain in left ribs, reported to (Nurse Practitioner) NP YYY) who ordered chest x ray, (MD XXX) saw resident this shift, prn (as needed) pain medication given and effective, daughter here visiting during Dr visit. Review of Resident #304's Physician Progress Note dated 11/29/2022 at 14:09 (2:09 P.M.) revealed, .experienced last night (sic) a fall in the shower with subsequent rib injury as well as back injury. Also daughter is present at bedside .Back pain: Bilaterally, The pain is moderate .Plan: Recent mechanical fall with rib and back pain going to do an x-ray of both areas at present time . Review of Resident #304's X-Ray of Spine exam date 11/29/22 at 11:08 P.M. revealed, .T9 (thoracic spine) vertebral body fracture . In an interview on 03/06/23 at 12:28 P.M., Certified Nursing Assistant (CNA) X reported that she was assisting Resident #304 in the shower room when Resident #304 fell on [DATE] some time during first shift. CNA X reported that Resident #304 was complaining of back pain, but was able to stand up and sit down on the chair. CNA X reported that she then left the shower room to inform Registered Nurse (RN) DD of the fall. CNA X reported that RN DD did not assess Resident #304 or the situation, but requested that CNA X obtain vital signs and transfer Resident #304 into bed. CNA X reported that the day following the fall, Resident #304 was in so much pain, that she could not even move in her bed. Attempt to interview RN DD on 03/07/23 at 11:24 A.M., but did not receive a return call. In an interview on 03/07/23 at 11:28 A.M., RN D reported that she was not working on the day that Resident #304 fell and broke her back, and that RN DD was the nurse assigned to Resident #304 that day. RN D reported that on 11/29/22 when she started work, she was not informed that Resident #304 had fallen the day prior, until Resident #304 was complaining of severe pain, and CNA X explained that Resident #304 had fallen back really hard onto the shower chair the day before. RN D reported that she assessed Resident #304 and she was in a lot of pain and stated, .I think there was a bruise on her side . RN D reported that she notified the doctor immediately and he went into Resident #304's room right away. RN D reported that Resident #304's daughter was very upset because she had not been informed of the fall. In an interview on 03/07/23 at 11:52 A.M., Director of Nursing (DON) reported that when an fall occurs the nurse is expected to perform a full assessment on the resident and the environment prior to moving the resident, and obtain vital signs every shift, along with documentation of the fall and notification to the doctor and family. DON reported that RN DD did not document a progress note or an assessment on Resident #304 on 11/28/22, but that based on the documentation charted by RN D (that worked with the resident the day after the fall) the fall occurred on 11/28/22 at 10:45 A.M., but the doctors note from 11/29/22 refers to a fall last night. DON was unable to definitively say when the fall had occurred, was unable to provide a root cause analysis, and reported that according to Resident #304's care plan she required a steady lift (mechanical lift) for transfers. Review of Initial Fall Document dated 11/28/22 at 10:45 A.M., created by RN D on 11/29/22 revealed, .Date of fall 11/28/22 .Most recent Blood pressure: .Date 11/29/22 at 8:08 A.M What was resident doing prior to the fall: Shower .Describe pain: ribs .Pain level: 6 .11/29/22 at 13:47 (1:47 P.M.) .Resident educated related to asking for assistance and waiting for help . This initial fall report was created the day after Resident #304's fall, by RN D who was not present at the time of the fall. Review of Resident #304's Witnessed Fall Report dated 11/28/22 at 10:45 A.M., created by RN D revealed, .Injuries Reported Post Incident: Fracture Vertebrae .Witnesses: (CNA X): I just finished showering resident and went to grab a towel to dry her off, as I was grabbing towel I hear a loud bang and found resident laying with her back against the chair seat and holding on so she wouldn't fall all the way, I grabbed her and helped her stand back up, I asked resident what happened and she said, I was standing up to come out of the shower to get to my chair and slipped and hit my back. People Notified: DON 11/29/22 at 13:54 (1:54 P.M.) .Family Member (FM III) 11/28/22 at 11:50 A.M., Physician 11/29/22 at 13:53 (1:53 P.M.). This report was created after Resident #304's fall, by RN D, who was not working at the time of the fall. The report does not include a statement or assessment notes from RN DD, who was responsible for Resident #304 at the time of the fall. Review of Resident #304's Un-Witnessed Fall Report dated 12/3/22 at 02:57 A.M. revealed, .Writer walked into residents room and found resident on the floor. Resident states she was trying to get in her chair when she fell. Resident assessed and no new injury noted. Resident was taken off the ground and into her chair .Fracture T9 from previous fall .People Notified: (FM IIII) on 12/4/22 at 10:30 A.M., NP YYY on 12/5/22 at 10:41 A.M.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interviews the facility failed to provide a homelike environment that allowed residents to use their belongings to the extent possible in 1 of 30 sampled residents (Resident #79) reviewed for homelike environment, resulting in complaints of dissatisfaction with their living situation. Findings include: A review of a Face Sheet for Resident #79 dated 5/1/21 revealed pertinent diagnosis of adult failure to thrive (syndrome of global decline often accompanied by depressive symptoms). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Basic Inventory of Mental Status (BIMS) score of 15, indicating Resident #79 was cognitively intact. During an observation on 2/27/23 at 2:20pm, it was observed that personal belongings were stacked against both closet doors in Resident #79's room. The belongings extended 6 feet across and 24 inches high, some were in boxes, others piled directly on the floor. In an interview on 2/27/23 at 2:26 pm, Resident #79 reported her closet was blocked by her roommate's belongings and as a result she could not easily access it. Resident #79 voiced frustration regarding not being able to access the closet for storage and indicated she kept anything she wanted to use regularly in a small drawer near her bed. Resident #79 stated I can't use that space (the closet) .so I can't use my stuff. During on observation on 2/28/23 at 8:37am, the same personal belongings remain in front of Resident #79's closet, blocking the door. During an observation on 3/1/23 at 11:03am, personal belongings belonging to Resident # 79's roommate continued to block the door of Resident #79's closet. During an observation on 3/2/23 at 11:14am, Resident #79's closet door remained blocked by personal belongings. In an interview on 3/1/23 at 11:04 am, Certified Nursing Assistant (CENA) X confirmed the belongings in front of Resident #79's closet belonged to the roommate and had been stored there on an ongoing basis. CENA X reported it was often difficult for staff to retrieve items from the closet for Resident #79, and as a result Resident #79 did not regularly use items from the closet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide baseline care plans for 1 (Resident #69) out of 20 residents reviewed for care plans resulting in the potential for inappropriate care and decreased quality of life. Findings include: Review of a facility Policy with a revision date of 1/1/21 revealed: Policy- .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to .i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. social services. vi. PASARR recommendation, if applicable Resident #69 Review of an admission Record revealed Resident #69, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: renal insufficiency (kidney). Review of a Minimum Data Set (MDS) assessment for Resident #69, with a reference date of 2/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #69 was cognitively intact. Review of Resident #69's Care Plans from admission date of 02/10/2023 revealed Resident #69 had no baseline care plan for Focus: Dialysis. Resident #69's Care Plan with a focus of The resident has renal insufficiency. Date Initiated: 02/10/2023 did not display any Focus area for Dialysis, or interventions for Dialysis. In an interview 3/06/23 at 10:40 AM., MDS- Licensed Practical Nurse (LPN) Q reported when a resident enters the facility for an admission which ever nurse admits the resident usually puts in place a baseline care plan. LPN Q reported (Resident #69) should have had a focus area of Dialysis not only on his baseline care plan but also his admission comprehensive care plan. LPN Q reported it was a mistake by herself, by not ensuring that the care plan for Resident #69 was correct and reflected focus areas that are person centered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise a comprehensive, individualized plan of care for 1 of 30 residents (Resident #59) reviewed for care plans, resulting in inconsistent respiratory treatment and services, and the potential for impaired physical, mental, and psychosocial well-being. Findings include: Resident #59 Review of an admission Record revealed Resident #59 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic obstructive pulmonary disease (COPD) (lung disease that blocks airflow and makes it difficult to breathe.) Review of a Minimum Data Set (MDS) assessment for Resident #59, with a reference date of 12/10/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #59 was cognitively intact. Review of Resident #59's Care Plan revealed, The resident has alteration in respiratory status related to COPD, and a history of COVID-19, chronic cough, nose, bleeds, history of oxygen dependence. Date initiated, 3/23/2022. Revision on 2/14/2023. Interventions: administer medication as ordered by MD/NP (nurse practitioner), See MAR (medication administration record). Date initiated 09/27/2022. Monitor for difficulty breathing (dyspnea) on exertion. Remind resident not to push beyond endurance. Monitor for s/sx (signs and symptoms) of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest, somnolence. Monitor/Document report PRN (as needed) to MD/NP any s/sx of respiratory infection .Date initiated 03/23/2022. Review of current care plan on 2/28/2023 did not include self administration use of inhalers or oxygen use. During an observation on 02/28/23 at 11:42 A.M. of Resident #59's room there was an oxygen concentrator (a device that takes ambient air and forms it into oxygen), with nasal cannula (device used to deliver oxygen through the nose) tubing attched, and a portable tank of oxygen; Resident #59 was not observed in the room. During an observation and interview on 02/28/23 at 01:18 P.M. Resident #59 was lying in her bed and there was an Albuterol (medication that increases flow of air through the lungs) inhaler observed on the over the bed table. There was an oxygen concentration machine set at 2L (liters) running at the bedside, and Resident #59 was observed receiving the oxygen via nasal cannula. Resident #59 reported that she did not know if she was supposed to have oxygen all the time, but that she always used it when she was in her room and stated, .and I have my inhalers right here .they want me to do that myself .I use it 3 times a day or more .whenever I want . Resident #59 reported that facility staff had taken her oxygen away, but then they had to give it back due to her oxygen levels (saturation: the amount of oxygen in a person's blood) dropping recently. Review of Resident #59's MAR revealed, Monitor: Does the resident have shortness of breath when lying down or diagnosis of COPD? (sic) If: Pulse ox (oxygen saturation level) less than 88% apply oxygen at 2L and notify MD/NP every day and night shift .Start date 2/2/2023. There was no order to record actual administration of oxygen. Review of Resident #59's MAR, indicated orders for Ventolin (Albuterol) inhaler 2 puffs every 6 hours as needed for SOB (shortness of breath)/wheezing related to COPD with a start date of 2/1/23. There were no checks or staff initials to indicate that the inhaler was used for the entire month of February, and did not indicate self-administration. In an interview on 03/01/23 at 11:20 A.M., Restorative Aide (RA) NN reported that she did not know when Resident #59 was supposed to be wearing her oxygen. In an interview on 03/01/23 at 11:31 A.M., Registered Nurse (RN) DD reported that Resident #59 is not currently on oxygen and stated, .it was discontinued .(Resident #59) has COPD .was on oxygen for a long time .it was more of a comfort thing .she does not get short of breath .but if it drops below a certain level then we can put it on her . RN DD reported that Resident #59 self administers Albuterol inhaler and stated, .she regulates it herself .it's ordered PRN (as needed) . RN DD reported that Resident #59 care plan did not indicate self administration of her Albuterol/Ventolin inhaler. Review of Resident #59's Physician Orders revealed, Oxygen: RUN @ 2L PRN as needed for o2 below 88. Active 3/1/2023 at 11:45 A.M. In an interview on 03/01/23 at 11:54 A.M., Resident #59 reported being very upset and stated, .they took my oxygen away again .they say that I am dependent on it and don't really need it . Review of Resident #59's updated Care Plan revealed, The resident has alteration in respiratory status r/t COPD and a history of COVID 19, chronic cough, nose bleeds, current supplemental oxygen use. Date Initiated: 03/23/2022 Revision on: 03/01/2023 .Oxygen as ordered by MD/NP, see MAR. Date Initiated: 03/01/2023 . In an interivew on 03/01/23 at 01:56 P.M., Certified Nursing Assistant (CNA) L reported that Resident #59 is short of breath a lot and is supposed to wear oxygen. In an interview on 03/06/23 at 12:37 P.M., CNA X reported that Resident #59 uses oxygen when she wants to, and is not supposed to have her inhalers in the room and stated, .the nurses leave them in her room and the resident is supposed to call and let us know when she uses it, then we take them to the nurse .sometimes I find a few inhalers in the room at a time . During an interview and observation on 03/06/23 at 01:42 P.M. Resident #59 was lying in her bed wearing her oxygen nasal cannula and the concentrator was set at 2 liters. Resident #59 reported that she feels better when she has her oxygen on and stated, .had low oxygen levels over the weekend .I only take it off when I go outside . Resident #59 reported that the facility removed her Albuterol/Ventolin inhalers that she had last week and gave her a new one to use on her own and stated, .they talked to me about how to use it . In an interview on 03/06/23 at 02:48 P.M., Director of Nursing (DON) reported that Resident #59 was weaned off of oxygen, but then was restarted on 3/1/23 due to her oxygen levels being low. DON reported that Resident #59's oxygen order indicates PRN and not continuous or self administration. DON reported that Resident #59 frequently uses her oxygen when she is in her room, but that the orders and care plan do not reflect the residents preferences. In an interview on 03/06/23 at 04:19 P.M., DON reported that Resident #59's oxygen order has been changed to PRN for comfort purposes, and will be self administered by the resident as she feels needed. DON reported that Resident #59 does require oxygen during times of exertion, and feels more comfortable wearing it all the time when she is in her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing standards of practice for physician orders were followed and/or obtained for 2 of 30 residents (R3 and R65) reviewed for professional standards of care, resulting in the lack of documentation, and the potential for the worsening of a condition and a delay in treatment. Findings include: Resident #3 According to the Minimum Data Set (MDS) dated [DATE], R3 scored 7/15 (cognitively impaired) on her BIMS (Brief Interview Mental Status), with diagnoses that included coronary artery disease, heart failure, diabetes, and partial paralysis and required oxygen therapy. Review of R3's Order Summary 2/18/2022 revealed, Oxygen at 1.5 L (delivery of liters per minute) via NC (nasal cannula) continuous every morning and at bedside for SOB (shortness of breath)/hypoxia (low oxygenation) related to chronic diastolic (congestive) heart failure. Review of R3's Care Plan Altered Respiratory status/difficulty breathing r/t (related to) allergies, CHF, COVID recovered, dependence on supplemental oxygen 6/23/2022. The goal for the resident were for her not to have s/sx (signs/symptoms) of poor oxygen absorption. To meet these goals, interventions included: -Administer medication as ordered by MD/NP (medical director/nurse practitioner), see MAR (Medication Administration Record) . -Oxygen settings: O2 (oxygen) via N/C (nasal cannula) per physician orders 12/9/2021. During an observation on 2/28/2023 at 7:47 AM, R3 was in her bed wearing oxygen via NC in her left nares (nostril). Registered Nurse (RN) EE had just administered the resident's medications left the room without adjusting the NC. Oxygen was set at 3 LPM. During an observation on 3/1/2023 at 3:51 PM, R3 was in bed wearing oxygen via NC set at 3 LPM. During an observation on 3/6/2023 at 9:10 AM, R3 was in bed wearing oxygen via NC set at 3 LPM. During an observation on 3/7/2023 at 07:00 AM R3 was supine in bed softly snoring wearing oxygen via NC set at 3 LPM. During an observation, and interview on 3/7/2023 at 8:15 AM RN EE stated, (R3's) order is for her oxygen to be set at 1.5 LPM. If it is set differently than the order it could adversely affect the resident. I chart on my shift (R3's) SPOX and verify the oxygen is set at 1.5 LPM. RN EE and Surveyor observed the resident's oxygen concentrator. RN EE stated, It is set at 3 LPM. That is not what the order states. Review of R3's MAR February 2023 revealed, Oxygen @ 1.5 L via NC- continuous every morning and at bedtime for SOB/Hypoxia related to CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE -Start Date 02/18/2022 2000 with documentation of nurse verification of oxygen and oxygen saturation twice each day 2/27/2023 and 2/28/2023. Review of R3's MAR March 2023 revealed, Oxygen @ 1.5 L via NC- continuous every morning and at bedtime for SOB/Hypoxia related to CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE -Start Date 02/18/2022 2000 with documentation of nurse verification of oxygen and oxygen saturation twice each day 3/1/2023 through 3/6/2023. Resident #65 According to the Minimum Data Set (MDS) dated , 12/29/2022, R65 scored 10/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status) required oxygen for diagnoses that included heart failure (CHF-congestive heart failure) and respiratory failure. Review of R65's Order Summary revealed no order for oxygen. Review of R65's Medication/Treatment Administration Record (MAR TAR) did not have oxygen listed as a medication/treatment. Review of R65's Care Plan Altered Respiratory Status 1/16/2023 related to chronic respiratory failure with hypoxia, CHF, and pleural effusion. The goal was to have the resident maintain a normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern. Interventions to meet this goal was to administer medications as ordered. During an observation on 2/27/2023 at 2:44 PM R65 was in her bed wearing oxygen via NC (nasal cannula) set at 4 LPM (liters-per-minute). During an observation on 2/28/2023 at 3:00 PM R65 was in bed wearing oxygen via NC set at 4 LPM. During an observation on 3/6/2023 at 9:00 AM R65 was in bed wearing oxygen via NC set at 4 LPM. During an observation on 3/7/2023, R65 was supine in bed wearing oxygen via NC set at 4 LPM. During an interview and record review on 3/6/2023 at 4:00 PM with Clinical Consultant ZZZ and Nursing Home Administrator (NHA) A reviewed with Surveyor, R65's Order Summary, Clinical Consultant stated, (R65) does not have an order for oxygen. It looks like her oxygen order was discontinued in December (2022) with no explanation. It is important to have the order, so the correct amount of oxygen is administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00132767. Based on observation, interview and record review, the facility failed to ensure assistance with Activities for Daily Living (ADL-personal hygiene, combing hair, brushing teeth, etc.) care was consistently provided for 1 (Resident #56) of 30 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's dependent on staff for assistance. Findings include: Resident #56: Review of an admission Record revealed Resident #56 was a female with pertinent diagnoses which included dementia, stroke, muscle weakness, GERD, COPD, reduced mobility, transient ischemic attack (mini strokes) stiffness of left hand, morbid obesity, abdominal pain, and paralysis on left side. Review of a Minimum Data Set (MDS) assessment for Resident #56, with a reference date of 1/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #56 was cognitively intact .MDS Assessment Section G: Activities of Daily Living (ADL) Assistance dated 11/4/22, revealed, .J. Personal Hygiene - how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) .3. Extensive Assistance - resident involved in activity, staff providing weight-bearing support .2. One person physical assist . In an interview of 2/28/23 at 10:29 AM, Resident #56 reported the staff were not assisting her with obtaining her supplies to perform oral care each day. Resident #56 reported she has a special toothpaste which always seems to get lost quite a bit. Resident #56 asked this writer to look in her drawer for her toothpaste and her toothbrush. Toothpaste was not observed in drawers or pink bins lined along the floor under a rolling bedside table along the wall. A toothbrush was located in the top drawer of her dresser and her electric toothbrush was located in her 2nd drawer down in her dresser. Review of Pertinent Charting - Pain dated 3/3/2023 at 10:01PM, revealed, .Pain Type: New Onset Pain characteristics: Resident voicing increased pain due to broken teeth .MD notification necessary: Norco ordered TID (three times a day) . Review of Physician Progress Note dated 3/3/2023 at 3:33 PM, revealed, .This is a [AGE] year-old female with history of CVA with left-sided weakness morbid obesity BMI (Body Mass Index) greater than 50, immobility, chronic constipation, recurrent UTI (urinary tract infection), diabetes, hypertension, depression, long-term resident in the nursing home .Patient has broken teeth in the upper gums complains of intractable pain, she is awaiting to see dentist .Neurologic: Alert, Left hemiparesis .Impression and Plan .Diagnosis: Mouth pain . In an interview on 3/07/23 at 12:55 PM, Assistant Nursing Home Administrator (ANHA) C reported those who were assigned to residents for caring partners review the [NAME] for those residents. ANHA C reported we would observe if the resident was cleaned up and ready for breakfast, ensure everything they need was in their reach, and when there were concerns we would report them to the appropriate department, follow up with those departments to ensure the they have followed up, and if there were any abuse concerns it would be reported to the abuse coordinator. Review of Caring Partners Communication Log for weeks 1-4 each week has a section which revealed, .Observations: Is the resident clean, odor free and well groomed (shaved, nails clean and trim, hair brushed) and dressed appropriately? (note concerns) . Review of policy, Activities of Daily Living (ADLs) last reviewed/revised on 01/01/2022, revealed, .3. 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 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate indwelling catheter care, monitoring the patency of the tubing, and collection bag for one (Resident #70) of 3 residents reviewed for indwelling catheter care, resulting in the potential of a urinary tract infection. Findings include: Review of Fundamentals of Nursing ninth edition by [NAME] & [NAME] revealed, Indwelling Catheter Care Delegation Considerations .The skill of perineal care is often part of routine hygiene care that can be delegated to nursing assistive personnel. Proper assessment and care of the perineal area is the responsibility of the nurse. If patient has had trauma or surgical procedures that involve the perineal area, do not delegate this care. Resident #70: Review of an admission Record revealed Resident #70 was a female with pertinent diagnoses which included dementia, Alzheimer's Disease, diabetes, vascular disease (condition that affects your circulatory system), contracture (permanent tightening of the muscles, tendons, skin and surrounding tissues that causes the joints to shorten and stiffen), neuropathy (peripheral nerve damage that causes numbness, pain, and weakness), abnormal posture, and pityriasis versicolor (flaky discolored patches on the skin due to a fungal infection, commonly affects the trunk and shoulder). Review of a Minimum Data Set (MDS) assessment for Resident #70, with a reference date of 12/13/22 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated Resident #70 was severely cognitively impaired. MDS Section G: Activities of Daily Living (ADL) Assistance .A. Bed Mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture .3. Extensive Assistance .3. Two+ person physical assist . Review of current Care Plan for Resident #10, revised on 8/13/22, revealed the focus, .Resident has an alteration in urinary status r/t (related to) bladder incontinence and current indwelling foley catheter r/t contractures, pain with brief changes . with the intervention .Foley bag to gravity drainage with privacy bag in place .Brief use: The resident uses disposable briefs. Check q (every) 2-3 hours and change prn (as needed) .Monitor/document for s/sx (signs and symptoms) UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns .Administer treatments as ordered by MD/NP, see TAR .Provide peri-care with each incontinence episode . A urinary catheter is a tube placed in the body to drain and collect urine from the bladder .An indwelling catheter collects urine by attaching to a drainage bag. The bag has a valve that can be opened to allow urine to flow out. Some of these bags can be secured to your leg. This allows you to wear the bag under your clothes. An indwelling catheter may be inserted into the bladder in 2 ways: Most often, the catheter is inserted through the urethra. This is the tube that carries urine from the bladder to the outside of the body .A catheter is most often attached to a drainage bag. Keep the drainage bag lower than your bladder so that urine does not flow back up into your bladder. (https://medlineplus.gov > Medical Encyclopedia) .A CAUTI (Catheter associated urinary tract infection), or a UTI (urinary tract infection) associated with a catheter, is common if you have an indwelling catheter inside your urethra .Symptoms are similar to a general UTI and include bloody or cloudy urine, gritty particles or mucus in your urine, urine with a strong odor, pain in your lower back, chills and fever . (https://www.healthline.com/health/sediment-in-urine) .Encrustations can occur either in the lumen of the catheter or extraluminally. This can possibly result in blockage or retention of the catheter. The main cause of catheter encrustation is infection by urease-producing organisms .crystals of calcium and magnesium phosphate are formed and a crystalline bio film develops which eventually blocks the flow of urine from the bladder . (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066753). Review of a physician's order revealed, .Change foley drainage bag & label with date as needed AND every night shift starting on the 12th and ending on the 12th every month .Active .8/13/2022 16:30 . Review of a physician's order revealed, .Change indwelling foley catheter 18F (French) 8.30mL (milliter) balloon as needed .Active 12/12/2022 . Review of a physician's order revealed, .Maintain indwelling catheter 18F every day and night shift for contractures/hospice care .Active 12/12/2022 . Review of a physician's order revealed, .Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify MD/NP as needed of any changes every day and night shift .Active 10/16/2022 . Review of Physician Progress Note dated 10/25/22 at 2:53 PM, revealed, .Subjective: Labs as well as recent UA reviewed. Urine shows contamination .Vital signs: 10/25/22 at 09:02 EDT .Respiratory rate 16 br/min, Systolic Blood Pressure 145 mmHg (millimeter mercury), Diastolic Blood Pressure 80 mm HG .Pulse Rate: 70 bpm .Temperature Oral: 97 degrees .Plan: recent available UA (urinalysis) shows some gross contamination, so I do not think we need to start any antibiotics .Altogether patient seems to be comfortable at her baseline . Review of NP/PA (nurse practitioner/Physician assistant) progress Note dated 1/16/23 at 8:48 AM revealed, .Review/Management: Results review: Interpretation: 9/19/22- wbc (white blood count) 17 (normal range between 5 and 10) . Note: [NAME] blood count was elevated. In an interview on 2/27/23 at 2:31 PM, Family Member (FM) CCCC reported the catheter tubing has a lot of stuff in it and looks clogged and the catheter has not been changed for a long time as it can be difficult due to Resident #70's contractures. FM CCCC reported the resident received the catheter due to the difficulty of providing personal care to her after incontinence because of her contractures to her legs. FM CCCC reported the resident does not show the classic symptoms of a UTI and she never has a fever and have discussed the concern with staff and they stated because she does not have a fever, she does not meet criteria for a UA to be done. During an observation on 2/27/23 at 4:50 PM, Resident #70's catheter tubing urine was cloudy, had sediment was encrusted to tubing for approximately 18 inches observed when exiting from under the bedding to the catheter bag. The connection and neck to the catheter bag had sediment coating on all sides. The catheter bag had sediment lining it. Resident #70's urine was a dark amber color with a hint of brownness to the urine. Review of Treatment Administration Record (TAR) dated 8/13/22 - 8/31/22, revealed, .Change indwelling foley catheter 14F as needed .Start Date- 08/13/2022 .D/C Date- 12/12/2022 . revealed, No notation that the catheter was changed. Review of Treatment Administration Record (TAR) dated 9/1/22 - 9/30/22, revealed, .Change indwelling foley catheter 14F as needed .Start Date- 08/13/2022 .D/C Date- 12/12/2022 . revealed, No notation that the catheter was changed. Review of SOC- Infection note dated 9/20/2022 at 10:24 AM, revealed, .Type of infections/Signs & symptoms: on 9/16/22 Fever 102.2 F, P-115, congestion, fatigue, poor appetite, SOB -patient denies s/s of UTI but does have increased chest congestion and fatigue-patient denies back and flank pain -no c/o burning w/ urination -no temperature Antibiotic ordered/Susceptibility: Ceftriaxone Sodium 1 gm (gram) McGeer's criteria followed: Yes Precaution type: Are they on blood thinner or antibiotic: Interventions (increased fluids/VS/etc.): Comments: -chest x-ray -CBC, CMP, leukocytosis -UA -urine if indwelling catheter bag is cloudy, concentrated, and sediment is present . .Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised . Guideline for Prevention of Catheter- Associated Urinary Tract Infections 2009. https://www.cdc.gov/infectioncontrol /guidelines/cauti/. Review of Treatment Administration Record (TAR) dated 12/12/22 - 12/31/22, revealed, .Change indwelling foley catheter 18F & 30 mL balloon as needed .Start Date- 12/12/2022 .D/C Date- 03/01/2023 at .revealed, No notation that the catheter was changed. Review of Treatment Administration Record (TAR) dated 1/1/23 - 1/31/23, revealed, .Change indwelling foley catheter 18F & 30 mL balloon as needed .PRN .Start Date- 12/12/2022 . revealed, No notation that the catheter was changed. Review of Treatment Administration Record (TAR) dated 1/1/23 - 1/31/23, revealed, .Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify MD/NP (physician/nurse practitioner) as needed of any changes every day and night shift .Start Date- 10/16/2022 .No documentation of monitoring on Day 2 1/24/23 and 1/26/23 . Note: On 1/24/23, no notation for monitoring, 1/26/23, no notation for monitoring. Review of Treatment Administration Record (TAR) dated 2/1/23 - 2/28/23, revealed, .Change indwelling foley catheter 18F & 30 mL balloon as needed .PRN .Start Date- 12/12/2022 . revealed, No notation that the catheter was changed. Review of Treatment Administration Record (TAR) dated 2/1/23 - 2/28/23, revealed, .Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify MD/NP as needed of any changes every day and night shift .Start Date- 10/16/2022 0 .No documentation of monitoring on Day 2 on 2/15/23 . Review of Treatment Administration Record (TAR) dated 3/1/23 - 3/7/23, revealed, .Change indwelling foley catheter 18F as needed for malfunctioning, leaking, obstructed, dislodged foley cath .PRN .Start Date- 3/1/23 . revealed, No notation that the catheter was changed. Review of Treatment Administration Record (TAR) dated 3/1/23 - 3/7/23, revealed, .Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify MD/NP as needed of any changes every day and night shift .Start Date- 10/16/2022 .No documentation on night shift on 3/5/23 . During an observation on 2/28/23 at 8:58 AM, observed Resident #70's catheter bag has a privacy bag on it, the urine was a very dark, dark amber color. Observed approximately 200 ml in the bag. The catheter tubing was encrusted with sediment, cloudiness of urine in the tubing, and the catheter bag connection site was encrusted with sediment. In an interview on 2/28/23 at 3:53 PM, Certified Nursing Assistant (CNA) RRR reported when empting the catheter bag, clean the top with an alcohol wipe, and when open the bag, wipe that down. CNA RRR reported if there was any color changes, odor, or cloudiness, the nurse would be notified right away, and they usually sample it to see if there was any kind of infection. CNA RRR reported staff would ensure the tubing was not kinked up, supposed to be over the leg so it can drain, and also ensure the tubing was secured to the leg with a Velcro band or a securement device. In an interview on 2/28/23 at 4:17 PM, Director of Nursing (DON) B observed the catheter tubing and bag for Resident #70. DON B reported the resident was on hospice and she would speak to hospice on how they would like to proceed with her care. DON B reported an order for Resident #70 to receive a catheter was due to her contractures and the difficulty with providing pericare on the resident with positioning and turning. During an observation on 3/1/23 at 11:08 AM, Resident #70 was lying in her bed and observed the resident's catheter tubing and catheter bag had been changed and dated 3/1/23. In an interview on 3/1/23 at 11:23 AM, Registered Nurse (RN) DD reported she changed the resident's catheter tubing and bag this morning when requested to do so by DON. RN DD reported no urine sample was taken. In an interview on 3/1/23 at 11:14 AM, Hospice Nurse EEEE reported the standard for hospice was to change the catheter every 4-6 weeks, routinely unless the patient requests that it not be done during the disease process. Hospice Nurse EEEE reviewed the residents record and reported most recent assessment indicated the urine was dark slightly amber on 2/28/23, week of 2/21/23 the urine displayed as light moderate amber color. Hospice Nurse EEEE reported per hospice's standard, they would flush the catheter or change the catheter based on the description provided to her on this writer's observation of the catheter tubing and bag. Note: No order to flush the catheter noted since initial placement of catheter on 8/13/22. In an interview on 3/1/23 at 11:29 AM, Licensed Practical Nurse (LPN) G reported she would change the catheter bag and flush the foley if the tubing was cloudy and covered in sediment and see if we get sediment from the bladder out of there. In an interview on 3/06/23 at 12:11 PM, Resident #70 was observed the catheter tubing and it appearred milky, with white sediment lining the tube, and surrounding the clasp to the catheter bag, and into the catheter bag. During an observation on 3/07/23 at 08:07 AM, observed foley secured to right thigh leg strap. Condensation noted in top of tubing at leg strap. [NAME] sediment in section after condensation until section where tubing has dependent drainage. At site where tubing hands dependent off-white coating of tubing and drainage bag with orange-yellow urine less than 100 cc. In an interview on 3/07/23 10:20 AM, Director of Nursing (DON) B reported Resident #70 if she becomes symptomatic