**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to comprehensively assess and monitor non-pressure related skin impairments for 1 of 3 residents (R1) reviewed for skin integrity. In addition, based on interview and document review the facility failed to comprehensively assess and monitor for change in condition for 1 of 1 resident (R1) who had a change of condition and was admitted to the hospital with sepsis. Findings include:R1's face sheet dated 7/16/25, identified R1 admitted 6/2025, with diagnoses of fracture of neck of left femur (broken hip), hypertension (high blood pressure), malnutrition (not consuming enough food/fluids), gastrointestinal stromal tumor of large intestine ([NAME]) (rare cancerous tumor in digestive system), colon cancer (cancer that begins in the large intestine).R1's discharge Minimum Data Set (MDS) dated [DATE], identified short term memory issues and moderately impaired decision making. R1 was independent with eating, supervision/touching assistance required for oral hygiene, personal hygiene, and upper body dressing. Moderate assistance required for toileting hygiene, showering, lower body dressing, footwear. R1 required moderate assistance with sitting, lying, standing, toilet and tub transfers. R1 was able to walk 10 feet with supervision/touch assistance. R1 was frequently incontinent of bowel and bladder. R1 was five feet tall and weighed 113 pounds. R1 did not have any skin conditions. R1 did not receive oral chemotherapy. R1's impaired skin integrityR1's hospital Discharge summary dated [DATE], identified R1 admitted to hospital from a fall that resulted in left femoral neck hip fracture and underwent surgical repair of the hip. A hydrocolloid dressing was placed on the surgical incision and not to be removed until seven days after the surgery date. R1's admission assessment dated [DATE], identified R1 had frequent pain in the left hip area. Skin assessment identified intact abrasions to right and left scapula and upper-mid vertebrae-not measured; skin tear to left elbow; left hip surgical incision; bruising on palms of right and left hands, left upper extremity, and right upper extremity; right eye was blood shot and puffy. Surgical dressing on left hip was to stay in place for seven days post-surgery. Multiple scattered purple to maroon bruises on bilateral upper extremities and hands, the skin tear has a mepilex in place. The abrasions on left and right scapula are intact and square shaped most likely from hospital electrodes. The blood shot right eye had puffiness noted on the top of the right eyelid and has been present for a while. The skin assessment did not include any further descriptions or characteristics of the bruising such as exact locations, measurements, and pain nor identify the skin integrity around the occlusive bandage such as redness, tenderness, swelling, shadowing, and pain. R1's care plan dated 6/7/25, identified alteration in elimination with interventions to assist with toileting, provide assistance with peri-cares morning, evening, and as needed.R1's care plan dated 6/7/25, identified alteration in skin integrity related to mobility, fragile skin, and occasional incontinence. Interventions included leave dressing in place until 6/13/25, monitor skin integrity daily during cares, weekly skin inspection by nurse, monitor for skin breakdown for signs/symptoms of infection, report signs/symptoms to medical doctor or physician assistant, document on skin condition and keep doctor informed of changes, treatment/dressing orders for the left femur/hip incision and left elbow skin tear. Additionally, the care plan directed staff to bath R1 on Saturday evenings, showers only, assist of one with personal hygiene and dressing.R1's Braden Scale for Predicting Pressure Score Risk dated 6/12/25, identified no sensory impairment, occasionally moist skin, walks frequently, slightly limited mobility, adequate nutrition, potential problem with friction and shear. R1 scored 19 which did not indicate a risk.R1's physician order dated 6/5/25, identified a weekly skin inspection by licensed nursing staff every Saturday.R1's Treatment Administration Record (TAR) dated 6/2025, identified weekly skin inspection by licensed nurse every Tuesday beginning 6/17/25. Prior order was for weekly skin inspection every Saturday and was discontinued on 6/12/25. No skin assessment was assigned for 6/10/25.R1's Weekly Skin Inspection dated 6/7/25, Skin Summary identified R1 refused bath. A correlating skin check was not completed.R1's daily skilled progress notes from 6/6/25-6/13/25 identified wound to left hip was unable to be visualized due to non-removable dressing in place. R1's daily skilled progress note dated 6/14/25, identified left hip no open wounds noted, treatment provided as ordered, no drainage, peri-wound intact.R1's daily skilled progress note dated 6/15/25, surgical incision was open to air. At 9:35 p.m., unable to visualize wound due to unremovable dressing (even though surgical dressing was documented as removed earlier the same day).R1's daily skilled progress note dated 6/16/25, identified no open wounds noted, dressing to wound remains clean, dry and intact, wound not visualized.R1's daily skilled progress note dated 6/17/25, identified dressing to wound remains clean, dry and intact, wound not visualized. R1's daily skilled progress note dated 6/19/25, identified no open wound noted, treatment to wound performed on shift as ordered. No drainage noted. Peri-wound skin is intact.R1's oncology visit note dated 6/9/25, identified her Positron Emission Tomography (PET) scan was showing more activity in the small intestine and activity in the rectal area. These areas are concerning for new cancer in the rectal area and/or worsening of [NAME]. Doctors' communication handwritten included reports of pain 8/10 in the left hip. PET scan showing more cancer in the intestines, rectal area, and a mass in the left intergluteal cleft (vertical partition that separates buttocks). The note did not indicate if the mass that was identified in the left intergluteal cleft was palatable. R1's Point of Care (POC) response history dated 6/19/25 identified R1 had a shower. Review of R1's record between 6/6/25 through 6/20/25 did not identify or include comprehensive skin assessments or monitoring of the impaired skin integrity that was identified on the 6/6/25 assessments which included intact abrasions to right and left scapula and upper-mid vertebrae-not measured; skin tear to left elbow; left hip surgical incision; bruising on palms of right and left hands, left upper extremity, and right upper extremity. Additionally, after the surgical dressing was removed the record did include a comprehensive assessment of the surgical line that would include measurements, integrity of sutures/staples/surgical glue, wound edge proximity, and signs/symptoms of infection.R1's hospital Wound evaluation and treatment note dated 6/20/25, R1 came to emergency room for weakness, fever, low blood pressure, and tachycardia. When rolling R1 it was discovered that she had a pressure area that was tunneling and draining on her left ischial tuberosity. Redness is extended to the front including left labia and most of left buttock. It is also indurated. Facility just noticed it today before she came to the emergency room. Assessment included pressure injury-community acquired, full thickness, wound base covered in slough, around wound had edema, redness, indurated (abnormal hardened tissue), was intact and warm to the touch. Measurements: length 1.4 cm, width 0.6 cm, depth 0.9 cm. Tunneling 0.8 cm at 12 o'clock, 1.0 cm at 3 o'clock, 1.9 cm at 5 o'clock, and 0.9 cm at 9 o'clock. Moderate amount of yellow/gold malodorous foul drainage. Pain 7/10 when touching area. R1 stated I just want to die, I don't want to deal with this.During an interview on 7/16/25 at 9:45 a.m., nursing assistant (NA)-A stated R1 had a little redness in her peri area, but no open sores. NA-A recalled that R1 had special precautions for chemotherapy and a lot of loose bowel movements from that. NA-A could not recall specific dates when she assisted R1.During an interview on 7/16/25 at 9:59 a.m., NA-B stated she worked with R1 primarily the first two weeks that she was at the facility. NA-B walked with a walker, went to meals, had some loose stools but did not notice redness in her peri area.During an interview on 7/17/25 at 9:19 a.m., NA-C stated she thought she last assisted with toileting R1 about four days prior to 6/20/25. At that time, R1 was not red or irritated in the peri area but did complain that it hurt when NA-C completed peri-care. NA-C asked if she had pushed too hard during peri-care, R1 replied, maybe. At that time, nothing looked concerning that she would notify the nurse about.During a phone interview on 7/17/25 at 3:50 p.m., nurse practitioner (NP)-A stated upon review of hospital documentation it appeared they were questioning an internal abscess. If the abscess was internal the facility would not have seen it until it opened. Potentially, it could have not been able to be visualized and not unheard of that it was not noticed until it opened, and it could have opened when the staff was wiping R1.During a phone interview on 7/17/25 at 11:05 a.m., medical doctor (MD)-A stated R1 did not have a pressure ulcer when she was sent to the facility from the hospital on 6/6/25. Pressure wounds happen when people are sitting to much, not eating or drinking, and not mobile. Pressure wounds do not happen overnight. R1 was already very weak and frail, not very mobile and was not motivated. Upon assessment the wound looked very consistent with a pressure ulcer and would be visible to see if R1 was on the toilet or being rolled side to side.During an interview on 7/17/25 at 2:13 p.m., Administrator and director of nursing (DON) were present. DON stated the expectation was that all skin issues were identified on the weekly skin assessments along with descriptions of skin impairments including required measurements.Change in ConditionR1's hospital discharge orders dated 6/6/25, identified an order for atenolol 50 milligrams daily for hypertension.R1's physician order dated 6/6/25, identified weekly vital sign monitoring.Review of R1's vital signs identified between 6/6/25 through 6/18/25, identified ranges for blood pressures of 156/67 to 102/51; HR 84-99; oxygen saturations (O2) 97%-95%. The vital sign record identified a decrease in systolic pressure that started on 6/16/25 with an increase in HR. R1's identified blood pressure readings from 6/16/25-6/18/25 were:-6/6/25: 120/51, and 156/67-6/7/25: 142/76, 136/88, and 143/72-6/8/25: 139/80-6/10/25: 130/54-6/12/25: 145/64-6/14/25: 140/60-6/16/25: 102/51-6/17/25: 118/60-6/18/25: 104/50R1's Occupational Therapy notes dated 6/8/25-6/20/25, identified on 6/17/25, care conference was held and discussed R1 complaining of nausea during sessions and it is impacting her performance. R1's Occupational Therapy note on 6/18/25, R1 was in recliner and refusing therapy, stating she would not get up today. No nausea but pain in left hip and back area, however, R1 has only been lying in recliner for the past three days and only occasionally moving to the bed.In review of R1's record there was no indication vital signs were re-assessed and/or increased monitoring nor the physician notified of the change in BP and/or HR in conjunction with in R1's refusals of therapy and lying in recliner for the past three days R1's hospital Discharge summary dated [DATE], identified R1 was hospitalized from [DATE] to 6/25/25 for diagnoses that included severe sepsis secondary to buttock abscess and cellulitis.During a phone interview on 7/17/25 at 4:17 p.m., registered nurse (RN)-B stated R1 was always tired, ate in her room, and stayed in her room. Review of R1's blood pressure of 90/43 and pulse of 100 on 6/19/25, RN-B stated normally she would recheck a blood pressure with that reading and was unsure why she did not. If that was R1's baseline it would not have been a trigger for her to recheck it. RN-B was not aware of R1 having any emesis or loose stool on 6/19/25. RN-B stated with sepsis a resident would have a higher temperature, elevated heart rate and low blood pressure. RN-B did not notify the medical doctor of the low blood pressure or high pulse and did not articulate a reason why she did not.During a phone interview on 7/16/25 at 1:43 p.m., nursing assistant (NA)-D stated he worked with R1 on 6/20/25. R1 was very tired and was not good at holding a conversation which was not R1's typical behavior. During an interview on 7/16/25 at 10:16 a.m., LPN-A stated she had not seen R1's skin prior to the hospital transfer. R1 had a skin assessment done by LPN-A on 6/7/25, and that was the only one she could see in the chart. R1 would only allow staff to look at her peri area on bath day. LPN-A stated R1 had supervision assistance with toileting and was able to wipe herself after using the toilet as R1 was working hard to get back to an independent status. LPN-A was not aware of a low blood pressure reading on 6/19/25 and recalled her vitals were within normal limits when she took them the morning of 6/20/25 (not documented). On 6/20/25, LPN-B went with LPN-A to assess R1's vital signs. R1's temperature was elevated. LPN-A stated she was suspicious of R1 having a urinary tract infection and an ambulance was called. R1 was on the cot for the ambulance transfer and LPN-A and LPN-B had performed peri cares on her and that was when they noticed she had a tunneling wound that was opened on her left inner thigh, LPN-A described the area as the size of a pencil eraser head and the location was the inner thigh where the skin connects to the thigh. During a follow-up interview on 7/17/25 at 5:12 p.m., LPN-A stated R1 was tired and had room trays on 6/20/25 but did not want her daughters called. LPN-A stated she assumed R1 was calling them herself as she had a personal cell phone. During an interview on 7/16/25 at 10:45 a.m., LPN-B stated she did not recall what prompted her to check R1's VS on 6/20/25, but R1's cheeks were flushed and she was laid back in her chair, which was out of baseline for R1. LPN-B was unsure when R1's VS had been taken and completed a set. LPN-B noted an increased temperature when she took VS and had R1 sent to the emergency department for evaluation. During a phone interview on 7/17/25 at 3:50 p.m., nurse practitioner (NP)-A stated would not have gotten too excited if she had been informed of R1's low blood pressure and high pulse on 6/19/25 as R1 had a higher blood pressure and pulse when she was seen on 6/11/25 and was a frail person. NP-A did not mention what R1's blood pressure or pulse were on 6/11/25, or when she would become concerned with them. During an interview on 7/17/25 at 2:13 p.m., Administer and director of nursing (DON) were present. DON stated if she had done a blood pressure and it was low, she would re-check but on the opposite arm, review the other vital signs including pulse and temperature, document and notify the physician of the changes. DON would also continue to monitor throughout the shift and document any changes and alert on-coming staff of findings. The blood pressure should have been retaken, the pulse was 100 and that is not flagged on our computer as a high pulse, so that would not have been an alarming vital sign. The expectation was to document findings, monitor, and notify physician of changes identified.The facility Skin Assessment and Wound Management policy dated 2/2025, identified staff will perform routine skin inspections with daily care, nurses to be notified if skin changes identified, and a weekly skin inspection will be completed by licensed staff. When a pressure ulcer is identified the following actions will be taken: notify provider/treatment ordered, notify resident representative, complete education with resident/resident representative including risks and benefits, notify nurse manager, referral to dietary and therapies if appropriate, review and update care plan including interventions, update resident care lists, update care plan to identify risk of skin breakdown, follow ongoing treatments per order, updated provider and resident representative as needed.The facility Notification of Changes policy dated 3/2024, identified nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the residents physician, to ensure the best outcomes of care for the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to apply enhanced barrier precautions (EBP) while performing cares on 1 of 3 residents (R4).Findings include:Enhanced Barrier Precautions are a set of guidelines aimed at preventing the spread of infections caused by multidrug-resistant organisms (MDROs). These precautions are particularly important in skilled nursing facilities where the risk of transmission is high due to close contact among residents and healthcare providers.R4's face sheet dated 7/16/25, identified diagnoses of acute pyelonephritis (kidney infection) and malignant neoplasm of endometrium (uterine cancer).R4's comprehensive Minimum Data Set (MDS) dated [DATE], identified R4 had an indwelling catheter.R4's care plan dated 5/2/25, identified R4 was on EBP related to a chronic foley catheter. Interventions included to follow EBP, use appropriate communication to follow EBP, explain reason for use of EBP, and staff to don/doff (put on and take off) EBP when providing high contact cares.During an observation on 7/17/25 at 8:35 a.m., nursing assistant (NA)-C entered R4's room without donning EBP, a sign directing the use of EBP was on the door with a cart outside the room with gown, gloves, and masks in it. nursing assistant (NA)-C filled a wash basin with water, donned gloves, washed R4's hands, under her arms, and peri-area including catheter tubing then dried the areas. NA-C removed large urinary collection drainage bag and attached a smaller, more discreet urinary collection bag to R4's leg without using an alcohol wipe to sanitize the connection between the inserted catheter and the urinary drainage bag. Licensed practical nurse (LPN)-B entered room and did not have EBP on. LPN-B pushed on R4's feet and ankles to check for edema. When R4 stood up, LPN-B had gloves on and removed dressing on R4's coccyx, assessed, and put a new dressing on, LPN-B changed gloves and sanitized hands in between touching dirty and clean products. LPN-B listened to R4's lungs. LPN-B requested registered nurse (RN)-A come to room and assess lung sounds on R4. RN-A entered room and assessed lung sounds without applying EBP.During an interview on 7/17/25 at 9:19 a.m., NA-C stated she should have worn EBP when performing cares on R4 because she had a catheter.During an interview on 7/17/25 at 9:25 a.m., RN-A stated EBP should have been worn in R4's room.During an interview on 7/17/25 at 9:26 a.m., LPN-B stated she would not have to wear EBP while caring for R4 because she was not performing any cares with the catheter and the area on her coccyx was not an open wound, it was just a dressing for protection. Director of nursing (DON) came to the cart and verified that LPN-B would have to wear EBP because she was providing cares to a resident with a catheter.During an interview on 7/17/25 at 2:13 p.m., DON stated R4 was on EBP, and it is the expectation that staff wear EBP when providing cares to any resident on EBP.The Enhanced Barrier Precautions policy dated 4/1/24, identified staff should utilize gown and gloves for high contact resident care activities for residents known to be colonized or infected with multi-drug-resistant organisms (MDRO) as well as those at an increased risk of MDRO acquisition such as residents with wounds or indwelling medical devices. Implement EBP for indwelling catheters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure an oxygen tank was handled safely for 1 of 1 resident (R54) reviewed for safety hazards. Findings include: R54's facesheet printed on 2/25/25, indicated R54 had been admitted on [DATE], with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease (COPD) (inflammation of the airway causing difficulty breathing). R54's physician orders dated 2/24/25, included oxygen delivery system via nasal cannula 3-4 LPM (liter per minute) every shift. During an observation on 2/24/25 at 5:14 p.m., observed licensed practical nurse (LPN)-A, carry an E-sized metal oxygen tank, holding it to her chest with both arms wrapped around it, down hallway three. LPN-A walked from the oxygen storage room at the beginning of hallway three to the last room on hallway three. During an interview on 2/24/25 at 5:19 p.m., LPN-A stated she did not know an oxygen tank should not be carried. LPN-A was able to verbalize if dropped, an oxygen tank could explode or become a projectile injuring residents and staff. Together with LPN-A, went to the oxygen storage room where there were three empty oxygen tank hand carts available for use. During an interview on 2/25/25 at 1:23 p.m., nursing assistant (NA)-A stated, you don't carry an oxygen tank, you put it on a wheelie, adding, she didn't want to get blown to pieces if she dropped it. NA-A stated she knew this because she had training. During an interview on 2/25/25 at 2:07 p.m., the director of nursing (DON) stated LPN-A informed her she had carried an oxygen tank to a resident's room because she didn't know she shouldn't. The DON stated staff should not travel with an oxygen tank as it was a safety risk. Skills training that occurred in July 2024, indicated LPN-A received training on oxygen use. The training did not specifically identify safe handling of an oxygen tank. A policy on safe handling of oxygen tanks was requested and a competency titled Oxygen Administration dated 2/14, was received indicating oxygen tanks must be transported in oxygen cart or immediately placed in approved holder on a wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and document review, the facility failed to ensure care-planned interventions for communication with a Spanish speaking resident were consistently implemented to reduce alteration in psychosocial wellbeing, the risk of isolation, and barriers with communication for 1 of 1 resident reviewed for (R12) communication and activities. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 needed or wanted an interpreter to communicate with a doctor or health care staff, moderate cognitive impairment, no behaviors, nearly every day feeling down depressed or hopeless, nearly every day feeling tired or having little energy, always feeling social isolation, no rejection of care, utilized a walker and wheelchair, required partial/moderate assistance with toileting, shower, dressing, and mobility, and diagnoses included depression and insomnia. R12's care plan dated 5/1/24, indicated R12 does not speak English, but understands some English, Spanish speaking staff often help with translations especially for simple things, staff to use translator when speaking with R12, staff to assist with TV and make sure on Spanish translation, R12 is friendly, but there is a communication barrier as he does not speak English, talks very little English and understands very little English, use the interpreter on a stick outside by room to help me get my wants known to staff. Document titled Hall 2, 24 Hour Daily Nurse Report dated 5/10/24, indicated R12 was A-1 (assist one) 4ww (4 wheeled walker), Spanish speaking only. On 5/13/24 at 5:34 p.m., R12 was observed to walk out of his room with no walker, the walker remained in R12's room. The administrator approached and spoke English to R12 outside of his room and assisted R12 into a wheelchair in the hallway. While the administrator assisted R12 he spoke in English and asked do you want me to push you and R12 said ok ok ok and then R12 started pushing himself and used his hands to self propel the wheelchair through the hall, and administrator said again I can push you, and R12 did not answer back. R12 was observed to use his own hands to self propel himself through the hallway and to the dining room and the administrator walked away. On 5/14/24 at 8:00 a.m., during an interview with R12 and the assistance of the Language line, R12 stated he spoke Spanish, and did not understand English. R12 stated he did not understand the staff who did not speak Spanish. R12 stated he was stir crazy and stated the facility did not provide him activities, and just sits in his room all day and watched TV, and further stated what else can I do. R12 stated he wished there were activities to do and people to talk with. R12 stated he doesn't get to do activities often, because he speaks Spanish and that's why he wants to go to [named a different facility]. R12 stated the staff who do not speak Spanish ignore him, and again stated people at the facility don't speak Spanish to him and he does not understand the staff who speak English. A sign was posted on R12's wall that indicated tirar de la cuerda para pedir ayuda y [NAME]. [Pull the rope to ask for help and a bathroom, thank you.] No Spanish communication tools were observed in R12's room and color crayons were located at foot of R12's bed and not within reach of R12. R12 stated he did not know what activities he could do at the facility because the staff did not speak Spanish or understand him, and he did not understand the staff. On 5/14/24 at 8:07 a.m., R12 was observed in his room and stood up out of recliner and walked out of room independently towards his wheelchair located in the hallway that was approximately 12 feet from his door and did not use call light. Licensed practical nurse (LPN)-A was observed about 20 feet from R12 and stated un memento towards R12, R12 did not respond and continued to walk towards the wheelchair in the hallway. At 8:11 a.m., LPN-A walked down the hallway towards R12 and spoke in English and asked R12 .can I help you get your walker and R12 said no, and LPN-A continued to talk in English and R12 did not respond. R12 did not follow LPN-A commands, and facial expressions were confused and R12 said no to LPN-A as he brought the walker to R12, LPN-A continued to bring the walker to R12 and placed gait belt around R12's waist and assisted R12 to his wheelchair and pushed R12 through the hall. On 5/14/24 at 8:21 a.m., LPN-A stated he was an agency staff not familiar with R12 and stated R12 was independent with transfers and stated he was not sure what the sign on R12's wall stated. LPN-A verified he was not aware R12 spoke Spanish and was not provided information by the facility or tools to communicate with R12. On 5/14/24 at 8:25 a.m., nursing assistant (NA)-B stated he was not familiar with R12, and was not aware R12 was Spanish speaking and was not sure how he was to communicate with R12. On 5/14/24 at 8:31 a.m., NA-A stated R12 was Spanish speaking and did not understand English. NA-A stated she was fluent in Spanish and spoke Spanish with the R12. NA-A stated herself and assistant director of nursing (ADON) were Spanish speaking staff at the facility. NA-A stated she was not sure how R12 understood other staff and how other staff understood R12. NA-A stated it was very difficult for R12 to communicate with staff, and if he had visual aides that would help. NA-A stated R12 knew how to read Spanish, and the facility had not provided tools in Spanish for R12. On 5/14/24 at 8:40 a.m., activity aide (AA)-A stated there was a translator computer at the facility and she had not been trained to use or attempted to use it to participate in activities with R12. On 5/14/24 at 8:54 a.m., social services director (SS)-A stated R12 was Spanish speaking and understood limited English, and staff were expected to use the interpreter services located on the computer outside of R12's room. SS-A confirmed the translator computer was located in storage area out of sight from staff and was not located as expected outside R12's room. SS-A stated she was trained on the use of the translator computer, however usually relied on Spanish speaking staff to converse with R12. On 5/14/24 at 9:21 a.m., activity director (AD)-D stated activity staff were expected to communicate with R12 using the translator computer. AD-D stated the computer was not always located near R12's room. AD-D stated she thought R12 eventually catches on what staff saying in English, and stated she knows that because he will say yes or nod his head AD-D stated the computer translator was expected outside of R12's room readily accessible to staff, and stated there were a couple staff who were able to speak Spanish and translated if they were present at the facility. AD-D stated she was not sure how R12 understood staff when non-Spanish speaking staff. On 5/14/24 9:30 a.m., LPN-A confirmed the facility had not trained him how to use the translator computer and was not aware of any communication tools to be able to communicate with R12. On 5/14/24 at 9:33 a.m., NA-D stated she usually worked nights and