the facility would complete a urinalysis and since she was not symptomatic when they changed the tubing and bag on 3/1/23, the facility did not complete a UA for Resident #70. DON B reported she was probably already colonized per hospice notes and not having fevers so there was no indication to complete a urinalysis. Review of Resident #70's record shows she did receive Rocephin (antibiotic) injections starting on 9/21/22 for UTI. DON B reported she was unsure why there was no order to flush or to check for patency of the catheter and would contact hospice and confer with them to determine if it is recommended. DON B reported the foley catheter would not get changed unless it was causing discomfort per the hospice nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00132515. Based on observation, interview, and record review, the facility failed to provide treatment and services according to professional standards for 1 resident (Resident #59) of 6 reviewed for respiratory care, when physician orders were not followed and a resident centered care plan was not in place, resulting in the potential for hypoxemia (low oxygen in the blood). Findings include: Resident #59 Review of an admission Record revealed Resident #59 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic obstructive pulmonary disease (COPD) (lung disease that blocks airflow and makes it difficult to breathe.) Review of a Minimum Data Set (MDS) assessment for Resident #59, with a reference date of 12/10/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #59 was cognitively intact. During an observation on 02/28/23 at 11:42 A.M. of Resident #59's room there was an oxygen concentrator (a device that takes ambient air and forms it into oxygen), with nasal cannula (device used to deliver oxygen through the nose) tubing attched, and a portable tank of oxygen; Resident #59 was not observed in the room. During an observation and interview on 02/28/23 at 01:18 P.M. Resident #59 was lying in her bed and there was an Albuterol (medication that increases flow of air through the lungs) inhaler observed on the over the bed table. There was an oxygen concentration machine set at 2L (liters) running at the bedside, and Resident #59 was observed receiving the oxygen via nasal cannula. Resident #59 reported that she did not know if she was supposed to have oxygen all the time, but that she always used it when she was in her room and stated, .and I have my inhalers right here .they want me to do that myself .I use it 3 times a day or more .whenever I want . Resident #59 presented the Albuterol inhaler to this surveyor, and it was observed almost empty, and with no open date. Resident #59 then presented a second Albuterol inhaler to this surveyor, it was also observed used, and without an open date. Resident #59 held up the Albuterol inhaler and stated, .I keep this one on me when I go outside . Resident #59 reported that facility staff had taken her oxygen away, but then they had to give it back due to her oxygen levels dropping recently and stated, .I am so relieved to have it back again .but I still can't take it outside of my room . Resident #59 reported that she was worried about not being able to use her oxygen for outside appointments. Review of Nurse's Note dated 2/15/2023 at 13:38 (1:38 P.M.) revealed, Notified by (Physical Therapist), that (Resident #59) arrived at therapy room for afternoon session on room air saturating (amount of oxygen in a person's blood) at 85%. Oxygen 2L applied. Saturated at 92% and able to maintain during therapy without desaturating. Review of Resident #59's Medication Administration Record (MAR) revealed, Monitor: Does the resident have shortness of breath when lying down or diagnosis of COPD? If: Pulse ox (oxygen saturation level) less than 88% apply oxygen at 2L and notify MD/NP (physician/nurse practitioner) every day and night shift .Start date 2/2/2023. There was no order to record actual administration of oxygen. Review of Resident #59's MAR, indicated orders for Ventolin (Albuterol) inhaler 2 puffs every 6 hours as needed for SOB (shortness of breath)/wheezing related to COPD with a start date of 2/1/23. There were no checks or staff initials to indicate that the inhaler was used for the entire month of February, and did not indicate self-administration. Review of Resident #59's Care Plan revealed, The resident has alteration in respiratory status related to COPD, and a history of COVID-19, chronic cough, nose, bleeds, history of oxygen dependence. Date initiated, 3/23/2022. Revision on 2/14/2023. Interventions: administer medication as ordered by MD/NP, See MAR. Date initiated 09/27/2022. Monitor for difficulty breathing (dyspnea) on exertion. Remind resident not to push beyond endurance. Monitor for s/sx (signs and symptoms) of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest, somnolence. Monitor/Document report PRN (as needed) to MD/NP any s/sx of respiratory infection .Date initiated 03/23/2022. Review of current care plan on 2/28/2023 did not include self administration use of inhalers or oxygen use. In an interview on 03/01/23 at 11:20 A.M., Restorative Aide (RA) NN reported that she did not know when Resident #59 was supposed to be wearing her oxygen. During an observation on 03/01/23 at 11:24 A.M. Resident #59 was sitting in her wheelchair in the dining room, not observed wearing her oxygen. In an interview on 03/01/23 at 11:31 A.M., Registered Nurse (RN) DD reported that Resident #59 is not currently on oxygen and stated, .it was discontinued .(Resident #59) has COPD .was on oxygen for a long time .it was more of a comfort thing .she does not get short of breath .but if it drops below a certain level then we can put it on her . RN DD reported that Resident #59 self administers Albuterol inhaler and stated, .she regulates it herself .it's ordered PRN (as needed) . RN DD reported that she would only document administration of Resident #59's Albuterol inhaler if the resident reported to have used it. RN DD reported that Resident #59 did not have an assessment on record indicating that she is safe to self administer medications, the order did not include self administration, and her care plan does not indicate self administration of her Albuterol/Ventolin inhaler. Review of Resident #59's Physician Orders revealed, Oxygen: RUN @ 2L PRN as needed for o2 below 88. Active 3/1/2023 at 11:45 A.M. In an interview on 03/01/23 at 11:54 A.M., Resident #59 reported being very upset and stated, .they took my oxygen away again .they say that I am dependent on it and don't really need it . Review of Resident #59's updated Care Plan revealed, The resident has alteration in respiratory status r/t COPD and a history of COVID 19, chronic cough, nose bleeds, current supplemental oxygen use. Date Initiated: 03/23/2022 Revision on: 03/01/2023 .Oxygen as ordered by MD/NP, see MAR. Date Initiated: 03/01/2023 . Review of Resident #59's Oxygen Saturation Summary revealed the past months dates and levels for oxygen saturation while on room air: 3/5/23 97%, 3/3/23 82%, 3/1/23 85%, 2/25/23 98%, 2/24/23 94%, 2/19/23 93%, 2/16/23 97%, 2/15/23 85%, 2/13/23 97%, 2/12/23 91%, 2/11/23 93%, 2/10/23 84%, 2/9/23 86% and 2/8/23 91%. In an interview on 03/01/23 at 01:56 P.M., Certified Nursing Assistant (CNA) L reported that Resident #59 is short of breath a lot and is supposed to wear oxygen. In an interview on 03/06/23 at 12:37 P.M., CNA X reported that Resident #59 uses oxygen when she wants to, and is not supposed to have her inhalers in the room and stated, .the nurses leave them in her room and the resident is supposed to call and let us know when she uses it, then we take them to the nurse .sometimes I find a few inhalers in the room at a time . During an interview and observation on 03/06/23 at 01:42 P.M. Resident #59 was lying in her bed wearing her oxygen nasal cannula and the concentrator was set at 2 liters. Resident #59 reported that she feels better when she has her oxygen on and stated, .had low oxygen levels over the weekend .I only take it off when I go outside . Resident #59 reported that the facility removed her Albuterol/Ventolin inhalers that she had last week and gave her a new one to use on her own and stated, .they talked to me about how to use it . In an interview on 03/06/23 at 02:48 P.M., Director of Nursing (DON) reported that Resident #59 was weaned off of oxygen, but then was restarted on 3/1/23 due to her oxygen levels being low. DON reported that Resident #59's oxygen order indicates PRN and not continuous or self administration. DON reported that Resident #59 frequently uses her oxygen when she is in her room, but that the orders and care plan do not reflect the residents preferences. In an interview on 03/06/23 at 04:19 P.M., DON reported that Resident #59's oxygen order has been changed to PRN for comfort purposes, and will be self administered by the resident as she feels needed. DON reported that Resident #59 does require oxygen during times of exertion, and feels more comfortable wearing it all the time when she is in her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify PTSD (Post Traumatic Stress Disorder) triggers and implement interventions to mitigate triggers for 1 of 30 residents (Resident # 17) reviewed for trauma informed care, resulting in the potential risk of re-traumatization and unmet care needs. Findings include: A review of a Face Sheet for Resident #17 dated 6/10/22, revealed pertinent diagnosis of PTSD (Post Traumatic Stress Disorder). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Inventory of Mental Status (BIMS) score of 15 indicating Resident #17 is cognitively intact, required supervision for transferring self from one location to another, supervision for personal hygiene, and supervision for dressing self. A review of a Psychiatry Initial Consult dated 5/5/22 pertinent diagnoses listed included: PTSD (Post Traumatic Stress Disorder), anxiety and depression. A review of a Social Services Assessment dated 8/11/22, section E labeled Trauma Informed Care, question one, the response inaccurately indicated Resident #17 did not have a diagnosis of PTSD (Post Traumatic Stress Disorder). A review of a Care Plan initiated on 8/11/22 revealed no Focus/Goal/Approach for Resident #17's diagnosis of PTSD (Post Traumatic Stress Disorder). A focus was present that stated Resident has anxiety and depression diagnosis, with a goal which stated, Resident will remain free from signs of anxiety and two interventions were listed: Administer medication and ordered, report changes to or escalation of anxiety. A review of shower records dated from 5/29/22-9/28/22 revealed Resident #17 had accepted 3 of 37 offers for showering. No attempts to shower the Resident were documented after 9/28/22. During on observation on 2/28/23 at 8:35 am, a strong smell of body odor was detected beginning 15 feet from the doorway and intensified upon entering Resident #17's room. In an observation and interview on 2/28/23 at 8:40am, Resident #17 was sitting on the edge of her bed, linens were soiled with yellow moisture and food crumbs, hair appeared oily, disheveled, a strong smell of body odor and urine were present. Resident #17 was asked if she was receiving support with showering. Resident #17 reported she does not shower because she was not comfortable getting naked in front of anyone. Resident #17 reported her fear was the result of childhood trauma. Resident #17 voiced that the staff had repeatedly asked her about showering when she was admitted to the facility which made her feel very stressed, that she was concerned she would be forced to shower which brought back old memories. After a few months, she contacted her previous counselor who provided a written statement that supported Resident #17 not being approached about showering. Resident #17 pointed to a case of personal wipes that sat on the floor and stated I bought those and clean myself up that way. In an interview on 3/1/23 at 11:04 am, Certified Nursing Assistant (CENA) X reported being told by Resident #17 that she (Resident #17) had PTSD related to childhood trauma and showering was a trigger. CENA X indicated staff reached out for members of the IDT (Interdisciplinary Team) to ask for interventions to mitigate Resident #17's PTSD triggers and were told to stop offering showers and allow Resident #17 to perform personal hygiene independently using body wipes and dry shampoo. CENA X stated nothing has been done to help (Resident #17) feel more comfortable with showering. CENA X reported Resident #17 had not showered in months, could not maintain a healthy level of personal hygiene, and often sat in own urine because Resident #17 refused care and would not allow staff to remove soiled linens. CENA X indicated that Resident #17's lack of hygiene also caused her roommate to complain, then said the smell even makes the staff sick. In an interview with Social Services Director HHH on 3/1/23 at 2:09 pm it was reported Resident #17 received counseling services for diagnoses of anxiety and depression. Social Services Director HHH initially indicated she was not aware of Resident #17's diagnosis of PTSD (Post Traumatic Stress Disorder) and asked where it was documented. Social Services Director HHH reviewed the medical chart and acknowledged the diagnosis of PTSD. then reported the Resident's condition caused her to startle easily and that the Resident preferred washing up rather than showering. When asked what interventions were in place to mitigate Resident #17's PTSD triggers (Post Traumatic Stress Disorder), Social Services Director reported staff had stopped offering Resident #17 showers, no other interventions were attempted to mitigate the triggers. Social Services Director indicated the facility had other options for bathing, including a private room with a bathtub but this had not been presented as an option to Resident #17. Social Services Director HHH indicated it is the responsibility of Social Services staff to coordinate counseling services, assess Residents' psychosocial needs and develop care plans to address each Resident's psychosocial needs, including trauma informed care approaches. In an interview on 3/2/23 at 11:10 am, Certified Nursing Assistant (CENA) FFF reported she was successful at assisting Resident #17 with a shower twice before being told to no longer offer showers to the Resident. CENA FFF reported there were no instructions on the kardex (care interventions guide for CENAs) or care plan regarding how to approach Resident #17 about showering, so CENA FFF offered reassurance, encouragement and allowed Resident #17 to do as much as possible alone during the shower. CENA FFF reported Resident #17 needed very little help with showering, transferred and washed herself, managed most of her dressing and afterward (Resident #17) said it felt good to get cleaned up. In a follow-up interview with Social Services Director HHH on 3/7/23 it was reported the staff had received education on trauma informed care and improvements were underway to better assess Resident needs related to trauma. Social Services Director HHH reported social work assessments now include identifying triggers for Residents with PTSD (Post Traumatic Stress Disorder) and that care plans should reflect person specific interventions to mitigate those triggers. Social Services Director HHH acknowledged that Resident #17 should have person-centered interventions in place to mitigate her PTSD (Post Traumatic Stress Disorder) triggers, including her stress related to showering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to provide medically related social services to attain the highest practicable psychosocial well-being for 2 of 30 residents (Resident #79 and Resident #17) reviewed for medically related social services, resulting in ongoing dissatisfaction with living conditions. Findings include: Resident #17 A review of a Face Sheet for Resident #17 dated 6/10/22, revealed pertinent diagnosis of PTSD (Post Traumatic Stress Disorder). A review of a Psychiatry Initial Consult dated 5/5/22 pertinent diagnoses listed included: PTSD (Post Traumatic Stress Disorder), anxiety and depression. A review of a Social Services Assessment dated 8/11/22, section E labeled Trauma Informed Care, question one, the response inaccurately indicated Resident #17 did not have a diagnosis of PTSD (Post Traumatic Stress Disorder). A review of a Care Plan initiated on 8/11/22 revealed no Focus/Goal/Approach for Resident #17's diagnosis of PTSD (Post Traumatic Stress Disorder). A focus was present that stated Resident has anxiety and depression diagnosis, with a goal which stated, Resident will remain free from signs of anxiety and two interventions were listed: Administer medication and ordered, report changes to or escalation of anxiety. In an interview on 2/28/23 at 8:40 am, Resident #17 reported she does not shower because she was not comfortable getting naked in front of anyone. Resident #17 reported her fear was the result of childhood trauma. Resident #17 voiced that the staff had repeatedly asked her about showering when she was admitted to the facility which made her feel very stressed, that she was concerned she would be forced to shower which brought back old memories. After a few months, Resident #17 contacted her former counselor who provided a written statement that supported Resident #17 no longer being approached about showering. Resident #79 A review of a Face Sheet for Resident #79 dated 5/1/21 revealed pertinent diagnosis of adult failure to thrive (syndrome of global decline often accompanied by depressive symptoms). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Basic Inventory of Mental Status (BIMS) score of 15, indicating Resident #79 was cognitively intact. In an interview on 2/27/23 at 2:26 pm, Resident #79 reported she complained to the facility for months regarding roommate's personal hygiene and the cleanliness of their room. Resident #79 stated the smell in the room makes me sick to my stomach. My roommate refuses to shower, to allow staff to clean up feces and urine off the floor and to change soiled linens. Resident #79 reported the staff clean the room after her roommate leaves for medical appointments three days a week. Resident #79 stated I told the Administrator my concerns and they told me to close the curtain and spray air freshener. Resident #79 pointed to a case of air freshener on the floor and reported the facility provided it to her because she complained about the smell in the room. Resident #79 reported she was approached about changing rooms, but she refused to do so because she struggled to trust staff, had refused care in the past because she did not trust staff, and now had a rapport with the staff in her hall. Resident also reported she was reluctant to change rooms as her current room was located near the supply/utility closets and as a result the staff were near her room often and she could get help quickly. Resident #79 stated It makes me feel disrespected because they're not doing anything about it, referring to a resolution about her grievance. In an interview on 3/1/23 at 11:04 am, Certified Nursing Assistant (CENA) X confirmed that Resident #79's roommate refuses incontinence care, removal of soiled linens and trash from the room. During an observation on 3/1/23 at 11:33am, after Resident #79's roommate left for a medical appointment, the roommate's bed was observed visibly soiled, linens appeared wet with yellowish tinge, strong smell of urine present in room and partially eaten food on bed and floor. During an observation on 3/123 at 11:40 am, Certified Nursing Assistant (CENA) X removed a large clear bag of soiled linens and clothing belonging to Resident #79's roommate, from the room. In an interview with Social Services Director HHH on 3/1/23 at 2:09 pm, it was revealed that a room change was offered to Resident #79, but the Resident refused and Social Services Director HHH did not determine why Resident #79 was reluctant to change rooms. Social Services Director HHH said other options such as a exploring the roommate's willingness to move, providing an air purifier were also not explored. In an interview on 3/7/23 at 12:27 pm, Social Services Director HHH indicated it is the responsibility of Social Services staff to coordinate counseling services, assess Residents' psychosocial needs and develop care plans to address each Resident's psychosocial needs, including trauma informed care approaches and to assist Residents in obtaining resolution to grievances. Social Services Director HHH confirmed additional person-centered interventions could have been pursued for both Resident #17 and Resident #79.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00132515. Based on observation, interview, and record review, the facility failed to label and date insulin pens in 1 of 2 medication carts, maintain secured medication carts, and ensure privacy of resident information for 1 Resident (Resident #69) in a facility of 96 residents, reviewed for labeling/storage of medications, resulting in the potential for decreased efficacy of medications and diversion. Findings include: Review of a facility Medication Storage Policy with a revision date of 01/01/2022 revealed: Policy-It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security Policy Explanation and Compliance Guidelines .1. General Guidelines: .a. All drugs and biological's will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls b. Only authorized personnel will have access to the keys to locked compartments (see attached listing) c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . During an observation and interview on 3/1/2023 at 10:25 AM of A Hall medication (med) cart with Staff Member (SM) DD all medication drawers were had dust, debris, and clutter. Two foiled-wrapped suppositories were loose in the drawer with insulin pens, lubricants, alcohol wipes and resident-shared glucometer. Ten (10) of 11 insulin pens did not have expiration dates written on them. The bottom drawer had an unlabeled box of cigarettes. SM DD stated, This is not my usual medication cart. I am responsible for it and the medications in it while I am assigned to it. The insulin pens should have the expiration written on the. Expiration for insulin pens is 28 days after opening. A nurse should know that. During an interview on 3/1/2023 at 4:37 PM, SM EE stated, Insulin pens should have the expiration date written on them, so the medicine does not go bad. During an interview on 3/7/2023 at 9:12 AM, Director of Nursing (DON) B stated, Insulin should be dated with the open date and the expiration date for the efficacy and infection control of the medication. Suppositories should not be kept in the same drawer or space as other medications. Each nurse at the start of their shift and thorough out their shift should make sure the medication cart is kept neat and clean, with medications properly labeled and stored. Resident #69 Review of an admission Record revealed Resident #69 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: stage 4 chronic kidney disease and kidney failure. Review of a Minimum Data Set (MDS) assessment for Resident #69, with a reference date of 2/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #69 was cognitively intact. In an observation on 3/01/23 at 10:13 AM., noted the medication cart on C hall left unlocked and with the computer open to a resident's chart. Noted no nurse present near medication cart. Other staff members and a resident visitor noted to be walking past the medication cart while it was unlocked. During an interview on 3/1/23 at 10:24 AM., Registered Nurse (RN) E reported the medication cart should be locked if left unattended. RN E reported it was her responsibility to ensure that, if she left the medication cart, it was locked. In an observation on 3/1/23 at 10:44 AM., RN E noted to leave medication cart unlocked and Resident #69's discharge paperwork including diagnosis, medication list, full name, date of birth , and other personal medical information visible. Noted other floor staff, residents, and visitors in the hall walking/ambulating by the medication cart/computer. In an interview on 3/1/23 at 10:56 AM., RN E reported the computer screen should not be open, and Resident #69's discharge paperwork should have been turned over or kept in a folder for privacy. RN E reported the medication cart should also be locked. RN E reported she just forgot to ensure the medication cart was locked, and Resident #69's paperwork covered, as she (RN 'E) was busy with Resident #69 discharging.

Based on observation, interview, and record review, the facility failed to ensure 1) resident-shared equipment (glucometer) was properly cleaned, 2) perform appropriate hand hygiene during medication administration, and 3) practice adequate infection control measures with staff wearing longer and artificial fingernails, resulting in the potential for cross-contamination and bacterial harborage, and the spread of infection to a vulnerable population. Findings include: During an observation on 3/1/2023 at 7:41 AM, Registered Nurse (RN) EE exited a resident room with a resident-shared glucometer that had been used to check blood glucose level and returned to medication (med) cart placing the glucometer on top without a barrier. RN EE used a yellow top bleach wipe for less than 15 seconds to wipe off the glucometer and placed the machine on top of the medication (med) cart without using a barrier. During an observation on 3/1/2023 at 8:00 AM, RN EE entered a resident room to administer medications and check blood glucose level with the same resident-shared glucometer as used on prior resident. After using the glucometer, RN EE placed the machine on the resident's bedside table that appeared tacky with a substance, without using a barrier. Without performing hand hygiene, RN EE donned gloves to boost resident in bed, use the bed controller to adjust bed, and hand resident their call light. After administering medications, RN EE returned to the med card, doffed gloves, donned on clean gloves without performing hand hygiene and used yellow-topped bleach wipes to wipe off glucometer less than 5 seconds and then placed it on top of the med cart without using a barrier. During an observation on 3/1/2023 at 8:05 AM, RN EE was at a med cart, touched the computer battery charger cord, locked the med cart and donned gloves without performing hand hygiene. The RN EE then entered a resident room, placing the resident-shared glucometer on top of personal items on the bedside table without using a barrier. Returning to the med cart with the glucometer, RN EE placed it on the top without using a barrier, doffed gloves, donned clean gloves without using hand hygiene, and wiped the glucometer with yellow-topped bleach wipes. The glucometer was then placed back on top of the med cart with no barrier. During an observation on 3/1/2023 at 8:14 AM, RN EE entered a resident's room and placed the portable resident-shared pulse oximeter on the resident's bedside table next to a breakfast tray and personal belongings without using a barrier. After using the resident-shared equipment, RN EE placed it back on the bedside table without using a barrier. Multiple times, the resident coughed without covering their mouth. The pulse oximeter was within 6 feet of the resident's mouth. RN EE left the resident's room without the pulse oximeter. At 8:47 AM, RN EE remembered the pulse oximeter had been left in a resident's room and retrieved it, donned gloves without performing hand hygiene, used a yellow-top bleach wipe to wipe off the resident-shared equipment for 30 seconds, and placed it on top of the med cart without using a barrier. During an interview and record review on 3/1/2023 at 8:52 AM, RN EE stated, I use bleach wipes to clean the glucometer after each resident use. I wipe off the equipment for 30 seconds and let it air dry. Hand hygiene should be done before preparing medications. Reviewed the yellow-top bleach wipes Clorox in the med cart with RN EE. The guidelines on the wipes label reported, .wipe glucometer after each resident use with bleach wipe at least 30 seconds and let air dry . During an interview on 3/7/2023 at 12:40 PM, Director of Nursing (DON) B stated, The glucometer should be treated like equipment in the hallways sanitized after each use. It does not matter what wipes are recommended; the nurses should be following the times indicated on the wipes for how long it should be in contact with the glucometer, then let air dry. It does not necessarily have to have a barrier under it. Review of facility procedure Blood Glucose Specimen and Sanitation undated, revealed, .Set up work area with disposable barrier between work and surface and items for task .using sanitizing cloth, wipe down all surfaces of machine, allowing for proper contact time of product . Observed on 2/27/2023 at 1:57 PM Certified Nursing Assistant (CNA) T emptying an ostomy bag for a resident with fingernails that extended ¼ inch past fingertips on both hands. Observed on 2/27/2023 at 3:53 PM CNA T wearing fingernails that extended ¼ inch past fingertips on both hands while performing incontinence care. Observed on 2/28/2023 at 7:56 AM CNA T wearing fingernails that extended ¼ inch past fingertips on both hands while performing direct resident cares. Observed on 3/1/2023 at 7:59 AM, CNA V tapping her artificial nails on the wall in the hall next to a medication cart the Surveyor was standing at. The nails extended more than ¼ inch past fingertips on both hands. During an observation and interview on 3/1/2023 at 8:14 AM, CNA V was performing incontinence care and a bed bath for a resident while wearing artificial nails that extended ¼ inch past fingertips on both hands. CNA doffed gloves and donned clean gloves tearing the gloves in the process due to the long fingernails. CNA donned another glove, brushed resident's hair, boosted the resident up in bed, arranged blankets, and assisted with breakfast tray, all while their thumb nail on right hand had ripped through the glove during care. CNA V stated, I am wearing artificial fingernails. During an interview on 3/1/2023 at 8:52 AM RN EE stated, Direct care staff, nurses and CNA's should not be wearing long fingernails for infection control purposes. During an observation and interview on 3/6/2023 at 12:20, CNA SSS was serving residents in the main dining room while wearing artificial nails that extended more than 1/4 inch past fingertips on both hands. During an interview on 3/7/2023 at 9:14 AM, DON B stated, Staff are not to wear artificial fingernails or wear any fingernail that extends ¼ inch past their fingertips because of infection control. Review of facility Employee Handbook revealed, .Direct care employees must comply with various CDC (Centers for Disease Control) guidelines and company guidelines regarding care and hygiene, such as appropriate length of nails . Hand hygiene is also indicated after contact with a patient's intact skin, contact with body fluids or excretions, non-intact skin, or wound dressings, and after removing gloves .Nail length is important because even after careful handwashing, HCWs often harbor substantial numbers of potential pathogens in the subungual spaces. Numerous studies have documented that subungual areas of the hand harbor high concentrations of bacteria, most frequently coagulase-negative staphylococci, gram-negative rods (including Pseudomonas spp.), corynebacteria, and yeasts. Natural nail tips should be kept to ¼ inch in length. A growing body of evidence suggests that wearing artificial nails may contribute to transmission of certain healthcare associated pathogens. Healthcare workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing. Therefore, artificial nails should not be worn when having direct contact with high-risk patients . https://www.cdc.gov/handhygiene/download/hand_hygiene.

Based on interview and record review, the facility failed to ensure staff received all required doses of COVID-19 vaccine, and maintain complete and accurate records of the COVID-19 vaccination status for all required facility staff. Findings include: A COVID-19 STAFF VACCINATION MATRIX was requested from the Nursing Home Administrator (NHA) during the entrance conference interview on 2/27/23 at 1:21 P.M. Review of COVID-19 STAFF VACCINATION MATRIX received on 2/28/23 at 9:06 A.M. via email from the NHA, revealed 182 total staff, 21 staff had declined the vaccination, and were not listed as having an exemption. Resident Aide (RA) XX and Staff Member (SM) JJJJ were listed as receiving 1 dose of a multi-dose vaccine and were eligible for a second dose. In an interview on 02/28/23 at 11:53 A.M., the NHA reported that the 21 staff that declined all had non-medical exemptions. This surveyor requested that NHA provide an updated accurate document. An updated document was provided via email on 2/28/23 at 12:26 A.M. which included added exemption column for the staff that had declined the vaccine. In an interview on 03/02/23 at 01:33 P.M., NHA reported that the COVID-19 STAFF VACCINATION MATRIX included some of the contracted staff that are in the facility frequently, but not all contracted staff. NHA reported that SM JJJJ was not currently employed, and RA XX attended our CNA class, but was removed from the schedule until she received her second dose of the vaccine and stated, .I think she got it this week .she is back to work . At 03:45 P.M., requested an updated complete and accurate COVID-19 STAFF VACCINATION MATRIX as soon as possible. In an interview on 03/02/23 at 02:00 P.M., RA XX reported that she was hired a few weeks ago, that she had received her first dose of the vaccine in October 2022 and received her second dose on 2/27/23. RA XX reported that she completed her orientation, and then was told that she could not come back until she had her second vaccine. Review of COVID-19 STAFF VACCINATION MATRIX received on 3/6/23 at 6:46 A.M. via email from the NHA, revealed 195 total staff, 22 staff with non-medical exemptions and 3 staff (SM JJJJ, CNA LLLL, RA WW) were listed as receiving 1 dose of a multi-dose vaccine and were eligible for a second dose. In an interview on 03/07/23 at 08:40 A.M., Human Resources (HR) KKKK reported that RA XX had received her first dose on 10/10/22 and was hired on 1/24/23. HR KKKK reported that RA XX was allowed to attend orientation and also CNA class 2/13/22-2/20/23 located at a sister facility and stated, .(RA XX) was removed from class due to other issues in the classroom . HR KKKK reported that RA XX did not get her second dose of the vaccine and stated, .it slipped through the cracks .she should have not attended class .our policy is they are not to come to orientation without second dose or approved exemption . HR KKKK reported that RA XX met with NHA on 2/22/23 and was informed that she could not return to work until after her second dose of the vaccine. Review of Covid Vaccine Attestation dated 1/23/23 revealed, .(RA XX) received a single dose of a two dose vaccine and was scheduled to receive the second dose on 1/25/23 .I understand I will need to provide proof no later that the first day of employment . Review of RA XX's vaccine card indicating 2 doses of covid-19 vaccine; 10/10/22 and 2/27/23. In an interview on 03/07/23 at 12:51 P.M., NHA reported that RA WW's second dose was accidentally deleted off of the COVID-19 STAFF VACCINATION MATRIX, Staff Member JJJJ was hired but never came to orientation. No further information related to CNA LLLL was received prior to exit. Review of a facility policy Staff COVID-19 Vaccinations Mandate Policy dated 5/21/21 revealed, .To help reduce the risk for residents and staff contracting and spreading COVID-19, the facility will establish a process to comply with the Federal staff vaccine mandate unless they have a medical or religious exemption or any CDC approved reason to delay receiving the vaccine. It is the policy of this facility to ensure that all eligible staff are vaccinated against COVID-19 as per applicable Federal, State and local guidelines. For those staff who have pending or approved exemptions/delays, accommodations may be made per the Interim Final Rule, CMS/CDC/State and local guidelines .1. The facility will ensure that all eligible staff are fully vaccinated against COVID-19, unless religious or medical exemptions are pending approval or granted, or there is a CDC approved delay, as per CMS guided timeframes. (See CMS Vaccine Mandate Timeframes Attachment). 