does not frequently communicate with R12, and further stated R12 communicated in Spanish and she does not carry on conversations or full sentences with R12 due to the language barrier. NA-D stated she was not aware of any communication tools or interpreter computer services to use with R12. On 5/14/24 at 9:48 a.m., during a follow up interview NA-B sated he was not aware of a translator computer at the facility and had not been trained to use one or how to communicate with R12. On 5/14/24 at 1:49 p.m., during a follow up interview AA-A stated the communication she had with R12 was limited and he watched her play cards with the other residents but does not participate. AA-A confirmed she did use not the computer or communication tools to communicate with R12. On 5/14/24 at 3:21 p.m., R12 seated in recliner in room and television was on in English language. On 5/15/24 at 7:20 a.m., trained medication aide (TMA)-B stated R12 communicated in Spanish and stated due to herself and other staff not knowing Spanish and R12 not knowing English, it was likely there was a chance for miscommunication and misinterpretation of R12's wants and needs, that could make him feel lonely or frustrated. On 5/15/24 at 7:24 a.m., TMA-C stated R12 spoke Spanish and she knows what R12 might want based on routine and acknowledged she only spoke English with R12. TMA-C stated she was not sure if R12 understood her or not. TMA-C stated she had not been trained or had used the translator computer or other communication tools to be able to communicate with R12. On 5/15/24 at 7:49 a.m., NA-F stated R12 spoke Spanish, and stated R12 was not offered choices of meals, activities, and wants and needs in a form or language he could understand. NA-F confirmed she does not use the translator computer. On 5/15/24 at 8:40 a.m., NA-H was instructed from staff to assist R12 to the bathroom, NA-H asked R12 in English do you use the EZ lift, R12 did not respond. NA-H was observed to continue to assist R12 to the bathroom and only communicated with R12 in English then and no attempt use computer in hallway and was observed to assist R12 to the bathroom. R12 did not respond to NA-H questions. On 5/15/24 at 8:53 a.m., the administrator stated when NA-A and ADON were at the facility they provided translation for R12. The administrator stated staff were expected to use the interpreter computer if it was available and working, and stated when the staff and R12 communicated with gestures and yes and no. On 5/15/24 at 9:43 a.m., the ADON stated R12 spoke Spanish and she acted as a translator and would assist with communication occasionally while at the facility and during R12's care conference. ADON stated she was not at the facility 24/7 and when she was at the facility she was not always available to act as the translator for R12. ADON stated she was not sure if the translator computer still worked, and stated if it worked staff should use the computer to communicate with R12. ADON stated R12 had not been provided other communication tools to utilize. On 5/15/24 at 10:52 a.m., NA-H and NA-G were observed in R12's room and attempted to converse in English with R12 as they changed the television from Spanish to English, NA-H and NA-G were not heard or observed to ask R12 choices of a television show. On 5/15/24 at 11:11 a.m., AA-B stated she does not have a communication tool to communicate with R12. On 5/15/24 at 11:51 a.m., the director of nursing (DON) stated staff were expected to use computer translator for communication with R12. The DON stated SS-A was responsible for staff education for the use of the computer translator and was not aware staff were not trained to use the computer. The DON discussed previously she wanted to provide visual aides for R12 as a communication tool and stated that was discontinued as she was told that was a dignity concern. The DON acknowledged she was not sure how staff communicated with R12 if the computer translator is not used. On 5/15/24 5:35 p.m., during a telephone interview with R12's emergency contact (EC)-A stated R12 was lonely at the facility because he did not have anyone that visited with him or communicated with him regularly. EC-A stated some staff at the facility spoke Spanish, and confirmed R12 does not speak English or understand English. EC-A stated the impression of Spanish speaking people was when they smiled or nodded it was thought they understood what a person was saying, but that is not always true. EC-A stated R12 was lonely at the facility. On 5/15/24 from 7:00 a.m.-1:00 p.m., the computer translator was observed outside R12's room and located in the hallway, however, was not observed utilized by staff. Facility assessment dated [DATE]. indicated: Our facility uses [NAME] Translation services to provide our non-English speaking /ASL residents with the ability to communicate their needs and preferences. We employ several bilingual direct care givers. We provide person-centered/directed care. Person-centered care - This should include but not be limited to person-centered care planning Our admission process includes identifying these elements and understanding what is important for the individual. We believe this information is essential for a person-centered/person driven care delivery system/program. This knowledge allows us to determine the necessary skills/competencies our staff need along with what contracted services we may also need. This information has led the interdisciplinary team to develop specific services to assist individuals in achieving their highest practicable level of function while also enjoying living in our community of care. Cultural competency (ability of organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of residents)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure individualized activities and activities for a non-English speaking resident were provided for 1 of 3 residents (R12) reviewed for activities. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 needed or wanted an interpreter to communicate with a doctor or health care staff, moderate cognitive impairment, no behaviors, nearly every day feeling down depressed or hopeless, nearly every day feeling tired or having little energy, always feeling social isolation, no rejection of care, utilized a walker and wheelchair, required partial/moderate assistance with toileting, shower, dressing, and mobility, and diagnoses included depression and insomnia. R12's document titled Resident Mood (PHQ-9) dated 4/29/24, indicated nearly every day felt feeling down, depressed, or hopeless, sad and feeling tired or having little energy, and always feel lonely or isolated from those around you. R12's care plan dated 5/1/24, indicated R12 does not speak English, but understands some English, Spanish speaking staff often help with translations especially for simple things, staff to use translator when speaking with R12, he did very well using the translator during TR (therapeutic recreation) Assessment; at risk for psychosocial disruption/trauma r/t (related to) experiencing loneliness, staff to assist with TV and make sure on Spanish translation, staff to visit with resident, resident/family currently wishes to remain at facility until opening at Living Meadows at [NAME] - Madelia, please encourage to make my room homelike to my liking, R12 is friendly, but there is a communication barrier as he does not speak English, he does understand some English, but speaks only a couple words of English; Spanish Speaking Staff, who are willing to help with translating as needed, declines to sit in with group activities, but will often sit at a distance and observe, does not speak English, able to understand some English. enjoys Spanish/Mexican Music, staff to assist with the TV as needed, respond to question/statement with appropriate verbalization, explain each activity/care procedure to resident prior to beginning it, give resident simple choices that will not be overwhelming, talks very little English and understands very little English, use the interpreter on a stick outside by room to help me get my wants known to staff. R12's record review indicated no documentation of mood or behavior interventions related to R12's feeling down, depressed, or hopeless, sad and feeling tired or having little energy, and always feel lonely or isolated. Document titled Hall 2 24 Hour Daily Nurse Report dated 5/10/24, indicated R12 was A-1 (assist one) 4ww (4 wheeled walker), Spanish Speaking only. Progress note dated 4/29/24, social services (SS)-D indicated BIMS (cognitive screening) and PHQ-9 (depression screening) were completed today with translation services. BIMS score was 11 indicating moderate impairment. PHQ-9 score was 6, indicating mild depression. R12 stated he was sad and had little energy daily. R12 wondering if they have any opening at Living Meadows in Madelia to be closer to his friends. R12's IDT Care Conference Form dated 4/30/24, indicated care conference was held today with Spanish translator, will occasionally comes out for dice game, socialize with staff in the facility, watches TV in his room, attends very few group activities, writer believes that it is language barrier that keeps him from participating in activities, but he will on rare occasion join in an activity, he does attend entertainment held in the facility, he will often come into the dining room when a group activity is going on and he appears to observing what is happening. Prefers to be in his room watching Spanish speaking Channels on TV. He sits in his recliner and rests or sleeps, has a roommate, but due to the language barrier there is little interaction, often self transfers or coming out into the hallway walking on his own, very pleasant with writer and other staff and will often ask how are you, appears to understand more English than he can speak, on occasion will receive visitors. Psychosocial concerns/vulnerability: stated he was sad and had little energy daily and another facility was assessing for possible placement to be closer to his friends. On 5/13/24 at 2:53 p.m., R12 was seated in a recliner in his room with the television on in Spanish, R12's roommates television was also on in English. R12's television could not be heard due to the loud volume of the roommates television. On 5/14/24 at 8:00 a.m., during an interview with R12 and the assistance of the Language line, R12 stated he spoke Spanish, and did not understand English. R12 stated he did not understand the staff who did not speak Spanish. R12 stated he was stir crazy and stated the facility did not provide him activities, and just sits in his room all day and watched TV, and further stated what else can I do. R12 stated he wished there were activities to do and people to talk with. R12 stated he doesn't get to do activities often, because he speaks Spanish and that's why he wants to go to [named a different facility]. R12 stated the staff who do not speak Spanish ignore him, and again stated people at the facility don't speak Spanish to him and he does not understand the staff who speak English. A sign was posted on R12's wall that indicated tirar de la cuerda para pedir ayuda y [NAME]. [Pull the rope to ask for help and a bathroom, thank you.] No Spanish communication tools were observed in R12's room an art with colors located at foot of R12's bed and not within reach of R12. R12 stated he did not know what activities he could do at the facility because the staff did not speak Spanish or understand him, and he did not understand the staff. On 5/14/24 at 8:31 a.m., NA-A stated R12 was Spanish speaking and did not understand English. NA-A stated she was fluent in Spanish and spoke Spanish with the R12. NA-A stated herself and assistant director of nursing (ADON) were Spanish speaking staff at the facility. NA-A stated she was not sure how R12 understood other staff and how other staff understood R12. NA-A explained R12 had voiced to her that he was not happy at the facility and wanted to go to a different facility. NA-A stated R12 had voiced he does not understand staff at the facility, and had a meeting about going to a different facility, but has not heard back about if he could go. NA-A stated it was very difficult for R12 to communicate with staff, and if he had visual aides that would help. NA-A stated R12 knew how to read Spanish, and the facility had not provided tools in Spanish for R12. NA-A stated R12 occasionally attended activities not involving speaking or words, and would go to more activities if he was given some that that did not involve words or word puzzles, or some type of activity in Spanish. NA-A stated she felt R12 was a little neglected and ignored because of language barrier and R12 had requested somewhere more calm for himself and with people to interact with. On 5/14/24 at 8:40 a.m., activity aide (AA)-A stated she invited R12 to attend activities through gestures and broken English. AA-A stated R12 frequently refused activities such as church and word puzzles. AA-A stated the church was in English and there was not a Spanish church offered. AA-A stated she knew some very limited Spanish such has hi, sun, hello, how are you and stated she also used gestures to communicate with R12. AA-A confirmed she did not have full conversations with R12 or offer one on one activities. AA-A stated the broken Spanish could cause confusion and frustration for the R12 if he did not know what she was saying. AA-A stated church in English may not be beneficial or meaningful for R12, if he did not understand English or music. AA-A stated when other residents are doing word puzzles as an activity R12 is not offered another activity because word puzzles was the facility activity scheduled. AA-A stated she was not aware of R12 having any individualized activities offered to meet his preferences and she was not sure what his activity preferences were. AA-A stated there was a translator computer at the facility and she had not been trained to use or attempted to use it to participate in activities with R12. On 5/14/24 at 8:54 a.m., social services director (SS)-A stated R12 was Spanish speaking and understood limited English, and staff were expected to use the interpreter services located on the computer outside of R12's room. SS-A stated R12 was on a waiting list to go to another facility to be closer to friends. SS-A confirmed the computer was not located outside R12's room as expected and further stated staff were expected to know where to find the computer and use the computer to communicate with R12. SS-A stated staff not communicating in full conversations may not provide the social interactions that a R12 would need and may become confused or not understood by staff. SS-A stated staff should be trained on orientation to use translator computer and not sure whose responsibility it was. SS-A stated she had limited interactions with R12, besides care conferences and other then that does not have frequent interactions or conversations with R12. SS-A could not articulate any specific interventions related to R12's sad mood or loneliness that was determined on the depression screening, and stated she had not provided R12 with any other interventions. SS-A confirmed the translator computer was located in storage area out of sight from staff and was not located as expected outside R12's room. On 5/14/24 at 9:21 a.m., activity director (AD)-D stated activity staff were expected to communicate with R12 using the translator computer. AD-D stated the computer was not always located near R12's room. AD-D stated she thought R12 eventually catches on what staff saying in English, and stated she knows that because he will say yes or nod his head. AD-D stated R12 was offered happy hour and church which he declines. AD-D confirmed R12 was not offered a Spanish church at the facility. AD-D stated activities R12 participated in were TV in his room, occasional exercises and music entertainment. AD-D confirmed the language barrier was why R12 did not participate in activities because he can not understand what people were saying. AD-D stated Spanish activities or other tools to allow R12 to feel included had not been offered to R12. AD-D stated the computer translator was expected outside of R12's room readily accessible to staff, and stated there were a couple staff who were able to speak Spanish and translated if they were present at the facility. AD-D stated she was not sure how R12 understood staff when non-Spanish speaking staff. AD-D acknowledged there was a lack of individualized activities or interactions with R12 that would have meaning or individualizing to meet R12's needs. On 5/14/24 at 1:49 p.m., during a follow up interview AA-A stated the communication she had with R12 was limited and he watched her play cards with the other residents, but does not participate. AA-A confirmed she did use not the computer or communication tools to communicate with R12. AA-A stated she would make observations of what R12 does during the day and would document those as activities such as transferring himself in the wheelchair to meals, sitting in his chair looking out the window by himself with out interactions with others. AA-A stated she considers those as activities even though they might not be meaningful or individuated for R12 because they were options in the computer documentation . On 5/14/24 at 3:21 p.m., R12 seated in recliner in room and television was on in English language. On 5/15/24 7:15 a.m., R12 was seated in recliner and staring at the curtain that divided the shared room, and television was off. On 5/15/24 at 7:49 a.m., NA-F stated R12 spoke Spanish, and stated R12 was not offered choices of meals, activities, and wants and needs in a form or language he could understand. NA-F stated R12 mainly sat in his room and does not have much interaction with staff due to the language barrier. NA-F stated R12 had been at the facility for a long enough time that he should be given tools to be able to communicate with staff and the facility should be doing something so staff can communicate with him and give him activities he might like to do so he is just not sitting in his room all day. NA-F stated the language barrier and lack of activities for R12 would place him at risk for increased depression and loneliness. NA-F confirmed she does not use the translator computer. On 5/15/24 at 8:30 a.m., R12 was observed in his room with the television turned on in the English language. R12 gestured with fingers in circle towards head and pointed to roommate and stated loco [crazy]. On 5/15/24 at 8:53 a.m., the administrator stated when NA-A and ADON were at the facility they provided translation for R12. The administrator stated staff were expected to use the interpreter computer if it was available and working, and stated when the staff and R12 communicated with gestures and yes and no. The administrator acknowledged yes and no, were not meaningful conversations and did not provide social interaction or individualized care for R12. On 5/15/24 at 9:43 a.m., the ADON stated R12 spoke Spanish and she acted as a translator and would assist with communication occasionally while at the facility and during R12's care conference. ADON stated she was not at the facility 24/7 and when she was at the facility she was not always available to act as the translator for R12. ADON stated she was not sure if the translator computer still worked, and stated if it worked staff should use the computer to communicate with R12. ADON stated R12 does not go to activities due to the language barrier, and has not been provided other activities or communication tools to utilize. ADON stated she had discussed other activities were needed for R12 to provide social interaction and get him out of his room, and nothing had been done. ADON stated R12 struggled with his roommate due to the volume of the television, and the roommate was supposed to wear headphones and that was no longer taking place. ADON stated R12 would not be able to hear his TV with the volume level of his roommate's television, and caused R12 frustration. ADON confirmed R12 and his roommate were not a good match, and R12 really wanted to leave the facility to go to a different facility. ADON stated SS-A was working on transfer to a different facility, but have not heard an update. The ADON stated R12 had stated he was uncomfortable and miserable in his room because of his roommate and lack of interaction with others. ADON stated she had brought her Spanish speaking grandma in a few times for R12 to have someone to chit chat with and interactions, and that ended because her grandma got sick. ADON confirmed the lack of communication R12 has with others could cause loneliness and isolation. On 5/15/24 at 10:52 a.m., NA-H and NA-G were observed in R12's room and attempted to converse with R12 as they changed the television from Spanish to English, NA-H and NA-G were not heard or observed to ask R12 choices of a television show. On 5/15/24 at 11:11 a.m., AA-B stated R12 had attend three or four activities that she was aware. AA-B stated R12 did not activities involving words or speaking, and recently attended picture Bingo and a balloon game. AA-B explained R12 will say no no no about things and she would say yes yes yes and make a game out of saying no and yes. AA-B stated she was not sure if R12 fully understood her to have the activities provide socialization or met R12's needs, because R12 doesn't understand English. AA-B further stated she does not have a communication tool to communicate with R12. On 5/15/24 at 11:18 a.m., AA-D stated activities staff charted observation of residents throughout the day and if R12 was wheeling to and from meals in the wheelchair staff would document transfer in a wheelchair to a meal as an activity. AD-D stated activities staff chart what they see the residents do throughout the day even if its not a scheduled activity because that's what the computer charting had for selection. AD-D confirmed R12 self-propelling to the dining room would not be a activity provided by the activity department, however was still charted by the activity. AD-D stated she was not sure what activities were offered to R12 that provided him enrichment, enjoyment, and socialization, but will see him seated at a table by himself when others are participating in the activity in the dining room. AA-D stated there were no specific individualized activities to provide socialization for resident. On 5/15/24 at 11:51 a.m., the director of nursing (DON) stated staff were expected to use computer translator for communication with R12. The DON stated SS-A was responsible for staff education for the use of the computer translator and was not aware staff were not trained to use the computer. The DON discussed previously she wanted to provide visual aides for R12 as a communication tool and stated that was discontinued as she was told that was a dignity concern. The DON acknowledged she was not sure how staff communicated with R12 if the computer translator is not used, and would expect staff to be having meaningful conversations to prevent R12 does not experience increased loneliness and isolation. On 5/15/24 at 5:27 p.m., during an interview with the administrator, registered nurse (RN)-C known as the regional nurse consultant, and DON confirmed R12 was expected to have been offered activities that met his language and activities of interest. RN-C stated not having activities of interest could result in R12 withdrawing, loneliness and not wanting come out of room due to the language barrier. The administrator stated having broken conversations of English and Spanish between staff and R12 were not conversations that would fully assess R12 and may be an area that R12 would not fully be able to communicate his wants and needs. The DON stated visual aides would be beneficial to ensure R12 was getting what needed and wanted, and stated having a sign up on the wall that staff did not know what it meant did not do any good. RN-C confirmed the facility did not complete mood or behavior monitoring related to R12. On 5/15/24 5:35 p.m., during a telephone interview with R12's emergency contact (EC)-A, stated R12 was lonely at the facility because he did not have anyone that visited with him or communicated with him regularly. EC-A stated prior to admitting to the facility R12 was very active in the community and church. EC-A stated R12 voiced on multiple occasions he wanted to go to a different facility that was closer to friends and people who spoke Spanish and he understood. EC-A stated some staff at the facility spoke Spanish, and confirmed R12 does not speak English or understand English. EC-A stated the impression of Spanish speaking people was when they smiled or nodded it was thought they understood what a person was saying, but that is not always true. EC-A stated R12 was lonely at the facility. Facility assessment dated [DATE], indicated: Resident preferences 1.7.Our admission process includes identifying our residents' needs in therapeutic recreation, nutritional services, and religious services. We also consider our residents' preferences with regard to daily schedules including but not limited to waking, bathing, activities, naps, food, going to bed, etc. Our admission process includes identifying these elements and understanding what is important for the individual. Life Enrichment/Activities The Life Enrichment department consists of one activity director, one memory care coordinator, and three activity assistants. Life Enrichment departmental meetings are held subject to the discretion of the director. Education includes: Point of Care documentation, instructions how to perform certain programs, and annual mandatory training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure weekly comprehensive skin assessments with measurements were completed for 1 of 1 resident (R35) reviewed for pressure ulcers. Findings include: Pressure Ulcer stages defined by the Minimum Data Set (MDS) per Center Medicare/Medicaid Services: Stage II pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ ruptured blister.) R35's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, no behaviors or rejection of care, dependent on staff for toileting, transfers, required substantial/maximal assistance with shower/bathe, dressing, personal hygiene, utilized a wheelchair, frequently incontinent of urine and bowel, diagnoses included: chronic venous hypertension with ulcer and inflammation of lower extremity, one stage two unhealed pressure ulcer, treatments included: pressure reducing device for chair and bed, nutrition intervention, pressure ulcer care, application of nonsurgical dressings, and hospice care. R35's Care Area Assessment (CAA) dated 4/22/24, indicated triggered due to bladder incontinence, R14 needing assist with bed mobility, and presence of stage 2 pressure ulcer on coccyx, Braden scale for predicting pressure sore risk on 4/17/24, scoring 13, indicating that she is at moderate risk for skin breakdown. R14's condition has declined significantly in the past month, she is weak, appetite is very poor, and she tires easily, unable to stand and now transfers with Hoyer lift and extensive assist of 2. On 4/21/24, hospice care for comfort measures, proceed to the care plan as before to ensure good skin integrity, promote healing of current coccyx wound, and prevention of any further skin breakdown. R35's care plan dated 4/24/24, indicated on 4/16/24, open area to coccyx (small triangular bone at the base of the spinal column) upon return from the hospital and the hospital had covered the area with a Mepilex (conformable and highly absorbent wound dressing ) for additional protection and interventions included: assist of 1 to 2 with bed mobility and boosting up in bed, repositioned every 1 when in bed to keep her off of her bottom, use pillows to pad bony prominence's, between knees and ankles, keep her skin from rubbing on the sheets, dietary interventions as ordered, treatment to open areas per order, weekly skin inspections, inspect skin daily with cares and nursing assistant to report any concerns to the nurse, monitor for signs and symptoms of infection, pressure reducing air mattress for bed, pressure reducing cushion for wheelchair. R35's progress note dated 3/24/24 at 9:52 p.m., indicated R35 had an open sore on the coccyx area and should be repositioned and not sit for long. R35's document titled Weekly Skin Inspection indicated: 3/25/24, blanchable redness to buttocks. Small dimple area above coccyx area that looks intact, barrier cream applied, turned and repositioned. 4/1/24, small blanchable reddened area to the buttocks-small dimple area above coccyx that looks intact. Barrier cream applied, turned and repositioned. 4/15/24, small blanchable reddened area to the buttocks-small dimple area above coccyx that looks intact. 