2. Staff, who provide any care, treatment, or other services for the facility and/or its residents regardless of clinical responsibility or resident contact will be fully vaccinated against COVID-19 (unless religious or medical exemptions are pending approval or granted, or there is a CDC approved delay) .9. The facility will track and securely document for all staff: a. The name, role, assigned area of responsibility, contact level with residents b. The vaccination status of each staff member (current and as new staff are on boarded). c. Individuals whose vaccination is temporarily delayed, as recommended by the CDC due a clinical precaution or consideration and the reason for the delay. d. Documentation which confirms clinical contraindications for medical exemptions. Policy Staff COVID-19 Vaccinations e. Individuals who have requested religious or medical exemptions and the outcome of those requests. f. Individuals that have received an additional or booster dose(s) after their primary vaccination series .12. Vaccinations, as per brand and timing of doses, will be given per manufacturer ' s recommendations. 13. The facility will provide education, educational materials, vaccination fact sheets, counseling or other vaccine information to the employee prior to administration of the vaccine and consent for the vaccine will be obtained. 14. The facility will establish contingency plans in the event that staff have indicated that they will not get vaccinated and do not qualify for an exemption or staff who are not fully vaccinated due to an exemption or temporary delay in vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This portion of the citation pertains to Intake MI00132307. Resident #79 A review of a Face Sheet for Resident #79 dated 5/1/21 revealed pertinent diagnosis of adult failure to thrive (syndrome of global decline often accompanied by depressive symptoms). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Basic Inventory of Mental Status (BIMS) score of 15, indicating Resident #79 was cognitively intact. During on observation on 2/28/23 at 8:35 am, a strong smell of body odor was detected beginning 15 feet from the doorway and intensified upon entering Resident #79's room. In an interview on 2/28/23 at 2:26pm, Resident #79 reported she complained to the facility for months regarding roommate's personal hygiene and the cleanliness of their room. Resident #79 stated the smell in the room makes me sick to my stomach and gives me a headache. My roommate refuses to shower, to allow staff to clean up feces and urine off the floor and to allow the staff to change soiled linens. Resident #79 reported the staff clean the room after her roommate leaves for medical appointments three days a week. Resident #79 stated I told the Administrator my concerns and they told me to close the curtain and spray air freshener. Resident #79 pointed to a case of air freshener on the floor and reported the facility provided it to her because she complained about the smell in the room. Resident #79 stated It makes me feel disrespected because they're not doing anything about it. Resident #79 reported she was approached about changing rooms once but did not to pursue this as an option because it had taken her a long time to develop a rapport with her caregivers and she now felt she could trust them. Resident #79 reported she also worried about changing rooms because her current room was near supply closets and as a result the staff were near her room frequently and she felt moving could decrease her quality of care. Resident stated, I feel like I get good care in this room and I'm afraid to leave it. In an interview 03/01/23 at 11:04 am, Certified Nursing Assistant (CENA) X reported Resident #79's roommate regularly refused care after episodes of incontinence and staff were told to no longer offer the roommate showers. CENA X stated it stinks so bad in there and I know (Resident #79) has complained about it and nothing has been done. In an interview on 03/06/23 at 11:31 am with Social Services Director HH, it was revealed that an offer to change rooms had been presented to Resident #79 but was declined. Resident #79's reason for the decline of a room change was not explored and Social Services Director HH' offered no additional support to Resident #79. Resident #68 Review of a Face Sheet revealed Resident #68 was a male, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood), other specified anxiety disorders, and colostomy status (an opening formed by drawing the colon through an incision in the abdominal wall which is attached to a colostomy bag [or pouch] on the outside of the body to collect fecal waste). Review of a Minimum Data Set (MDS) assessment for Resident #68, with a reference date of 2/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #68 was cognitively intact. Review of the Functional Status assessment from said MDS revealed Resident #68 required extensive, two-person physical assistance for bed mobility, dressing, and personal hygiene. In an interview on 2/27/23 at 3:48 PM, Resident #68 reported staff did not consistently answer his call light timely. Resident #68 reported he had a colostomy bag. Resident #68 recalled an incident when his colostomy bag was getting too full (of fecal waste), and he had turned his call light on for assistance to empty it. Resident #68 reported nobody had come to assist after 30 minutes so he called the front desk and told the staff (could not recall name of staff member) who answered that it was full and needed emptied now. Resident #68 reported the staff member had said that they would send a nurse aide down to assist. Resident #68 reported waited another 15-20 minutes for staff to come, but nobody came, and he called the front desk again. Resident #68 reported the staff that answered the phone that time said they would come themselves. Resident #68 reported by the time someone came to assist him, he had waited an hour. Resident #68 reported the experience made him feel like nothing, like I didn't matter. Resident #83 Review of a Face Sheet revealed Resident #83 was a male, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood), and depression. Review of a Minimum Data Set (MDS) assessment for Resident #83, with a reference date of 12/2/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #83 was cognitively intact. In an interview on 2/27/23 at 3:16 PM, Resident #83 reported had waited 2-3 hours for his call light to be answered on 3rd shift sometimes. Resident #4 Review of a Face Sheet revealed Resident #4 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood), major depressive disorder, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #4 , with a reference date of 2/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #4 was cognitively impaired. Review of the Functional Status assessment from said MDS revealed Resident #4 required extensive, one-person physical assistance for bed mobility, toilet use, and personal hygiene. Review of the Bladder and Bowel assessment from said MDS revealed Resident #4 was Frequently Incontinent of bladder and bowel. In an interview on 2/28/23 at 12:12 PM, Resident #4 reported call light wait time had been 45 minutes to an hour at times. Resident #4 reported was frequently incontinent of urine and went in her brief, which meant she needed frequent brief changes from staff throughout the day. Resident #4 reported felt some of the staff did not treat her with dignity during brief changes because they had to change her brief frequently. Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect in 5 of 30 residents (R22, R65, R29, R68, R83, R4 and R79) reviewed for dignity/respect, resulting in the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Review of a facility policy, Call Lights: Accessibility and Timely Response date revised, 1/1/2022, revealed, . All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified . Review of facility policy, Resident Rights revised 1/1/2022, revealed, Policy: Employees shall treat all residents with kindness, respect, and dignity . Resident #22 According to the Minimum Data Set (MDS) dated [DATE], Resident #22 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), had impairment in one of her arms, required extensive assistance for turning/positioning, was always incontinent of bowel and bladder, with diagnoses that included heart disease, partial paralysis, anxiety, depression, and manic depression. Review of Resident #22's Concern Form dated 1/10/2023 indicated the resident had a concern with care provided by staff. Resident #22 reported call light response time and not being changed by staff. She further reported staff turned off the call light saying they would be back and then never returned. The form was given to the nursing department to review finding The call light response as times some staff turn off light and say they will be back and never come back. The plan/action was to educate staff on fast call light response and the importance of not turning off light until finished. During an observation and interview on 3/1/2023 at 4:05 PM Resident #22 stated, The staffing is short on second shift. There will only be one CNA (certified nursing assistant) on our hall (A) and we have to wait to be changed. The CNA will be frazzled, and it is hard for residents to see her worn out by being worked so hard. There are a lot of us who need two staff for care and not enough staff to help. Resident #65 According to the Minimum Data Set (MDS), Resident #65 scored 10/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status), required extensive assistance with two-person physical assistance with turning/positioning in bed, toilet use, had impairment in both her legs, was always incontinent of bowel and bladder, with diagnoses that included heart and respiratory failure. During an observation and interview on 2/27/2023 at 3:44 PM, Resident #65's door to her room was open with her bed area by the door. The resident was yelling out, Nurse, Nurse repeatedly. She had initiated her call light which was lit over her door that was seen by the end of the hall at the main nurse's station. Resident #65 stated to Surveyor, I need to be changed. CNA U entered the room, turned off the call light, and said to Resident #65 she would go get someone to help change her because she was not assigned to Resident #65. The CNA left the room and Resident #65 continued to yell out Nurse, Nurse. Observed on 2/27/2023 at 3:48 PM CNA U entered Resident #65's room and told resident, I'm on my way home, let me go get your aide. I've got to go pick up my son from school. I'll make sure she changes you. The CNA turned of Resident #65's call light and left the room. No CNA came to assist Resident #65, and she continued to yell Nurse, Nurse. During an observation and interview on 2/27/2023 at 3:49 PM Nurse Practitioner (NP) YYY was in the hall and heard Resident #65 yelling out Nurse, Nurse with Surveyor standing outside resident's door. The NP entered Resident #65's room stating to her I will let your nurse know you need to be changed. Resident stated, I've been asking for help. NP stated, Turn on your call light on. How can they know you need help if you do not turn it on. NP turned on call light on at 2/27/23 at 3:51 PM. NP stated to Surveyor, Her call light was not on. When Surveyor explained to NP Resident #65's call light had been on with a CNA shutting it off and not assisting her, NP YYY stared at Surveyor and walked towards nurse's station. Registered Nurse (RN) JJ entered Resident #65's room responding to resident yelling, Nurse, Nurse, Resident told RN Everyone comes in and tells me they will get someone to help me, but they never come back. RN stated, I will help you and then left the room. RN JJ did not return to Resident #65's room to assist her. Resident #65 continued to yell out repeatedly, Nurse, Nurse. During an observation and interview on 2/27/23 at 3:53 PM, CNA T entered Resident #65's room stating to resident, What is wrong? What can I help you with. Resident #65 stated, I need to be changed. Everyone that comes in tells me they will help me and then they leave. CNA turned off call light, assured resident she would be right back to assist resident and needed to get another CNA to assist in cares. At 3:55 PM, CNA KK entered Resident #65's room to assist CNA T with resident care. At 3:56 PM, CNA O entered Resident #65's to assist with resident care. Not 1 of the 3 CNAs closed the privacy curtain between Resident #65 and her roommate. The roommate was next to the window that had the blinds opened to the outside. CNA KK left the room to assist other residents. Resident #65's brief was pulled down by CNA T which exposed her private area to roommate and window. The privacy curtain and window blinds were open throughout the incontinence care. Resident #29 According to the Minimum Data Set (MDS) dated [DATE], Resident #29 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), required extensive assistance of two-persons physical assistance for turning/positioning in bed, with diagnoses that included heart failure. During an observation and interview on 3/01/23 at 9:28 AM Resident #29 initiated her call light to ask for assistance in rinsing her dentures. SM EE was two doors down the hall at the medication cart. During an observation and interview on 3/01/23 at 9:30 AM SM (Staff Member) AAAA looked into Resident #29's room and walked away without asking the resident what she needed. SM AAAA stated, Housekeeping can answer call lights if they see aides are busy. If the resident asks for something like water Housekeeping can give it to the resident. If not, we tell the resident's nurse. SM AAAA did not tell SM EE Resident #29's call light was on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #68 Review of a Face Sheet revealed Resident #68 was a male, with pertinent diagnoses which included: other specified anxiety disorders, and colostomy status (an opening formed by drawing the colon through an incision in the abdominal wall to collect fecal waste into a pouch at the outside of the body). Review of a Minimum Data Set (MDS) assessment for Resident #68, with a reference date of 2/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #68 was cognitively intact. Review of the Functional Status assessment from said MDS revealed Resident #68 required extensive, two-person physical assistance for bed mobility, dressing, and personal hygiene and was total dependence of 1 person for bathing. Review of Resident #68's Interview for Daily Preferences from the MDS assessment with a reference date of 8/23/22 revealed it was Very important to Resident #68 to be able to choose between a tub bath, shower, bed bath, or sponge bath. Review of Resident #68's current Care Plan revealed a focus of The resident needs activities of daily living assistance . with pertinent interventions which included, BATHING/SHOWERING: The resident requires 2 staff assistance to bathe/shower, resident preference to be transported in shower chair from room to shower room. Please discuss with the Resident what time a shower would work best for him at the beginning of the shift to allow him to prepare. He does tend to prefer an evening bath verses a morning one last reviewed 11/14/22. In an interview on 2/27/23 at 3:48 PM, Resident #68 reported he preferred to receive showers and that his preferred shower days were Wednesday and Saturday. Resident #68 reported that he did not always get showers as scheduled and that he had received a bed bath instead of a shower at times which was not his preference. Resident #68 reported has been told by staff that he would have to wait until the following day (not on his preferred shower day) to get showered when they had too many other showers to give other residents on the same day. On 3/7/23 at 1:05 PM, SA (State Agency) reviewed Resident #68's shower task documentation for the last 30 days (2/6/23 - 3/7/23) which revealed, Task: ADL (activities of daily living) - Shower (Weds (Wednesday) & Sat (Saturday) 1st shift) . Of the 4 opportunities for Resident #68 to receive a shower on his preferred shower day of Wednesday during the period reviewed, there were 2 showers documented as being given (2/15/23 and 3/1/23) and 2 showers documented as refused (2/8/23 and 2/22/23). Of the 4 opportunities for Resident #68 to receive a shower on his preferred shower day of Saturday during the period reviewed, there was documentation that Resident #68 refused the shower opportunity on 2/18/23, and that Resident #68 received a shower, per preference on Saturday, 2/25/23. There was no documentation for preferred for Saturdays 2/11/23 and 3/1/23. It was documented that Resident #68 received a shower on 2/6/23 (a Monday), and a bed bath on 2/12/23 (a Sunday). This citation pertains to Intakes: MI00132346, and MI00132312. Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) cares and assistance were provided per resident preference for 4 residents (Resident #58, #73, #89 and #68) of 20 residents reviewed for resident preferences, resulting in the potential for dissatisfaction with care and an overall decline in sense of physical, mental, and psychosocial well-being. Findings include: Resident #58 Review of an admission Record revealed Resident #58, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer's disease. Review of a Minimum Data Set (MDS) assessment for Resident #58, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09/15 which indicated Resident #58 was cognitively impaired. In an observation/interview on 2/28/23 at 10:11 AM., Resident #58 was in his bed, noted his face and hands soiled with food that was dried and stuck on. Resident #58's fingernails were long with grime underneath. Resident #58 indicated he would like to have both his face and hands cleaned as well as needing his fingernails trimmed. Resident #58 reported he could not trim his fingernails by himself. In an observation on 2/28/23 at 12:42 PM., Resident #58 was in his bed, noted his face and hands soiled with food that was dried and stuck on. Resident #58's fingernails were long with grime underneath. In an observation on 3/01/23 at 10:40 AM., Resident #58 was laying in his bed awake, staff members Certified Nurse Aide (CNA) J entered room, checked on resident and left his room abruptly. Resident # 58 indicated to this surveyor he would have like to have his hands washed which were noted by this surveyor to be soiled with dried crusted food, his fingernails were 1/4 inch longer than the tip of his fingers and all had dried, dark grime buildup. In an observation/interview on 3/01/23 at 12:14 PM., Resident #58 was laying in his bed asleep, noted his hands and fingernails were soiled. CNA J and CNA L came in to check and change Resident #58, while performing care (washing him up) neither CNA J nor CNA L looked at or washed Resident #58's hands, face and/or noticed Resident #58's fingernails which were long and soiled with grime. In an interview on 3/1/23 at 12:30 PM., CNA J reported it is challenging to get to the little things like nail care for residents. CNA J reported there are times when residents don't get their showers especially nights and weekends. CNA J reported nail care gets done by the CNA staff typically, and if Resident #58's hands and fingernails were soiled, they (CNA J and CNA L) should have noticed while performing care for Resident #58. In an observation on 3/02/23 at 10:49 AM., Resident #58 noted to be asleep in his bed. Resident #58's fingernails were noted to be long, the fingernail bed and underneath the fingernails were heavily soiled with grime. In an observation on 3/06/23 at 11:48 AM., Resident #58 was observed laying in his bed. Resident #58's fingernails had been trimmed. Noted Resident #58's fingernail bed, and underneath the fingernails were noted to be heavily soiled in appearance. In an observation on 3/06/23 at 2:36 PM., Resident #58 was observed laying in his bed asleep. Resident #58's fingernails were heavily soiled around the fingernail/cuticles and underneath the fingernails were noted to be heavily soiled with grime. In an interview on 3/07/23 at 12:55 PM., Registered Nurse (RN) JJ reported both nurses and CNA's are responsible for cleaning residents hands and face after meals and any time residents are noted to be soiled in any way. RN JJ reported residents with diabetes have their fingernails trimmed by nurses only. RN JJ reported residents hands and fingers should be washed before meals, and after. Resident #73 Review of an admission Record revealed Resident #73, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: type 2 diabetes. Review of a Minimum Data Set (MDS) assessment for Resident #73, with a reference date of 1/12/23 revealed a Brief Interview for Mental Status (BIMS) score of 08/15 which indicated Resident #73 was cognitively impaired. Further review of the MDS for Resident #73 revealed .Section G. Functional Status Personal hygiene - how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) Resident #73 was coded as a 3/2 indicating Resident #73 was extensive with 1 person physical assist .Section F. Preferences for Customary Routine and Activities .C. how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Resident #73 was coded with a #1 indicating Coding: 1. Very important . In an interview on 2/28/23 at 10:05 AM., Resident #73 reports staff does not help him shave. Resident #73 noted to have facial hair and would like to shave. Resident #73 reports he has not been given shaving cream or a razor, or a mirror. Resident #73 reported he has asked for shaving items but has never received them. In an interview on 2/28/23 at 2:47 PM., Resident #73 reports would like to have something to shave with. Resident #73 reported he thought by now someone would have come in to asked if he needed items for shaving. In an observation and interview on 3/01/23 at 10:43 AM., Resident #73 observed awake laying in his bed wearing a hospital type gown. Resident #73's facial hair was noted on his mustache area, and scruff around chin, cheeks, and neck. Resident #73 reported he would like a shave but none of the staff have given him shaving supplies. Resident #73 reported if he had the tools he could do it (shave) himself. In an interview on 3/02/23 at 11:00 AM., CNA L reported she has not shaved Resident #73 because she thought only nurses could shave the residents. CNA L reported Resident #73 has requested shaving items/supplies but she was unsure where to get them, and that she was unsure if he was capable to shave himself. CNA L reported she has not asked the nurse where supplies for shaving were kept, nor did she inform the nurse on duty that Resident #73 wanted to shave. Resident #89 Review of an admission Record revealed Resident #89, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic obstructive pulmonary disease. Review of a Minimum Data Set (MDS) assessment for Resident #89, with a reference date of 1/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 03/15 which indicated Resident #89 was cognitively impaired. In an observation and interview on 3/06/23 at 2:58 PM., Resident #89's hair was noted to be greasy. Resident #89's reported he gets a bed bath. Resident #89 reported he cannot remember the last time he had his hair washed. In an observation and interview on 3/06/23 at 3:15 PM., Family Member (FM) CCC reported many times when visiting (Resident #89) he has not been dressed or cleaned up. FM CCC reported they (FM CCC) were not sure when staff even shower him. FM CCC started to comb Resident #89's hair. FM CCC reported she notices a lot of the residents, especially the female residents, with longer hair that was often stringy and greasy. FM CCC stated it makes me sad, and I just want to come in and wash their hair for them (Resident #89 and other residents noted with greasy hair).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17 A review of a Face Sheet for Resident #17 dated 6/10/22, revealed a pertinent diagnosis of PTSD (Post Traumatic Stress Disorder). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Inventory of Mental Status (BIMS) score of 15 indicating Resident #17 is cognitively intact. A review of shower records dated from 5/29/22-9/28/22 revealed Resident #17 had been approached about showering 40 times during that time period. A review of a Care Plan initiated on 8/11/22 revealed no Focus/Goal/Approach for Resident #17's diagnosis of PTSD (Post Traumatic Stress Disorder). An intervention was added on 10/10/22 that identified Resident #17's preference to wash self independently in bathroom rather than shower. In an interview on 2/28/23 at 8:40am, Resident #17 reported that as a result of PTSD (Post Traumatic Stress Disorder) she does not shower because she was not comfortable getting naked in front of anyone. Resident #17 voiced that the staff had repeatedly asked her about showering when she was admitted to the facility which made her feel very stressed, that she was concerned she would be forced to shower which brought back old memories. After a few months, she contacted her previous counselor who provided a written statement that supported Resident #17 not being approached about showering. The Resident has not been asked to shower since that time. Resident #68 Review of a Face Sheet revealed Resident #68 was a male, with pertinent diagnoses which included: osteomyelitis (bone infection) of vertebra (bones of the spine), sacral and sacrococcygeal region (portion of the spine between lower back and tailbone). Review of a physician's order for Resident #68 revealed, Doxycycline Monohydrate (an antibiotic) 100 MG (milligram) Capsule Give 100 mg by mouth two times a day related to OSTEOMYELITIS OF VERTEBRA, SACRAL AND SACROCOCCYGEAL REGION with a start date of 1/24/23. A review of a current Care Plan for Resident #68 was conducted on 3/6/23 at 1:03 PM which revealed no care planned focus, goals, or interventions for the use of the antibiotic Doxycycline Monohydrate. In an interview on 3/7/23 at 10:07 AM, Interim Director of Nursing (IDON) B reported if a resident was on an antibiotic, it should be on their care plan. IDON B reported any staff member could update a resident's care plan, but the infection preventionist was the one who ensured that antibiotic use was care planned. In an interview on 3/7/23 at 10:47 AM, Infection Control and Preventionist (ICP) BBB reported Resident #68's osteomyelitis had resolved but that Resident #68 received the Doxycycline Monohydrate prophylactically (as a precaution to prevent infection). ICP BBB reported Resident #68 had been receiving that antibiotic for quite some time, but that the order had just been renewed on 1/24/23. ICP BBB reported there was no specific care planned focus, goals, or interventions for that antibiotic use, but that Resident #68 did have a care plan for his skin with an intervention to provide the resident with medications as ordered. ICP BBB reported that intervention covered the antibiotic. ICP BBB reported the Doxycycline Monohydrate that Resident #68 received was not for his skin. ICP BBB reported would have to check with other members of the team to see if there was a care plan for the prophylactic use of the Doxycycline Monohydrate for Resident #68 and would follow up with the SA (state agency) later. No additional information was provided to SA by ICP BBB on this matter prior to survey exit. Resident #47 Review of a Face Sheet revealed Resident #47 was a female, with pertinent diagnoses which included: hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side, feeding difficulties, and dysphagia (swallowing difficulty). Review of a Minimum Data Set (MDS) assessment for Resident #47, with a reference date of 1/12/23 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #47 was severely cognitively impaired. Review of the Functional Status assessment from said MDS revealed Resident #47 required extensive, one-person physical assistance with eating. Review of Resident #47's current Care Plan revealed a focus of, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Stroke, Limited Mobility .feeding difficulties with care planned interventions which included EATING: .utilizes a plate guard (a device affixed to a plate to prevent food from falling off the plate) & red foam handles on silverware (foam placed over handles designed for ease in grasping the silverware) . last revised 2/13/23. During an observation on 2/28/23 at 10:03 AM, noted Resident #47 in bed. Resident #47 was eating chocolate pudding out of a small bowl using a regular spoon. There was no red foam handle on the spoon. During an observation on 2/28/23 at 1:08 PM, noted Resident #47 in bed eating lunch at her bedside table. Resident #47 was using silverware that had red foam handles. There was a plateguard that was placed upside down (with the prongs used to affix the device to the plate pointing upward) on Resident #47's food plate, that was not affixed to the plate appropriately. There was a noticeable amount of food from Resident #47's plate on the bedside table that had been pushed off the plate. In an interview on 2/28/23 at 1:11 PM, Licensed Practical Nurse (LPN) G was requested to view the plateguard on Resident #47's plate and confirmed that the plateguard had not been affixed properly. During an observation/interview on 3/6/23 at 9:19 AM, Resident #47 was observed in her room in her bed eating breakfast. There was no plateguard affixed to Resident #47's plate. LPN G entered Resident #47's room and was queried about the plateguard for Resident #47. LPN G stated She is supposed to have a plateguard. There is not one there. In an interview on 3/6/23 at 11:49 AM, Occupational Therapist (OT) YY reported Resident #47 required a plateguard to use because of the hemiplegia (one sided weakness) and needed the device to help make sure she could scoop the food onto her silverware and not push the food off the plate to maintain as much independence as possible with eating. Based on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 5 residents (Resident #12, 17, 47, 68, and 204) of 30 sample residents reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident 's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident 's written plan of care . Resident #12 Review of an admission Record revealed Resident #12 was a male with pertinent diagnoses which included Parkinson's Disease, unsteadiness on feet, stroke, anxiety, specified disorders of bone density, cognitive communication deficit, pain, and constipation. Review of a Minimum Data Set (MDS) assessment for Resident #12, with a reference date of 2/7/23 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated Resident #12 was moderately cognitively impaired. MDS Section G: Balance During Transitions and Walking .E. Surface to surface transfer (transfer between bed and chair or wheelchair) .2. Not steady, only able to stabilize with human assistance . Review of current Care Plan for Resident #12, revised on 2/17/23, revealed the focus, .Resident is at risk for falls related to: Parkinson's disease, Cerebral Infarction, Pain, Anxiety, Sepsis, unsteadiness on feet, cognitive communication deficit .resident is at times forgetful and will attempt to get up and walk around room without notifying staff of needs . with the intervention .Bed in low position with Resident is in bed otherwise, bed to remain at transfer height .Fall mat to right side of bed at all times . Review of Incident Report dated 12/7/22 at 12:30 PM .Resident was observed on the floor next to his bed. He stated that he was attempting to walk to his w/c, which was located across the room. Bed was in lowest position. His call light was on & he had a pillow positioned under his head. Resident states that he pushed his call light after falling. He was educated on need to call for assistance with transfers to prevent falling. Staff were re-educated on leaving w/c at bedside with brakes locked while in bed .Shows with an abrasion to left shin. Cleansed & left open to air .Intervention: Staff educated on keeping w/c (wheelchair) at bedside with brakes locked while in the bed . Review of Incident Report dated 12/24/22 at 11:30 AM, revealed, .Resident was observed sitting on the floor next to his bed. He stated that he was attempting to check out the bathroom & slipped out of bed. No injuries or pain noted & denies hitting his head. Call light was on .Intervention: Floor mat will be placed on floor (right side of bed) . Review of Incident Report dated 1/26/23 at 10:05 AM, revealed, .Per nurse, when the CNA entered the Resident's room the resident was observed attempting to pull himself up on to bed and then to a seating position on his bedside floor .Per staff, resident stated he was attempting to self-transfer from w/c (wheelchair) in to bed. Resident also stated he had used the call light but attempted to self-transfer prior to staff arriving .Intervention: Bed height adjustment .bed in low position . During an observation on 2/27/23 at 1:29 PM, Resident #12 was observed lying in his bed. Resident #12's bed was not in a low position and a fall mat was not placed next to his bed. During an observation on 2/28/23 at 12:26 PM, Resident #12 was observed lying in his bed and his bed was not in a low position and the fall mat was not next to his head. During an observation on 3/01/23 at 9:07 AM, Resident #12 was observed lying in his bed, no fall mat in place next to his bed and his bed was not in low position. During an observation on 2/27/23 01:36 PM, Resident #12 was observed lying in his bed. Resident #12's bed was not in a low position and a fall mat was not placed next to his bed. During an observation on 2/28/23 at 3:57 PM, Resident #12 was observed lying in his bed, bed was not in the low position and no fall mat was next to his bed. During an observation on 3/01/23 at 9:07 AM, Resident #12 was observed lying in his bed, no fall mat in place and his bed was not in the low position. During an observation on 3/01/23 11:32 AM, Resident #12 was observed lying in his bed and his bed was not in the low position. In an interview on 3/01/23 11:33 AM, Certified Nursing Assistant (CNA) P reported CNAs have access to the resident's care needs in the computer on the [NAME] (a guide to individualize resident care). CNA P reported they could also speak to the nurse to get information on the resident. CNA P reported Resident #12 does not have fall interventions in place such as the fall mat and the bed was not in the low position. In an interview on 3/07/23 at 12:55 PM, Assistant Nursing Home Administrator (ANHA) C reported those who were assigned to residents for caring partners review the [NAME] for those residents. ANHA C reported we would observe if the resident was cleaned up and ready for breakfast, ensure everything they need was in their reach, and when there were concerns we would report them to the appropriate department, follow up with those departments to ensure the they have followed up, and if there were any abuse concerns it would be reported to the abuse coordinator. In an interview on 3/7/23 at 10:37 AM, Director of Nursing (DON) B reported ensured staff were implementing the resident's care plan interventions nurses should know who were the high fall risk residents were on the hallway. The caring partners review the [NAME] prior to meeting with their assigned residents and would make note of any interventions which were not in place. DON B reported the care plans were updated with an immediate intervention by the nurse when an acute change takes place, such as a fall. DON B reported during the morning meetings we discuss quality measures; changes needed for the care plans. Therapy was present in there as well, review charting, any discrepancies will follow up with the aides to determine if the change was a true change in condition or temporary; nurses complete assessments and we would go from there. Resident #204 Review of an admission Record revealed Resident #204 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dysphasia (trouble swallowing) and dry mouth. Review of a Minimum Data Set (MDS) assessment for Resident #204, with a reference date of 3/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #204 was-cognitively intact. In an observation on 2/28/23 at 2:00 PM., noted on Resident #204's bedside table 5 mouth swabs (moistening sponges) for moistening Resident #204's mouth (Resident #204 was NPO-Nothing By Mouth). During an observation on 3/06/23 at 12:10 PM., Resident #204 noted to have a styrofoam cup with a straw and thin liquid water on his bedside table within his reach. In an interview on 3/06/23 at 12:11 PM., Certified Nurse Aide (CNA) L reported Resident # 204 should not have a cup of water at his bedside table. CNA L reported she was unsure how Resident #204 got the water on his bedside table. CNA L reported any staff working with Resident #204 should know that he is NPO and gets his medications and nutrients through a feeding tube. In an interview on 3/06/23 at 12:12 PM., Physical Therapist (PT) OOO reported Resident # 204 was NPO (nothing by mouth). PT OOO reported Resident # 204 should not have had any cup of water or anything on his bedside table besides mouth swabs (moistening sponges) to help alleviate his dry mouth. Review of Resident #204's Care Plan revealed: The resident (Resident #204) is at nutritional risk r/t (related to) past medical history of chronic obstructive pulmonary disease dysphasia, congestive heart failure, angina, respiratory failure with hypoxia, emphysema NPO (nothing by mouth). Enteral support provided Date Initiated: 02/23/2023 Revision on: 02/28/2023---INTERVENTION --The resident needs the HOB elevated 30-45 degrees per aspiration precautions, NPO.