4/22/24, skin summary information as blank 4/29/24, blanchable redness to coccyx area, area is covered with Mepilex border dressing to prevent skin break down. R35's document titled Readmit Data Collection dated 4/8/24, indicated R35 returning from the hospital following a short stay for dehydration, hyponatremia (low sodium), UTI (urinary tract infection), R35 had a discolored coccyx a reddish color and has for a very long time, Mepilex dressing used to help protect skin. R35's document Skin & Wound Evaluation dated 4/16/24, indicated open lesion; area 1.2 cm (centimeters), length: 1.6 cm, width 1.0 cm, wound bed: slough (non-viable tissue), 100% of wound filled with slough, surrounding tissue: dark reddish brown, discoloration-black/blue, fragile skin that is at risk for breakdown, macerated, water logged tissue, primary dressing: foam, additional care: air flow pad, cushion, mattress with pump, moisture barrier, nutrition/dietary supplementation, turning/repositioning program, progress: new, PCP (primary care provider) notified for treat plan, and a color photograph was included in the assessment. The document failed to provide the location, acquired in house or present on admission, exudate (fluid that leaks out of blood vessels into nearby tissues), peri wound edges, and pain information. R35's wound evaluation form dated 4/21/24, indicated wound location: coccyx, pressure wound: yes, dressing change done using wound cleanser and gauzes and covered with Tegaderm dressing. Length 3.1 by width 1.3 (cm) there was reddening the surrounding, no slough ,the document failed to include unit of measurement, pressure stage, comprehensive description: depth, granulation. R35's document Skin & Wound Evaluation dated 5/14/24, indicated an open lesion, on the sacrum, in-house acquired, area <0.1 cm 2, length 0.3 cm, width 0.3 cm, progress improving, Cleansed area with wound dermal cleanser/normal saline. Pat dried with a gauze pad and applied Calmoseptime Ointment, practitioner notified, resident/responsible party notified, and color photograph was included in the assessment. R35's treatment administration record (TAR) on 5/13/24, dated 5/1/24-5/31/24, and 4/1/24-4/30/24 indicated: Weekly bath charting/Skin check Chart on mass left medial back every day shift every Mon for Facility Protocol with a start date of 12/25/23, and discontinued date of 5/13/24. The TAR failed to indicate chart on R35's coccyx. R35's order summary report reviewed 5/13/24, failed to indicate weekly skin checks of R35's coccyx and treatment orders. R35's medical record lacked evidence of weekly comprehensive skin assessments since R35 returned from the hospital on 4/8/24, that included measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. On 5/13/24 at 4:32 p.m., R35 was lying on an air mattress in bed on and positioned on her back. R35 verified she will refuse to reposition and staff had educated her to reposition. On 5/14/24 at 11:41 a.m., family member (FM)-J stated R35 had a problem area on her coccyx for quite sometime. FM-J stated when R35 went to the hospital on 4/4/24, he was not sure if the area on R35's coccyx was opened or not, and stated when R35 returned from the hospital 4/8/24 and FM-J stated the facility notified him on 4/16/24, the area on R35's coccyx had opened, and was found during her bath. FM-J stated she did not have an air mattress prior to the wound opening, and stated she had a decline and would refuse repositioning at times and spent more time in bed. R35 was lying in bed with an air mattress and positioned towards her right side. On 5/15/24 at 11:35 a.m., licensed practical nurse (LPN)-B stated she was the nurse responsible for completing R35's weekly wound checks and documention. LPN-B confirmed R35's open area on the coccyx was a stage 2 pressure related. LPN-B confirmed a skin assessment was completed on 4/1/24, 4/15/24, 4/22/24, 4/29/24, and measurements were not completed as expected. LPN-B further confirmed the next wound assessment after 4/29/24, was not completed until 5/14/24. LPN-B stated she helped the facility on the floor pass medications and helped with other resident cares and was not always able to complete residents comprehensive wound assessments that included measurements and pictures. LPN-B stated R35's wound had improved and was unavoidable due to her decline in health, and refusal of R35 and family for repositioning. On 5/15/24 at 11:42 a.m. the director of nursing (DON) stated pressure ulcers should be measurement weekly with a comprehensive assessment. The DON stated the daily charge nurse was responsible for the wound assessments and were completed on the residents bath day. The DON stated wounds were discussed during IDT (interdisciplinary team) meetings. The DON stated R35 had improvement with her coccyx wound and was an unavoidable and returned from the hospital on 4/8/24, with the area opened. The facility Skin Assessment and Wound Management policy dated 3/24, indicated Weekly skin inspection will be completed by licensed staff. Pressure wounds New Skin Problem: When a pressure ulcer is identified, the following actions will be taken: 17. Notify Provider/Treatment Ordered 18. Notify resident representative. 19. Complete education with resident/resident representative including risks & benefits. 20. Initiate Skin and Wound Evaluation. 21. Notify Nurse Manager/Wound Nurse 25. Update resident care lists

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide services to maintain and/or prevent loss of range of motion (ROM) for 2 of 3 residents (R4 and R32) reviewed for limited range of motion. Findings include: R4's facesheet printed on 5/15/24, included diagnoses of psychosis and blindness. R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R4 had moderately impaired cognition, clear speech, was understood and usually could understand. R4's vision was severely impaired. R4 was dependent upon staff for toileting; could walk 10 feet with supervision, and 50 feet with partial/moderate assistance. Walking 150 feet was not attempted. No rejection of care. R4's prior quarterly MDS assessment dated [DATE], approximately one month after a therapy referral to nursing to walk R4 daily, the MDS assessment indicated R4 was able to walk up to 150 feet with supervision. That was a change from the 5/4/24 MDS. R4's physician orders did not include an order for a walking program. R4's therapy referral to nursing dated 11/20/23, indicated: walk with R4 in halls daily with FWW (front wheeled walker), gait belt and wheelchair following behind. Needs assistance to avoid veering toward the wall. Benefits from encouragement. R4's care plan dated 11/22/23, indicated: assist of one with ambulating in hallway daily with wheeled walker, gait belt, and wheelchair following behind. Needs assistance to avoid veering towards the wall. Resident benefits from encouragement. During an interview on 5/13/24 at 4:41 p.m., R4, who resided on the memory care unit and who was blind, stated her balance was awful. R4 stated she walked with a walker or used a wheelchair to get around the unit. R4 stated she would like to walk in the hallway, but no one walked her. During an interview on the memory care unit on 5/14/24 at 2:15 p.m., trained medication aide (TMA)-I, who was also a nursing assistant (NA), stated NA's assisted residents who were on a walking program. TMA-I stated she didn't know if R4 was on a walking program and there was nothing written that staff should walk her. During an interview on 5/14/24 at 4:16 p.m., physical therapist (PT)-M stated R4 had been discharged from physical therapy on 11/20/23, with a referral to nursing to continue the walking program. PT-M provided a document titled Therapy Referral to Nursing dated 11/20/23, which indicated walk with resident in halls daily with FWW walker, gait belt and wheelchair following behind. Needs assistance to avoid veering toward the wall. Benefits from encouragement. PT-M stated the completed referral forms were put in a mailbox for the director of nursing (DON), the assistant DON, the MDS nurse, and the social services director to carry forward the referral instructions. R32's face sheet printed on 5/15/24, included diagnoses of stroke and post-polio syndrome (a condition that affects people who have had polio causing a gradual decline in muscle and nerve function). R32's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R32 required substantial/maximal assist for toileting. No rejection of care. Once standing, R32 could walk 150 feet with supervision. Physician orders did not include an order for a walking program. R32's care plan dated 9/16/21, indicated assist of one with 4WW/belt (four-wheeled walker with gait belt) for pivot transfers/short distance ambulation, to maintain current mobility status. R32's therapy referral to nursing dated 11/9/23, indicated: walk with R4 for 15-20 minutes seven days a week. During an interview on 5/13/24 at 1:35 p.m., R32 was in her wheelchair in her room. R32 stated someone was supposed to walk her once a day, but they didn't - they're busy and she wasn't the type of person who pestered the staff. R32 stated she wanted to walk because if you don't use it, you lose it, adding she wanted to walk, even if not very well. During an interview on 5/14/24 at 9:20 a.m., on the memory care unit, TMA-E stated R32 was on a walking program, but she often refused to walk. TMA-E looked in the electronic medical record/point of care documentation and stated R32 was supposed to walk in her room and in the corridor. No other information was listed, such as what type of assistance was required or distance to walk. During an interview on the memory care unit on 5/14/24 at 2:15 p.m., TMA-I (who was also NA), stated NA's assisted residents who were on a walking program. TMA-I stated she didn't know if R32 was on a walking program and there was nothing written that staff should walk her. During an interview on 5/14/24 at 4:16 p.m., PT-M stated R32 had been discharged from physical therapy on 11/9/23, with a referral to nursing to continue the walking program. PT-M provided a document titled Therapy Referral to Nursing dated 11/9/23, which indicated walk with resident for 15-20 minutes, 7 days a week. PT-M stated the completed referral forms were put in a mailbox for the director of nursing (DON), the assistant DON, the MDS nurse, and the social services director to carry forward the referral instructions. These instructions were not added to R32's care plan. PT-M stated she had only been at the facility two weeks and had not followed up with nursing to see how R32 was doing. During an interview on 5/15/24 at 11:11 a.m., the DON was informed of findings for R4 and R32 wanting to walk, but not being walked. The DON was informed there was no documentation located to determine if either R4 or R32 had been walked. The DON stated she had difficulty with the staff on the memory care unit -- you can ask, and you can help -- whether they comply is another matter. The DON was shown a copy of the therapy referrals to nursing for both R4 and R32. The DON stated when she received a referral, the therapy instructions were added to the resident's care plan and put in tasks in the electronic medical record (EMR) for NAs to implement. The DON stated PT was supposed to show NA's how to do it, stating there was an education piece to it. The DON stated she couldn't recall if she had received the therapy referrals for R4 and R32. The DON stated for R32, walking 15 minutes/day wasn't realistic, but had not questioned therapy at the time or since then. The DON stated, you have to remember, they [residents on the memory care unit] have poor mentation, and stated staff, Will get to it when they finish their tasks, then they can walk residents. The DON stated staff had other things to do first, like skin and falls. The DON was informed of the concern that R4 and R32 were not being walked according to the therapy referrals. If a resident refused the offer to walk, the DON agreed she would expect the NA to inform the nurse, the nurse to document it and inform the DON if there was a pattern so that therapy could be notified. The DON was asked to provide documentation of R4 and R32 being walked and/or refusals documented. The DON stated she would do that. This documentation was not provided. During an interview on 5/15/24 at 1:35 p.m., in her room, R32 stated she had not recalled a time when asked to walk, that she had declined. During an interview on 5/15/24 at 2:53 p.m., registered nurse (RN)-C who was also the regional nurse consultant, was informed of findings and stated would look for documentation of R4 and R32 being walked according to their therapy referral instructions. This documentation was not provided. Policies on restorative nursing and/or PT referrals to nursing for a walking program was requested. According to the administrator, the facility did not have a policy defining that process nor a restorative nursing program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R29) reviewed for nutrition had received a mechanically altered diet per physician orders. Findings include: R29's face sheet printed on 5/14/24, included diagnoses of dementia, adult failure to thrive (a syndrome that describes a general decline in older adults) and severe protein-calorie malnutrition (a condition that occurs when a body doesn't get enough nutrients to maintain its tissues and functions). R29's diet order dated 1/29/24, indicated a regular diet with mechanical soft texture (a type of texture-modified diet for people who have difficulty chewing and swallowing). R29's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, no loose or ill-fitting dentures, no problems swallowing, no mouth or facial pain, discomfort, or difficulty with chewing. R29's care plan dated 1/30/24, indicated R29 had the potential for alteration in nutrition related to diagnoses of dementia, adult failure to thrive and severe protein-calorie malnutrition; was on regular, mechanical soft texture diet and would maintain adequate nutritional status. During an interview and observation of the lunch meal on 5/13/24 at 1:30 p.m., R29 who ate meals in his room, was observed in bed with his meal tray on his overbed table. Observed R29 had been served a whole hamburger on a bun and noticed a couple of bites taken out of it. R29 stated the hamburger was hard to eat. During an interview and observation of the dinner meal on 5/13/24 at 5:45 p.m., R29 was observed in bed with his meal tray on his overbed table. Observed R29 pick up a chicken strip and attempt to bite off a piece but could not. Same occurred with a potato wedge. R29 stated the food was too hard for him to bite. R29 had dentures in place. During an interview and observation on 5/14/24 at 11:50 a.m., R29 was resting in bed. Observed his dentures in a cup on his overbed table. R29 acknowledged he had trouble eating potato wedges and chicken strips the day before. R29 stated he always wore his dentures when he ate and stated his dentures fit well. During this observation, R29 put his dentures in his mouth from the cup, stating he didn't use a dental adhesive. During an interview on 5/14/24 at 11:53 a.m., dietary director (DD)-F was informed of a dinner meal observation on 5/13/24, where R29 was not able to bite into a whole chicken strip or a whole potato wedge. DD-F was also informed of R29 receiving a whole hamburger for lunch on 5/13/24. DD-F stated R29 was on a mechanically altered diet and kitchen staff should have cut up his food in the kitchen prior to it being served. DD-F could not explain why R29's food had not been mechanically altered by kitchen staff and would look into it and provide re-education. During an interview on 5/15/24 at 11:11 AM, the director of nursing (DON) stated she had been made aware of R29 receiving meals without food being cut up and stated DD-F had started re-educating dietary and nursing staff on mechanical diets. The facility Diet Manual and Diet Orders policy dated 12/1/23, indicated a diet order is a prescription written by the attending physician to establish or change a patient's diet. A therapeutic diet order may be necessary as part of a patient's medical nutrition therapy treatment. Foods that must be cut up for the resident will be done by nursing or other designated staff persons at the table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure BiPAP (a type of ventilator that delivers two levels of air pressure to the lungs) was utilized in accordance with physician orders to meet the individual needs for 1 of 1 resident (R38) reviewed for respiratory care and services. Findings include: R38's facesheet printed on 5/15/24, indicated diagnoses of obstructive sleep apnea (OSA) (sleep-related breathing disorder which causes a person to repeatedly stop and start breathing while sleeping), pulmonary fibrosis (lungs become scarred and damaged causing difficulty in breathing), chronic obstructive pulmonary disease (COPD) (airflow limitations) and recent pneumonia. R38's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R38 was cognitively intact, hearing and vision were adequate, clear speech, and was able to make self understood and could understand others. The MDS indicated non-invasive mechanical ventilator, BiPAP use and oxygen therapy. R38 required partial to moderate assistance with toileting, and supervision with touching assistance for walking, and transfers. R38's plan of care dated 4/7/24, included an alteration in oxygen/gas exchange related to COPD and OSA. Interventions included administer oxygen as ordered and keep MD (medical doctor) informed of changes. A fall risk plan of care included diagnosis of pulmonary fibrosis, COPD and uses a bi-pap at hours of sleep as well as oxygen. The care plan did not include any further information on BiPAP or respiratory status. Physician orders dated 4/29/24, and related to BiPAP indicated: 1. BiPAP machine on at night daily for obstruction sleep apnea. 1. Change water on BiPAP daily. Empty and dry out chamber and fill water chamber with distilled water to fill line. 2. Clean BiPAP filter weekly and as needed every evening shift. 3. Clean BiPAP mask and tubing with gentle soap and warm water and let air dry. 4. Clean BiPAP water chamber with gentle soap and air dry weekly every shift on Monday. Physician orders dated 4/29/24, for oxygen included: 1. Oxygen continuous wean as able per nasal cannula to keep oxygen saturation greater than or equal to 88% every shift for oxygen. 2. Oxygen saturations every shift. 3. Change oxygen tubing weekly every day shift on Monday. On interview and observation 5/13/24 at 1:14 p.m., R38 indicated has a BiPAP machine and hasn't been able to use it since she came to the facility because she needs oxygen and there is no adapter on her machine for that. R38 stated she stops breathing at night, which is why she needs her BiPAP machine. R38 indicated her machine is from home and she wasn't using oxygen at home prior to her recent hospitalization. R38 stated no one has done anything to solve the issue of adding oxygen to the BiPAP machine. A BiPAP machine (Resmed, Air Curve 10), mask and tubing was present on night stand. During observation 5/13/24 at 7:23 p.m., R38 was in her pajamas and placed call light on asking staff to put her oxygen on. Nursing assistant (NA)-B answered call light and turned on oxygen machine set at 2L and applied nasal cannula to R38's face and into her nose. NA-B turned off the lights and left the room leaving door 1/2 ajar. BiPAP machine remained on nightstand and was not applied or turned on or offered to R38. During interview on 5/14/24 at 9:20 a.m., R38 stated she can't wear her oxygen and BiPAP at the same time so has not worn it at night since she has been here. R38 indicated she always wears it at home but hasn't since being at the facility. R38's Treatment Administration Record (TAR) orders included BiPAP machine on at night, one time a day. On 5/1/24 through 5/11/24 and 5/13/24 and 5/14/24 a check mark was present indicating administration. The documentation for 5/12/24, included a 9 indicating other/see nurses notes. Other orders included clean BiPAP filter weekly and and as needed and change water on BiPAP daily, empty and dry out chamber then fill water chamber with distilled water to fill line included a check mark for 5/1/24 through 5/14/24 indicating administration. Review of R38's progress notes for 5/12/24 did not include documentation related to BiPAP machine or oxygen. During interview on 5/14/24 at 8:54 a.m., trained medication assistant (TMA)-A indicated R38 has a BiPAP ordered but the machine is not at the facility. When questioned TMA-A regarding machine on nightstand, TMA-A indicated she wasn't aware there was one there. During interview 5/14/24 at 9:14 a.m., licensed practical nurse (LPN)-B, also identified as care coordinator, indicated she was aware of orders for R38 to have BiPAP on at night and is unsure why they aren't using the BiPAP machine. LPN-B indicated the nurse is the one responsible to ensure R38 has BiPAP on at bedtime and the documentation on TAR indicates R38 has BiPAP on at bedtime. LPN-B indicated she was unsure why they (staff)are documenting that if she isn't wearing the BiPAP at night. LPN-B was not aware if BiPAP machine had an oxygen adapter or not. During interview on 5/14/24 at 4:01 p.m., R38 indicated her son brought her machine in when she was admitted to the facility a few weeks ago. R38 stated staff have not cleaned it, or offered to put it on her since she has been at the facility. R38 indicated she wore her oxygen through the night, but not her BiPAP machine. During interview 5/14/24 at 11:50 a.m., R38's medical doctor (MD) indicated he was not aware the BiPAP machine was not adaptable to be used with oxygen. The MD indicated he was not notified of this issue but should have been since there was an order for both oxygen and BiPAP. During interview 5/14/24 at 4:18 p.m., registered nurse (RN)-A indicated he worked with R38 last evening until 11:30 p.m., and R38 did not have her BiPAP machine on when he left at 11:30 p.m. RN-A indicated R38 went to bed early in the evening around 8:00 p.m. During observation on 5/15/24 at 6:38 a.m., R38 was in bed with the lights off with oxygen on. BiPAP machine was on bedside table with mask and tubing hanging over machine and machine off. During interview on 5/15/24 at 6:42 a.m., registered nurse (RN)-B indicated staff are not putting on R38's BiPAP machine at night because it isn't here at the facility. During interview on 5/15/24 at 7:00 a.m., NA-C indicated R38 wears her BiPAP off and on throughout the night. NA-C indicated R38 is independent and does everything herself. During observation and interview on 5/15/24 at 7:27 a.m., R38 was sitting at the bedside and stated someone came and took her BiPAP machine a little bit ago, to see if they could find an adapter for oxygen hook up. During interview on 5/15/24 at 10:49 a.m., the director of nursing (DON) indicated R38 came from the hospital and she was told R38 refused to wear her BiPAP. The DON indicated when she was admitted to the facility on [DATE] she did not have her machine with her and is unsure when family brought it in for her. The DON indicated she took the BiPAP machine out of R38's room this morning and has contacted respiratory therapy to see if an adaptor can be purchased to be placed on the BiPAP machine for oxygen delivery. The DON confirmed the orders stated BiPAP on at bedtime and staff should have notified the provider or her that the machine did not have an adaptor for dual oxygen therapy. A policy and procedure for BiPAP use was requested and none received. The facility Medication and Treatment Orders policy and procedure dated 2/24, included orders for medications and treatments will be consistent with principles of safe and effective order writing. The facility Change of Condition policy and procedure dated 3/2024, included it is the policy of this facility that changes in a residents condition or treatment be shared with the resident and/or the resident representative, according to their authority and reported to the attending physician or delegate (hereafter designated as the physician).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance with activities of daily living (ADL's) as needed and requested and timely response to call lights for 11 of 20 residents (R7, R10, R13, R14, R18, R19, R24, R30, R33, R35, R47) with concerns for sufficient staffing. These deficient practices had the potential to affect all 20 residents who resided on Hall 2 of the facility. Finding include: Refer to F679: The facility failed to ensure individualized activities and activities for a non-English speaking resident were provided for 1 of 3 residents (R12) reviewed for activities. Refer to F686: The facility failed to ensure weekly comprehensive skin assessments with measurements were completed for 1 of 1 resident (R35) reviewed for pressure ulcers. Refer to F688: The facility failed to provide services to maintain and/or prevent loss of range of motion (ROM) for 2 of 3 residents (R4 and R32) reviewed for limited range of motion. Refer to F809: The facility failed to ensure nutrient and/or calorie substantive snacks were offered after the evening meal and before bedtime, for 17 of 17 residents residing on the memory care unit and 1 of 1 resident (R14) residing on hallway 2, when there was more than a 14-hour lapse between the dinner meal and breakfast the following day. R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], moderate cognitive impairment, no rejection of care, required assistance with personal hygiene and shower/bath, utilized a wheelchair. R7's care plan dated 3/1/24, indicated trigger in ADL's because I have preferences and other items of need listed in my interventions and interventions included: assistance to transfer on/off toilet, assist for bathing, and supervise/assist with dressing/undressing. R10's quarterly MDS assessment dated [DATE], identified R10 had moderate cognitive impairment, no behaviors or rejection of care, required substantial/maximal assistance with activities of daily living and utilized a wheelchair for mobility. R10's care plan dated 5/13/24, indicated trigger in ADL's because I have preferences and other items of need listed in my interventions and interventions included: extensive assist of one with bed mobility, toileting, transfers, and bathing. R13's quarterly MDS assessment dated [DATE], indicated R13 was cognitively intact, no behaviors or rejection of care, substantial/maximal assistance with activities of daily living and utilized a wheelchair for mobility. R13's care plan dated 4/25/24, indicated R13 was at risk for falls be sure call light is within reach and encourage to use it for assistance as needed, prompt response to all requests for assistance; trigger in ADL's because preferences and other items of need listed in my interventions included require one assist with transfers with ez stand, and making sure personal needs are met: toileting needs. R14's quarterly MDS assessment dated [DATE], indicated R14 had moderate cognitive impairment, no behaviors or rejection of care, required substantial/maximal assistance with eating, oral hygiene, shower/bathe, dressing, dependent on staff for toileting, mobility, personal hygiene, and used a wheelchair for mobility. R14's care plan dated 4/3/24, indicated R14 trigger in ADL's because I have preferences and other items of need listed in my interventions and included 2 assist with hoyer lift, if resident is awake please perform AM cares R/T (related to) fall risk, need extensive to total staff assist with personal hygiene and grooming, two assist to use the toilet, 15 minute checks, Be sure call light is within reach and encourage to use it for assistance as needed, prompt response to all requests for assistance R18's annual MDS assessment dated [DATE], indicated R18 was cognitively intact, no behaviors or rejection of care required substantial/maximal assistance with activities of daily living and transfers, and used a wheelchair for mobility. R19's annual MDS assessment dated [DATE], indicated R19 was cognitively intact, no behaviors or rejection of care, utilized a walker and wheelchair, required substantial/maximal assistance with required substantial/maximal assistance with activities of daily living and transfers, and used a wheelchair for mobility. R19's care plan dated 4/5/24, interventions included need assistance to transfer on/off toilet, use the sit to stand up lift for all transfers, require one assist for toileting using the sit to stand up lift for all transfers on and off the toilet, will request to be taken to the bathroom or for help placing the urinal, need staff assist with personal hygiene and grooming, establish daily routine, prompt response to all requests for assistance. R24's quarterly MDS assessment dated [DATE], indicated R24 had moderate cognitive impairment, no behaviors or rejection of care had clear speech, required