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #s: MI00132346, MI00133753, MI00132312, and MI00133665. Based on observation, interview, and record review, the facility failed to ensure 1.) published menu was served as planned, 2.) residents were consistently informed of the planned menu in advance and 3.) resident food choices were obtained and honored for 8 (Resident #s: 57, 68, 83, 4, 61, 77, 75, and 22) of 10 residents reviewed for meal services, resulting in resident dissatisfaction with their meal experience, feelings of frustration related to meals, and the potential for inadequate food/fluid intake and weight loss. Findings include: Review of the document MENU SELECTION . revealed, 1. All tickets are printed out in advance. Each Unit has its own binder. Nursing staff ask each Resident if they want the Main Meal, Alternative Meal or something listed on our 'Always Offered Menu' the day before service. Alternatives are written on the resident's meal ticket. 2. The kitchen staff tally's up the tickets prior to service and gives it to the cook to prepare. 3. The Dietary department identifies any new diet requisitions for any diet changes or new admissions within the facility. Changes are then made as necessary. Resident #57 Review of a Face Sheet revealed Resident #57 was a female, with pertinent diagnoses which included: other specified depressive episodes. Review of a Minimum Data Set (MDS) assessment for Resident #57, with a reference date of 2/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #57 was cognitively intact. In an interview on 2/28/23 at 8:26 AM, Resident #57 reported did not always receive what was on the planned menu. Resident #57 showed SA (state agency) a copy of her tray ticket from 2/24/23 that indicated she was to receive a pork chop, mashed potatoes, and corn. Resident #57 reported she received a pork chop, roasted potatoes, and green beans instead. Resident #57 reported it seemed there was a change in the planned menu almost every day and she did not know about it until she received her meal tray. Resident #57 stated felt like They give us what they feel like giving us regardless of what we want. In an interview on 3/6/23 at 10:33 AM, Resident #57 reported did not know what she was getting for lunch that day because staff had not come to ask her what she wanted. Resident #57 reported received mashed potatoes instead of the baked potato she had wanted for lunch on Sunday (3/5/23). Resident #68 Review of a Face Sheet revealed Resident #68 was a male, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) and other specified anxiety disorders. Review of a Minimum Data Set (MDS) assessment for Resident #68, with a reference date of 2/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #68 was cognitively intact. In an interview on 2/27/23 at 3:48 PM, Resident #68 reported the facility used to pass out menus to each resident but no longer did that. Resident #68 reported preferred to receive a menu in advance so he would know what he was having. Resident #68 reported the facility did not consistently ask him what he wanted for his meals and stated sometimes we don't know what we are getting until we get it. Resident #68 reported there had been times that he had not received silverware on his tray and that the staff that deliver the meal trays to the residents in their rooms were supposed to wait to make sure the resident got everything they needed but that some of them just plop the food down and leave the room and don't ask. Resident #83 Review of a Face Sheet revealed Resident #83 was a male, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood), and depression. Review of a Minimum Data Set (MDS) assessment for Resident #83, with a reference date of 12/2/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #83 was cognitively intact. In an interview on 2/27/23 at 3:16 PM, Resident #83 reported was supposed to receive double entrée portions for his breakfast meal but often received regular or small portions instead. In an interview on 3/6/23 at 9:27 AM, Resident #83 reported received four pieces of toast, two bowls of cereal, and nothing that he felt was an entrée for breakfast. Resident #83 reported he had no idea what was for lunch that day because no one had come around to ask him what he wanted. Resident #83 reported the facility did not pass out menus to the residents so they could see in advance what they were having and when nobody came around to ask him his meal choice, he had no idea what he was going to get. Resident #83 reported his choice was that he received a copy of the published menu to have in his room. Review of Resident #83's current Care Plan revealed the focus of The resident nutritional deficits r/t (related to) past medical history . with care planned interventions which include Diet order .double breakfast entrée . last revised 2/1/23. Resident #4 Review of a Face Sheet revealed Resident #4 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood), major depressive disorder, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 2/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #4 was cognitively impaired. In an interview on 3/6/23 at 9:16 AM, Resident #4 was visited in her room where she was eating breakfast in bed. Resident #4 asked what's for lunch today? Resident #4 reported nobody had come around to ask her what she wanted for lunch and stated, that happens all the time and reported often she did not know what she was getting until it was served to her. In an interview on 3/2/23 at 9:26 AM, Certified Nurse Aide (CNA) X reported residents had complained to them about the food. CNA X reported the kitchen often ran out of items and had to run to the store for something else. CNA X reported residents were not always asked what they wanted for their meals; instead, some staff filled out the menu the way they thought the resident wanted without bothering to check with the residents themselves. In an interview on 3/6/23 at 9:04 AM, CNA I reported residents had complained to them about the food. CNA I reported residents complained about missing items on their trays and not liking food choices - when they did get the choice. In an interview on 3/6/23 beginning at 10:55 AM, Registered Dietitian (RD) GGG reported menus were not passed out to the residents, it was discussed with them when the staff went around to obtain their meal choices. Dietary Manager (DM) QQ reported each hall was assigned a CNA (certified nurse aide) for the day who was responsible for getting the resident meal choices for the next day and recording the choices on the resident tray ticket. DM QQ reported the CNA was then supposed to put the completed tray tickets for their hall in the menu folder for that hall and the kitchen then went around and retrieved all the tray tickets. DM QQ reported thought that since a lot of the residents came down to the dining room for their meals, the CNA's didn't ask those residents what they wanted and, consequently, those residents didn't know what they were getting until they were in the dining room for that meal. SA (state agency) reviewed all the resident tray tickets for the residents on the A Hall (dining room and eat in room) for the 3/6/23 upcoming lunch meal. None of the tickets for the A Hall were filled out with resident preferences. During an interview with DM QQ, at 3:22 PM on 2/27/23, it was found that residents meal/tray tickets are to be filled out the day before. It was found that nursing staff would get the tickets at their 9:30 morning meeting, and are supposed to interview residents after the meeting and give the filled out tickets back to the kitchen for the next days meal. Early on, it was found that there was not many changes on the tickets for choices and preferences, and residents were complaining they were not getting what they wanted. It took a month or so to get staff in line, at this time we are seeing more changes to menus and more preferences labeled on the meal tickets. During an interview with DM QQ at 3:35 PM on 2/27/23, the surveyor asked if the kitchen is ever closed during the day. DM QQ stated that the kitchen is always open and when residents have an issue with something, we want to correct it. When asked if menus are provided to residents, DM QQ stated that each resident gets a copy of the four week menu cycle and I think we post it on the halls and the dining room. R61 According to the Minimum Data Set (MDS) dated [DATE], R61 scored 15/15 (cognitively intact) on his BIMS (Brief Interview Mental Status) and was able to independently move around in the facility. During an interview on 2/27/23 at 2:41 PM, R61 stated, The biggest issue for me is staff are supposed to ask residents daily what they want to eat. Residents do not get menus. I have to go down to kitchen to see what the alternate meal is. I will not eat the pork any more, it is never done. Neither is the chicken. I can't chew it, is so hard. R77 According to the Minimum Data Set (MDS) dated [DATE], R77 scored 15/15 on his BIMS (Brief Interview Mental Status and did not leave his room often. During an interview on 2/27/2023 at 3:34 PM, R77 stated, Staff ask me what I want to eat. I do not have a menu in my room. No menu was seen in resident's room. No menu was seen posted in A or B halls or in resident rooms of either hall. R75 According to the Minimum Data Set (MDS) dated [DATE], R75 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) and required assistance to move within the facility of one person. During an interview on 2/28/2023 at 8:21 AM, R75 stated, The facility does not hand out menus any longer. I'd like a menu. it would be nice to know what they are cooking so if I don't like it, I can order something else. A year ago, they handed out menus and we could choose what we wanted. I wish they would do it again. R22 According to the Minimum Data Set (MDS) dated [DATE], R22 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Status) and required assistance to move around in the facility of one person. During an observation and interview on 3/1/2023 at 4:05 PM, R22 stated, I do not get a menu and would like one to know what I am going to eat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #s: MI00132346, MI00133753, MI00132312, MI00133302, MI00133665, MI00132385, MI00131121, MI00132307. Based on observation, interview, and record review, the facility failed to provide appetizing and palatable food products to 8 of 10 sampled residents (Resident #57, #83, #4, #61, #77, #75, #22, #16) reviewed for food palatability, resulting in dissatisfaction with meals and the potential for decreased food acceptance and nutritional decline. Findings include: Resident #57 Review of a Face Sheet revealed Resident #57 was a female, with pertinent diagnoses which included: other specified depressive episodes. Review of a Minimum Data Set (MDS) assessment for Resident #57, with a reference date of 2/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #57 was cognitively intact. In an interview on 2/28/23 at 8:36 AM, Resident #57 reported was not happy with the food served at the facility. Resident #57 reported felt the kitchen didn't always thoroughly cook the food. Resident #57 gave the example that she had been served a turkey burger a couple weeks ago that was not cooked all the way and after two bites of the burger, she threw up. Resident #57 reported had felt fine that day otherwise until she ate the turkey burger. Resident #57 reported sometimes the food was served hot enough and sometimes it was not. Resident #57 stated, It depends on how long it sits in the hallway (referring to room meal trays). Resident #83 Review of a Face Sheet revealed Resident #83 was a male, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood), and depression. Review of a Minimum Data Set (MDS) assessment for Resident #83, with a reference date of 12/2/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #83 was cognitively intact. In an interview on 2/27/23 at 3:16 PM, Resident #83 reported the food served at the facility was not cooked well at all and was cold all the time. Resident #83 reported having been served an English muffin that had been toasted on the outside but was not separated into two pieces so was not toasted on the inside. Resident #83 reported he had complained about the English muffin and had been told the English muffin was cooked, it was just not cooked to his preference. Resident #83 reported room meal trays for residents who dined in their rooms (including himself) sometimes sat in the tray delivery cart in the hall for 15-20 minutes before staff even started delivering the trays to the resident rooms, which also affected the temperature of the food by the time it was served. Resident #4 Review of a Face Sheet revealed Resident #4 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood), major depressive disorder, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 2/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #4 was cognitively impaired. In an interview on 2/28/23 at 12:12 PM, Resident #4 reported her meals were sometimes cold by the time she got her food. Resident #4 stated, the food has no flavor. In an interview on 3/6/23 at 9:04 AM, Certified Nurse Aide (CNA) I reported residents had complained to them about the food being cold. In an interview on 3/2/23 at 9:26 AM, CNA X reported residents had complained to them about the food. CNA X reported the food was often either burnt or undercooked and that sometimes the food that should be hot was cold. CNA X reported had observed eggs that were served for breakfast that had looked like a burnt ball and that the oatmeal served was sometimes so thick that it comes out like cement. During an interview with Dietary Manager (DM) QQ, at 1:24 PM on 2/27/23, it was found that a vendor contract took over the food service in October, but he was not hired on until the middle of December. DM QQ stated that when he took over they had been trying to improve the food service, but was working with equipment that was not up to par. The regulators on the steamer were not working right, only one of the ovens would work, and the steam table wasn't working consistently. Now that we have those items fixed, we have been able to get a better workflow. When asked how long all three of these items had been fixed, DM QQ stated about three weeks. During an interview with DM QQ starting at 3:05 PM on 2/27/23, it was found that most of the staff is newer to their positions, and some came in before him, with little experience. So there were delays and meals that suffered because of it. Having to train staff and get equipment up and running to its potential took time. DM QQ stated that one of the issues they discovered was some of the PM dietary staff take the bus and have to leave by 7:45 PM to make it home, this would leave the morning staff with racks of dishes that still needed to be washed from dinner the previous night. DM QQ stated that once you already start your day playing catch up from the night before, it's hard to catch up over the course of the day. DM QQ stated that on days where they have bacon, for example, it takes close to two hours to make it all using the only two ovens they have. Most facilities this size have a double convection style oven. It was noted this facility has two ovens one with a flat top and the other with gas burners. DM QQ also stated that on days where they have ham and cheese sandwiches they have to have another staff onsite in order to cook these sandwiches without having them sit on hot hold and become soggy. R61 According to the Minimum Data Set (MDS) dated [DATE], R61 scored 15/15 (cognitively intact) on his BIMS (Brief Interview Mental Status) and was able to independently move around in the facility. During an interview on 2/27/23 at 2:41 PM, R61 stated, I will not eat the pork anymore, it is never cooked throughout (undercooked). Neither is the chicken. I can't chew it, is so hard. R77 According to the Minimum Data Set (MDS) dated [DATE], R77 scored 15/15 on his BIMS (Brief Interview Mental Status and did not leave his room often. During an interview on 2/27/2023 at 3:34 PM, R77 stated, The food it is not edible. It is cold, funny taste to it. It tastes horrible. R75 According to the Minimum Data Set (MDS) dated [DATE], R75 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) and required assistance to move within the facility of one person. During an observation on 2/28/2023 at 8:21 AM, R75 stated, The food is not edible half the time. Meaning it is undercooked and cold. It is cold by the time it gets to me at the end of the hall. Kitchen staff are not reading the slip that tells them what I do not like and send it anyway. R22 According to the Minimum Data Set (MDS) dated [DATE], R22 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Status) and required assistance to move around in the facility of one person. During an observation and interview on 3/1/2023 at 4:05 PM, R22 stated, Food is not good. They need help in the kitchen. We get the same thing over and over. R16 According to the Minimum Data Set (MDS) dated [DATE], R16 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) and required extensive assistance of two-person physical assistance to turn/reposition in bed. During an interview on 3/7/2023 at 8:26 AM, R16 was eating breakfast while in bed, stated, I asked for scrambled eggs this morning and they taste like sh*t. Back in September (2022) the facility was running out of food.