staff assistance for activities of daily living and transfers. R24's care plan dated 3/13/24, indicated need assistance to transfer on/off toilet, choices to transfer self and take self to the bathroom using her walker, client refuses to call for assistance when in her room, assist of one for all mobility with gait belt and wheeled walker, very impulsive and need frequent checks, fall risk, prompt response to all requests for assistance. R30's annual MDS dated [DATE], indicated 30 was cognitively intact, no behaviors or rejection of care, required staff assistance with ADL's and transfers, and utilized a wheelchair. R30's care plan dated 3/15/24, indicated need assistance to transfer on/off toilet, extensive to total staff assist with personal hygiene and grooming, and prompt response to all requests for assistance. R33's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment, no behaviors or rejection of care, required staff assistance with activities of daily living and transfers. R33's care plan dated 5/7/24, indicated dependent on staff for ambulation/locomotion, one person for transfers, require one assist for toileting, dependent on staff for toilet use, prompt response to all requests for assistance. R35's significant change in status MDS assessment dated [DATE], indicated moderate cognitive impairment, no behaviors or rejection of care, required staff assistance with activities of daily living and transfers, and utilized a wheelchair. R35's care plan dated 4/24/24, indicated need assistance with repositioning every two hours, offered to lay down in bed as well, extensive staff assist with personal hygiene and grooming. R47's quarterly MDS assessment dated [DATE], indicated R47 was cognitively intact, no behaviors or rejection of care, required staff assist with activities of daily living and utilized a wheel chair. R47's care plan dated 4/25/24, indicated use one person for locomotion/ambulation--resident is impulsive and often self transfers and ambulates on his own without notice due to cognition, staff to try to anticipate his need, on checks throughout the day minimum of every 15 minutes. Document titled Hall 2, 24 hour daily nurse report dated 5/10/24, indicated there were 20 residents on hall two, 6 residents required assist of two staff, and 10 residents required mechanical lifts. Resident and Family Interviews: On 5/13/24 at 3:24 p.m., R35's family member (FM)-I stated family routinely visited the facility and stated family pressed the call light for assistance and staff would enter the room and then turned off the call light and staff would state they will be back and will not return for 30 minutes and sometimes up to two hours. FM-I further stated she had concerns the facility was short staffed due to comments staff made regarding the facility not having enough staff and the amount of time staff took to answer the call lights. On 5/13/24 at 3:39 p.m., R30 stated the facility did not have enough staff and she waited too long for staff assistance and stated she consistently waited 30 minutes or more for staff to respond to her call light. R30 stated she had had to urinate and have a bowel movement in her pants because staff do not assist her timely, and stated what good would it do if she reported it, there are not enough staff. On 5/13/24 at 4:02 p.m., R18 stated she waited up to one hour for staff to answer the call light, and stated last weekend the facility was short staffed and she waited over an hour several times for staff to answer her call lights. R18 stated the agency staff were not familiar with the care she needed and took longer for pool staff to respond to her call light when she needed assistance. R18 stated had urinated and had a bowel movement in her pants due to the delay in staff answering her call light. R18 stated the delay in call lights were worse on the weekend, but happened at any time and staff would tell her she was not the only one that needs help when she voiced her concern. R18 further discussed when staff answered her call light at times they explained to her they needed someone to help with the lift and then not return. On 5/14/24 at 7:21 a.m. R14 was observed lying in bed and asked licensed practical nurse (LPN)-A help getting out of bed, and LPN-A stated to the R14 he would find assistance and was overheard and told NA-A R14 needed assistance to get out of bed. On 5/14/24 at 9:36 a.m., R14 was seated in a Broda chair in her room with her breakfast located on a cart outside of her room. R14 stated she was angry, wanted breakfast and could not reach it, was very hungry and frustrated. On 5/14/24 at 9:44 a.m., FM-J stated R35 had not been offered breakfast or morning cares from staff. FM-J stated he would expected R35 morning cares and breakfast offered and completed. FM-J stated he had observed delayed cares due to the inconsistent staff and staff not aware of R35's routine or specific needs. On 5/14/24 at 9:49 a.m., NA-B was observed and attempted to enter R14's room and prior to him entering NA-A asked NA-B for assistance in R35's room with a transfer. NA-A asked NA-B to bring a Hoyer lift to R35's room. NA-B was then observed to look for a mechanical lift and assisted NA-A with R35's morning cares. On 5/14/24 10:10 a.m., R14 food continued to sit outside of her room and R14 stated she had not ate since supper last night, and wanted to know why she hadn't ate yet, and stated she did not have a snack last night and would had been nice to had been offered one [snack]. On 5/14/24 at 10:15 a.m., human resources director (HR)-K stated she was also also a nursing assistant and stated R14 was expected to have had breakfast by this time, and her breakfast was delayed. On 5/14/24 at 12:12 p.m., R14's was lying in bed and her meal tray sat on chair next to her bed. On 5/14/24 at 12:28 p.m. NA-A entered R14's room and assisted R14 with her meal. On 5/14/24 at 3:02 p.m., R30 as seated in her wheelchair in her room, and stated today staff were late to get her dressed and morning cares completed. R30 explained she goes home with bus transportation on Tuesdays and Thursdays at 9:30 a.m., and staff were expected to have her ready by then and further stated when the bus came to the facility today she was not ready and the bus had to come back. R30 stated the two people who routinely work and keep things in order around here were not working today and then staff were not sure what to do and takes staff longer. On 5/15/24 at 9:12 a.m., R14 was lying in bed eyes closed and opened eyes when spoken to, R14 she had not been offered to get up today or had breakfast. On 5/15/24 at 10:17-10:35 a.m., during resident council meeting, R7, R10, R13, R19, R24, R30, R33, and R47 voiced concerns and voiced agreement regarding staffing concerns of the facility and long wait times for call lights to be answered. R7, R10, R13, R19, R24, R30, R33, and R47 stated delay in receiving staff assistance was mainly agency staff that usually were not familiar with the care and assistance needed. R7 and R13 stated when staff were not familiar with their care, they had to tell staff what to do. R7, R10, R13, R19, R24, R30, R33, and R47 stated staff would enter their room shut the call light off, exit the room and did not assist them, and further discussed they would put the call light back on again, because staff did not provide the assistance. Staff Interviews: On 5/14/24 at 8:20 a.m., NA-B stated he was an agency NA had worked at the facility for three days and today was his first time he worked on hall two. NA-B stated he was training on hall two today as he was not familiar with specific resident cares on hall two and acknowledged he was not sure of the resident's care plans on hall two. NA-B stated it was himself and NA-A on hall two today. On 5/14/24 at 10:01 a.m., NA-A stated the facility consistently utilized agency nursing who were not familiar with resident cares, and stated there was not consistent staff to provide timely and consistent resident care per the resident's care plan. NA-A stated two staff on hall two were not able to complete timely care routines,and answer call lights timely. NA-A stated the inconsistent staff caused a delay in answering call lights, delayed meals, delay in morning cares and baths and was due to staff not familiar with resident routines and interventions. NA-A stated two NA's on hallway two were not enough staff due to the increased number of residents who required two people transfers with mechanical lifts. NA-A stated residents were required to wait for extended periods of time to have their needs met such as toileting, and stated staff would answer the call light and tell the resident they would be back and residents consistently waited for 20-30 minutes for staff to go back into their room. NA-A confirmed residents had bowel and bladder accidents due to the delay in call lights answered. On 5/14/24 at 12:22 p.m., during a follow up interview NA-A stated the hall sheets indicated how residents transferred and stated agency staff were not familiar with how residents transfer and the specific care residents required. NA-A stated today was NA-B's first time working on hall two and had worked on hall three before and was expected to know to use the care sheet and stated NA-B was not using the care sheet to ensure resident's transferred per their care plan. NA-A stated NA-B should not have been scheduled on hall two because of the heavier workload and increased staff assistance residents required . NA-A stated another NA came to work on hall two late morning, and NA-B was moved to hall three because he was not trained enough to work on hall two. NA-A stated she had observed agency staff dress residents in their roommates clothes and had residents urinate in their brief versus on the bed pan because agency staff were not familiar with the residents. On 5/14/24 at 2:00 p.m. trained medication aide (TMA)- stated weekend staffing was pretty rough and short staffed due to the call ins, facility was primarily staffed with agency staff on the weekends, that were not familiar with the residents or residents care and would cause a delay in call lights answered timely. On 5/14/24 at 2:11 p.m., the dietary director (DD)-F stated R14 required staff assistance with meals and confirmed R14 had missed meals due to staffing. DD-F stated last Saturday the facility was short staffed and she was at the facility to work and at 11:00 a.m., R14 stated she had not been fed. DD-F stated she made a phone call to HR-K to voice her concerns over the shortage of staff and residents cares not provided. DD-F stated short staffing was not a rare occurrence, occurred more frequently on the weekends and the majority of the staff who filled the schedule were agency staff who were not familiar with the resident routines and caused a delay in care. On 5/14/24 at 2:30 p.m. LPN-B stated due to the facility being short staffed she routinely stayed late two-three times per week and stated the facility consistently utilized agency staff to fill the gaps in staffing. LPN-A stated pool staff were not familiar with resident routines and may cause delay in call lights answered timely. On 5/14/24 at 3:13 p.m., NA-G stated agency staff required more guidance from facility staff and residents may have a delay in morning and night cares due to more agency staff working at the facility then facility staff. NA-G stated more agency staff and inconsistent staff caused delay in meal times and morning resident routine. NA-G stated the residents would benefit with three NA's on hall two to assist with morning cares and meals to prevent the delays. On 5/15/24 at 7:32 a.m., NA-H stated he was still in his training period and was his first day on hall two, however was by himself today because someone called in sick On 5/15/24 at 7:54 a.m., NA-F stated hall two had two NA's scheduled and explained two consistent staff on hall two were able to meet the needs of the residents, however agency staff made it hard to meet the needs of the residents and answer call lights timely. NA-F stated agency staff were not familiar with the routines of the residents and don't know what they are doing and stated their had been occurrences when residents have a bowel or bladder accident in their brief related to staffing. NA-F stated hall two residents required more staff assistance and required more staff time. NA-F stated she was not sure how agency staff were supposed to know what to do and stated NA-H was supposed to still be on orientation and got thrown in today to work. On 5/15/24 at 8:43 a.m., Health unit coordinator (HUC)-L stated she also is a NA and stated she assisted at the facility with resident care when it was really busy and staff were behind. HUC-A stated today was extremely busy with unexpected stuff and stated two NA's on hallway two made it difficult for the NA's to provide timely resident care. HUC-A stated she assisted on the floor a few times a month. On 5/15/24 at 9:02 a.m., the administrator stated he believed the facility had enough staff to answer call lights timely, and the delay in call lights answered timely were due to other things happening in the facility and more how the staff choose to utilize their time. The administrator stated the facility utilized a lot of agency staff who don't always know the routine and specific care needs of the residents and caused delay in resident care. The administrator stated two staff were enough staff on hallway two and stated delay in resident care was related to the inconsistency of staff and due to agency staff not knowing routines of residents. On 5/15/24 at 9:27 a.m., HR-K stated she was also a NA and was helping hall 2 today because NA-H was new to the facility and new to hall two and was struggling with timely care for residents. HR-K stated she assisted the facility when staffing was short or staff needed assistance. HR-K confirmed yesterday R14's breakfast was late due to NA-B struggling on hall 2 and not familiar with hall two resident cares and today NA-H was struggling so things are behind again. HR-K was observed to enter R14's room and offered her breakfast and stated R14 slept often and was not sure of her typical breakfast routine. On 5/15/24 at 9:38 a.m., the assistant director of nursing (ADON) stated NA-H was technically in training and stated the facility had a call in on hall two which made the facility short staffed and required NA-H working by himself and not with someone orientating him. The ADON stated