This citation pertains to Intake #s: MI00132385, MI00133753, MI00132312, and MI00133665. Based on observation, interview, and record review, the facility failed to: 1.) ensure snacks were consistently delivered and 2.) meals were served in a timely manner and per facility scheduled times for four (R57, R68, R83, and R4) of 10 sampled residents, resulting in delayed meal service and the potential dissatisfaction with the dining experience affecting all residents who receive meals/snacks at the facility. Findings include: Review of the document Meal Times revealed, Breakfast - 730am Lunch - 12pm Dinner - 530pm. Review of the document SNACK PROTOCAL (sic) revealed, 1. The Dining Services department will collaborate with the residents, nursing and management team to identify necessary beverages and snack items to be provided to the residents. 2. The kitchen staff prepares the Bulk snacks and gives it to Nursing. Nursing staff delivers snacks to the residents according to their diet. A fridge is also in the Dining room with additional snacks and beverages for the residents. Resident #57 Review of a Face Sheet revealed Resident #57 was a female, with pertinent diagnoses which included: other specified depressive episodes. Review of a Minimum Data Set (MDS) assessment for Resident #57, with a reference date of 2/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #57 was cognitively intact. In an interview on 2/28/23 at 8:36 AM, Resident #57 reported ate in her room at breakfast. Resident #57 reported her breakfast tray usually came between 9:00 - 10:00 AM which was later than it was supposed to be there. In an interview on 3/6/23 at 10:33 AM, Resident #57 reported went to the dining room on Saturday, 3/4/23 for lunch which was supposed to be served at 12:00 PM. Resident #57 reported lunch did not get served to the residents in the dining room that day until 1:30 PM. Resident #57 reported had no idea when the poor people who ate in their rooms finally got their lunch that day. Resident #68 Review of a Face Sheet revealed Resident #68 was a male, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) and other specified anxiety disorders. Review of a Minimum Data Set (MDS) assessment for Resident #68, with a reference date of 2/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #68 was cognitively intact. In an interview on 2/27/23 at 3:48 PM, Resident #68 reported preferred to dine in his room. Resident #68 reported sometimes his dinner meal room tray was not served to him until after 7:00 PM and that sometimes they forgot to bring him a meal at all. Resident #68 reported times when his roommate would have gotten their food and after a half hour or more, he (Resident #68) would find out the facility had forgotten to bring him his tray. Resident #68 reported staff did not consistently offer an evening snack and that when there were snacks, the selection gets sparse toward the weekend. Resident #68 also reported that coffee was not available in the evening for residents who wanted it, including himself. In an interview on 3/6/23 at 3:34 PM, Resident #68 reported had a bad night the night before (3/5/23) because the facility had forgotten to bring him a dinner tray. Resident #68 reported when dinner time had come and gone and he had not received a meal tray, he finally called Confidential Informant (CI) QQQ to see if they could find out what was going on. Resident #68 reported CI QQQ finally got ahold of Nursing Home Administrator (NHA) A who determined that someone had messed up and thought his meal tray, which had been set on top of the tray delivery cart instead of inside the tray delivery cart, had already been delivered and returned, because the tray was not inside the cart, but on top. Resident #68 reported that NHA A had called him and ordered a pizza and garlic bread for him which didn't arrive until 8:30 PM. Resident #68 reported once the error had been discovered after he brought it to the facility's attention, somebody did come and offer him a turkey sandwich and potato chips but by that time he was upset and knew the pizza was coming so he declined the sandwich and chips at that point. Resident #68 reported both breakfast and lunch meals were late on Saturday, 3/4/23. Resident #68 reported couldn't remember what time breakfast came but knew it was late and didn't get his lunch meal tray until 2 or 2:15 that day. In an interview on 3/6/23 at 3:51 PM, NHA A reported Resident #68's dinner meal had been missed the night before. NHA A reported CI QQQ had called them (NHA A) asking why dinner had not been served yet and it turned out that staff had put Resident #68's tray on top of the tray delivery cart instead of inside it and his meal got missed. NHA A reported had called Resident #68 after the error was discovered and asked him if there was anything the facility could get for him, and then ordered him a pizza and garlic bread to be delivered. Resident #83 Review of a Face Sheet revealed Resident #83 was a male, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood), and depression. Review of a Minimum Data Set (MDS) assessment for Resident #83, with a reference date of 12/2/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #83 was cognitively intact. In an interview on 2/27/23 at 3:16 PM, Resident #83 reported meal delivery time varied. Resident #83 gave the example that sometimes his breakfast meal room tray arrived at 8:30 AM and sometimes it hadn't come until 9:30 AM. Resident #83 reported has been at the facility for almost a year and a half and the facility kept telling him that the food service was going to get better but it hasn't yet. In an interview on 3/6/23 at 9:27 AM, Resident #83 reported he hadn't received his lunch meal room tray on Saturday (3/4/23) until 2:15 PM. Resident #4 Review of a Face Sheet revealed Resident #4 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood), major depressive disorder, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 2/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #4 was cognitively impaired. In an interview on 2/28/23 at 12:12 PM, Resident #4 reported sometimes she received her dinner meal 5:00 or 5:30 PM and sometimes not until 7:00 PM. Resident #4 reported didn't always know what she was going to get until she received her tray because staff didn't always come around and ask for her meal choice. Resident #4 reported the kitchen closed at 7:00 PM, so if you don't like what they fixed, you are out of luck. In an interview on 3/2/23 at 9:26 AM, Certified Nurse Aide (CNA) X reported resident meals were always late, that there had been times that lunch meal room trays weren't delivered to the units until 1:30 PM and that sometimes breakfast meal room trays didn't arrive to the units until 10:30 AM. CNA A stated, It is inconsistent during the day. In an interview on 3/6/23 beginning at 10:55 AM, Dietary Manager (DM) QQ reported that the kitchen had been short staffed on the weekend (3/4/23 - 3/5/23) because one of the dietary aides who was scheduled was off because her grandmother had passed away the night before and another one of the dietary aides was waiting to receive her second dose of the COVID-19 vaccination and couldn't work. DM QQ reported they didn't have anyone else to come in, so there was just 3 people working in the kitchen when there should have been 5, and that was the reason for the late meals over the weekend. DM QQ reported the other times when meals are late it was often because there was not enough oven space to cook everything that needed to be cooked in a reasonable timeframe. In an interview on 3/7/23 at 10:39 AM, Registered Nurse Unit Manager (RNUM) GG reported had worked part of the day on Saturday, 3/4/23. RNUM GG reported when got to the facility, was informed that the breakfast meal that day had been very late. RNUM reported had talked to DM QQ who said they were short staffed that day. RNUM GG reported lunch that day was quite late, and that dietary staff didn't start serving the dining room until 1:00 - 1:30 PM. In an interview on 3/7/23 at 11:52 AM, NHA A confirmed the breakfast as lunch meals were late on Saturday 3/4/23 because some of the dietary staff had not shown up. NHA A reported was alerted of the late meals when CI QQQ had called to see what was going on with the meals. During an interview with Dietary Manager (DM) QQ, at 1:24 PM on 2/27/23, it was found that a vendor contract took over the food service in October, but he was not hired on until the middle of December. DM QQ stated that when he took over they had been trying to improve the food service, but was working with equipment that was not up to par. The regulators on the steamer were not working right, only one of the ovens would work, and the steam table wasn't working consistently. Now that we have those items fixed, we have been able to get a better workflow. When asked how long all three of these items had been fixed, DM QQ stated about three weeks. During an interview with DM QQ starting at 3:05 PM on 2/27/23, it was found that most of the staff is newer to their positions, and some came in before him, with little experience. So there were delays and meals that suffered because of it. Having to train staff and get equipment up and running to its potential took time. DM QQ stated that one of the issues they discovered was some of the PM dietary staff take the bus and have to leave by 7:45PM to make it home, this would leave the morning staff with racks of dishes that still needed to be washed from dinner the previous night. DM QQ stated that once you already start your day playing catch up from the night before, it's hard to catch up over the course of the day. DM QQ stated that on days where they have bacon, for example, it takes close to two hours to make it all using the only two ovens they have. Most facilities this size have a double convection style oven. It was noted this facility has two ovens one with a flat top and the other with gas burners. DM QQ also stated that on days where they have ham and cheese sandwiches they have to have another staff onsite in order to cook these sandwiches without having them sit on hot hold and become soggy. During an interview with DM QQ, at 3:22 PM on 2/27/23, it was found that residents meal/tray tickets are to be filled out the day before. It was found that nursing staff would get the tickets at their 9:30 morning meeting and are supposed to interview residents after the meeting and give the filled out tickets back to the kitchen for the next days meal. Early on, it was found that there was not many changes on the tickets for choices and preferences, and residents were complaining they were not getting what they wanted. It took a month or so to get staffed in line in, at this time we are seeing more changes to menus and more preferences labeled on the meal tickets. During an interview with DM QQ at 3:35 PM on 2/27/23, the surveyor asked if the kitchen is ever closed during the day. DM QQ stated that the kitchen is always open and when residents have an issues with something, we want to correct it. When asked if menus are provided to residents, DM QQ stated that each resident gets a copy of the four week menu cycle and I think we post it on the halls and the dining room. During an interview with DM QQ, at 3:45 PM on 2/27/23, it was found that the PM dietary aides would get the evening snacks around. When asked if there had been issues with getting the evening snacks out? DM QQ stated, that when he started working there it didn't seem like many snacks were being used. At times, we would have to throw a lot away because staff wouldn't put items back in the refrigerator after we would have delivered them to the nurses' station on ice. DM QQ went on to state that once we started tracking evening snacks in the kitchen, it had been getting better.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI0013121. Based on observation and interview, the facility failed to effectively clean/maintain the physical plant including resident rooms and shower rooms. This resulted in the increased likelihood for cross-contamination and bacterial harborage, with a possible decrease in the satisfaction of living, for residents who use these areas. Findings include: A tour of the facility revealed the following observations: During an observation on 2/23/23 at 1:44 PM in Room A7, noted two holes (approximately the size of a nickel) in the wall above the television for Bed 1. During an observation on 2/27/23 at 3:16 PM in Room A15, noted the control cover on the heater under the window was hanging and not properly affixed. There were large scrapes along the same wall such that paint was removed and drywall was exposed. During an observation on 2/28/23 at 9:00 AM in Room B7, there was a large black scuff mark on the wall that went from the length of the bathroom door across the wall to the bedroom door. There was a television wall-mount device (not in use) that was hanging on the wall above the bulletin board to the left of Bed 1. The bulletin board was located behind the television for Bed 1 that was not mounted, but atop the nightstand. The bulletin board was not visible or usable. Noted multiple areas of chipped paint throughout the room. There was a two-opening light switch outlet cover on the wall next to the bathroom door. One of the openings was missing the switch such that the inner wiring behind the drywall was visible. During an observation on 2/28/23 at 12:12 PM in Room D1, noted an area (slightly larger than the size of a piece of notebook paper) of the wall to the left of Bed 2 with primer that was not painted. On the same wall, there was an air bubble (slightly smaller than a tennis ball) in the paint below the calendar. There were several areas of peeling paint noted. During an observation/interview on 3/07/23 at 11:55 AM, Maintenance Director CC observed the two-opening light switch outlet cover on the wall next to the bathroom door in Room B7. Maintenance Director CC reported the opening was from a nightlight whereby the cover fell off, but nobody had reported it to maintenance to replace. Maintenance Director CC reported the facility was working on renovating all the resident rooms and that each one took approximately 3.5 weeks to complete. Maintenance Director CC reported had another person was assisting with the renovations a couple times a week but that person had other projects they worked on separate from the facility so they could not be at the facility all the time. During a tour of the D-Hall shower room, at 10:45 AM on 3/1/23, with Maintenance Director (MD) CC, it was observed that storage cabinets were found with accumulation of soap debris from leaking containers over time. It was observed that used gloves were found on the shower floor and a box of gloves was found on the partition shower wall, open and exposed. A disposable brief and an open container of wipes were also found on the shower partition. During a tour of the B-hall shower room, at 11:08 AM on 3/1/23, heavy accumulation of black rubber debris was found on the floor and walls of the shower area. At this time, an interview with MD CC found that wheelchairs get washed with a pressure washer in this area and the black debris was probably rubber getting sprayed off during cleaning. According to the Minimum Data Set (MDS) dated [DATE], R3 scored 7/15 (cognitively impaired) on her BIMS (Brief Interview Mental Status), with diagnoses that included coronary artery disease, heart failure, diabetes, and partial paralysis and required oxygen therapy. During an observation on 2/28/2023 at 7:47 AM, R3's bedroom floor under the head of her bed had food, including breakfast cereal flakes, debris of dirt and dust on the floor. During an observation on 3/1/23 at 3:51 PM, R3's bedroom floor under the head of her bed had food, including breakfast cereal flakes, debris of dirt and dust on the floor. During an observation and interview on 3/6/2023 at 8:30 AM, R3 was awake sitting up in bed. On the floor under the head of her bed was a large bag full of personal items, two pillows with no cases, breakfast cereal flakes, dust, and debris. At 8:35 AM, Housekeeping AAAA stated, Each resident room should be swept daily. Surveyor observed R3's room with Housekeeping. Housekeeping stated, This area looks like it has not been cleaned in a while. Housekeeping removed two bags of personal items and pillows from between the resident's head-of-bed, wall, and floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to clean food and non-food contact surfaces to sight and touch. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 96 residents who consume food from the kitchen. Findings Include: During the initial tour of the kitchen, at 1:20 PM on 2/27/23, a review of the two door [NAME] unit found that excess accumulation of salad debris was found on the bottom floor of the unit. A review of the two door True freezer found food and crumb debris inside the floor and bottom gasket of the unit. Observation of all the reach in units found a couple of the units had increased accumulation of black gunk debris on the top portions of the doors, gaskets and seals. During the initial tour of the kitchen, at 1:41 PM on 2/27/23, an interview with Dietary Manager (DM) QQ, found that clean pots and pans are stored on a metal wire rack to be stacked and stored. A review of the rack found two 1/8th pans stacked on top of one another with trapped moisture inside. A review of a third 1/8th pan found some green stuck on food debris on the inside of the pan. DM QQ took these pans to the three-compartment sink area. During the initial tour of the kitchen, at 1:45 PM on 2/27/23, an interview with DM QQ found that clean utensils are stored on drawers on the cook line. A review of the mechanical scoop drawer found two scoops with dried and stuck on food debris. Once shown to DM QQ, the scoops were taken to the three-compartment sink area. During an interview with DM QQ at, 1:45 PM on 2/27/23, it was found that the stand up mixer gets used about everyday. When asked why it was covered with a plastic bag. DM QQ stated it was to keep it protected from contamination once it was cleaned. Observation of the mixer found accumulation of cake and flour splatter marks underneath the arm of the unit. DM QQ stated they would clean it at this time. At 1:52 PM on 2/27/23, Observation of the plate warmer found it empty, as plates were being used and washed from lunch. Shinning a flashlight into the body of the plate warmer, it was found that copious amounts of dried excess food debris had accumulated in the plate warmer. DM QQ stated he had only been here a few months and never knew it looked like that inside. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.