two staff on hall two were not enough staff today to meet the needs of the residents and provide timely care. ADON explained hall two had more residents who required staff assist of two, required extensive staff assistance, and two staff weren't enough staff for the acuity of the residents on hall two. ADON confirmed she was aware hall two residents had urine and bowel accidents due to staffing. The ADON stated the facility expected nursing to help NA's on the floor in the morning with call lights, morning cares, however that was not realistic as the nurse was busy with medication pass and treatments. The ADON stated the facility ensures there were two NA's on hall two, and then hall three might work with one NA, if there was a staff who called in or a hole in the schedule. The ADON stated management helped when they were at the facility bring residents to breakfast, pass meal trays, and answer call lights. ADON stated since January 1st staffing had not been manageable and had been a concern to meet the residents needs. On 5/15/24 at 10:44 a.m., NA-B stated today was his fourth day at the facility and stated two NA's were not enough staff on hall two for morning cares, to answer call lights timely, and meet the needs of the residents on hall two. NA-B stated he was not familiar with the residents routines which caused the delay and further stated hall two needed three people to provide timely care. On 5/15/24 at 10:52 a.m., TMA-D stated she was originally scheduled on hall one on the medication cart today and was removed from hall one and moved to hall two because NA-H was working by himself and still was in orientation. On 5/15/24 at 11:35 a.m., LPN-B stated today she was pulled from her charge nurse role to work as a TMA on hall one and stated the facility did not have enough staff for her to complete all her work including comprehensive skin and wound assessments. LPN-B verified she was responsible for R35's weekly skin assessments and when she is pulled to work on the floor there were not enough staff and the skin assessments were not completed as expected. On 5/15/24 at 12:02 p.m., the director of nursing (DON) stated hall two was a hall with higher acuity residents, many residents required mechanical lifts and more extensive staff assistance. The DON stated staff were expected to utilize hall sheets which indicated how residents transferred. The DON confirmed the hall sheets indicated resident's transfer assistance required, however did not indicate other information about the residents such as diet, specific cares, and stated those things would be on the [NAME] in the computer. The DON stated staff were expected to look at the [NAME] in the computer before going into a resident's room. The DON stated NA-B struggled on hall two yesterday because of the heavy resident cares, and stated hall two would be staffed sufficient with two NA's who were seasoned and had been at the facility for longer then six months. The DON explained two staff who were not seasoned would struggle with completing timely care for the residents, answering call lights timely and familiarity of resident routines. The DON confirmed NA-H was still on orientation and was not supposed to be working by himself, and NA-H did not know the facility or resident routines and struggled this morning and was not fair to the residents. The DON confirmed the facility was currently taking admits and was not aware residents were not toileted timely or having bowel and bladder accidents due to the delay in staff answering the call lights, and staff not returning timely when the call light was turned off. The DON acknowledged hall two was a busy hall and agency staff required longer time with resident cares, the inconsistent staff caused delay in answering resident call lights and completing resident cares timely. On 5/15/24 at 1:44 p.m., during an interview with HR-K stated she was the human resources director and assisted the scheduling coordinator who was recently hired at the facility. HR-K stated staffing was determined by a combination of census and acuity. The schedules for the past month were reviewed with HR-K and stated there were consistently call ins and holes and the schedule however the schedule was filled by herself, the ADON, or the DON. HR-K stated the day and evening shift was staffed with two NA's on each of the three hallways. HR-K stated the facility would be short staffed if there was less then two NA's on the hall. The schedules were reviewed with HR-K, and revealed an a * next to times, and HR-K stated that was the staff who were mandated for the next shift, and stated there was not always a staff designated for mandating as the staff working have already worked a double shift or were mandated the day before. HR-K stated mandating staff to stay was a problem because and the policy and procedure needed to be reviewed because there were so few staff and the mandate was not used consistently. HR-K discussed agency staff were not dependable to show up for their shift and then the gaps in the schedule get filled by herself, the ADON, or DON. HR-K stated herself and the DON routinely come in on the weekends due to agency staff not showing up for their shift or sick calls. HR-K confirmed NA-H was still in orientation and the NA he was supposed work with called in sick and stated NA-H was not expected to work by himself today as he was still in orientation. HR-K stated hall two was a busy hall with residents that required assist of two with mechanical lifts and heavier care needs. HR-K stated when consistent facility staff worked hall two, two NA's were able to meet the needs of the residents, HR-K stated agency staff or staff that frequently do not work on hall two would not be familiar with the resident cares and routines, and HR-K confirmed that would cause a delay in call lights, delay in meals, and routines of residents not met. HR-K stated there is a problem with staff call ins because the facility had no back ups or anyone willing to pick up. HR-K stated the facility was hiring and included NA open full time positions were two on night shift, four-five on evening shift, and two-three on days, and have multiple NA part-time shifts opened. HR-K stated skilled nursing shifts the facility was hiring included three-four on day shift , three on evenings, and one night opening. HR-K stated the night shift had consistent staff. HR-K stated the facility currently had two skilled nursing staff that worked the floor, and explained the facility had a total of nine nurses and only two nursing staff were floor staff that filled the schedule the other ones were four administrative nursing and three on call nursing. HR-K stated the rural location of the facility and non competitive wages were problematic for hiring staff, and the facility made attempts for staff recruitment through social media, schools and job fairs. Review of the facility's staffing schedules for 5/1/24-5/15/24. The schedules lacked required nursing assistants for the following: 5/15/24: 8 hours on the day shift 5/13/24: 4 hours on the evening shift 5/13/24: 8 hours on the day shift 5/12/24: 8 hours on the day shift 5/11/24: 8 hours on the day shift 5/2/24: 4 hours on the evening shift. Call light logs: On 5/14/24 at 11:00 a.m., the call light logs were requested and the DON stated the facility did not have ability to produce call light logs and DON stated no audits had been done on call light times. Call light observations: On 5/15/24: 8:29 a.m., R205;s call light illuminated above door 8:34 a.m., R205 overheard can someone help me 8:43 a.m., HUC-L entered R 205's room and call light answered, and when exited the room stated to NA-F R205 was on the toilet. 8:34 a.m., R13's call light illuminated over door . 8:34 a.m. NA-F entered R13's room and stated it will be a couple minutes and we will be back. 9:07 a.m., R13's call light illuminated over door again and ADON entered room and stated to NA-F R13 requested to use the bathroom. 9:09 a.m., during an interview R13 was seated in her wheelchair in her room, and stated she had to go to the bathroom very badly and stated she had been waiting a long time. 9:10 a.m., ADON entered R13's room and assisted R13 into the bathroom and was overheard and told R13 to put light on when she is done in the bathroom Facility assessment dated [DATE], indicated: The individuals for which we provide care often have one or more co-morbid and/or chronic conditions. While residing in our community, we provide individualized self-care education for the management of the co-morbid conditions and/or chronic conditions to the individual or individual's representative. This is an essential component which can help reduce unnecessary re-hospitalizations. Social Services communicates with hospice, home health, and other community providers who are willing to provide education and/or support with various conditions and diagnoses. We take care in making decisions regarding approving admissions or continuing care for persons that have diagnoses or conditions that our facility is less familiar with or have not previously supported. When this unique care is required, we prepare for the new diagnoses by reviewing the patient's medical record looking not only at the new situation but the other conditions and diagnosis the patient may have to determine the complexity. We evaluate our resources and/or our ability to secure the necessary resources to provide care and support for the person. While we believe our orientation/competency process covers considerable skill areas, we consult with the medical director, the admitting doctor or the resident's primary care practitioner, CDC resources, and our own Company policy and procedure manuals to identify any new knowledge and skills the staff may need. Staff are given training as needed on best practices for the residents/new admission. This training may be informational, it may involve reviewing a skills procedure, and/or it may involve return demonstration. Records are kept of this training in individual training files and with Staff Development. We believe in living with chronic/co-morbid conditions verses dying. For our long-term care residents, we place the resident/resident representative at the [NAME] as to what is important for their remaining time. These individuals are not going to be cured, but can still fulfill goals they want to attain. Our staff are trained in person-centered care Having the right clinical capacity (competency) is essential in providing excellence care and services to those we serve. We specialize in and prepare our staff to deliver care and services utilizing evidenced based practices and competency-based training and education. This means staff are equipped with the knowledge, skills, and attitude (confidence) to perform the needed services Staffing needs are determined based on the census and acuity of our residents. Additionally, we utilize the Monarch Staffing hour excel tool to determine the appropriate staffing for each shift based upon current census. Daily nursing hours are posted. At times staffing is increased beyond the budgeted amount in order to provide the necessary care for our residents. Having the right clinical capacity is essential in providing excellence care and services to those we serve. We specialize in and prepare our staff in the use of evidenced based practices. Staff are provided the knowledge, skills, and attitudes of competency-based training and education

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R14's quarterly MDS assessment dated [DATE], indicated R14 had moderate cognitive impairment, no behaviors or rejection of care, and required substantial/maximal assistance with eating, and used a wheelchair for mobility. R14's care plan dated 4/3/24, indicated R14 trigger in ADL's preferences and other items of need listed interventions: two assist with hoyer lift, needs extensive to total staff assist with personal hygiene and grooming,15 minute checks, be sure call light is within reach and encourage to use it for assistance as needed, prompt response to all requests for assistance On 5/13/24 at 6:07 p.m., R14 was observed in bed and licensed practical nurse (LPN)-D was observed and provided R14 with assistance with eating her supper meal. On 5/14/24 10:10 a.m., R14's meal was observed on a tray outside of her room and R14 stated she had not ate since supper last night. R14 wanted to know why she hadn't ate yet, and further stated she did not have a snack last night and would had been nice to had been offered one [snack]. On 5/14/24 at 10:15 a.m., human resources director (HR)-K stated she was also a nursing assistant and stated R14 had not been offered or assisted with breakfast today. HR-K stated R14 was expected to have had breakfast by this time and her breakfast was delayed. HR-K entered R14's room and provided R14 assistance with eating her breakfast meal. On 5/14/24 at 3:12 p.m., the DON stated she delivered snacks on hall two last night and confirmed R14 was not offered a snack as R14 was already asleep . The DON stated R14 was expected to had been offered breakfast between 9:00 a.m. and 9:30 a.m. The facility Meal Times policy dated 9/2012, indicated it was the policy to serve meals to meet the standards of the surveying agencies specifying no more than 14 hours between the evening meal of one day and the breakfast meal of the next day. The Hospitality Services Manager was responsible to monitor the system to assure adherence to the schedule. All staff were responsible for following the schedule. Based on observation, interview and document review, the facility failed to ensure nutrient and/or calorie substantive snacks were offered after the evening meal and before bedtime, for 17 of 17 residents residing on the memory care unit and 1 of 1 resident (R14) residing on hallway 2, when there was more than a 14-hour lapse between the dinner meal and breakfast the following day. Findings include: During observations on the memory care unit on 5/14/24 at 9:15 a.m., and 5/15/24 at 9:06 a.m., observed breakfast trays delivered by dietary staff via an enclosed cart on wheels. According to a facility mealtime schedule, breakfast was offered from 7:30 a.m., to 10:00 a.m., and supper (also known as dinner) was offered from 6:00 p.m., to 7:00 p.m. Snacks were passed/available at 10:00 a.m., 3:00 p.m., and 7:00 p.m. Based on observations, residents on the memory care unit went 15 hours (5/13/24, at 6:00 p.m. to 5/14/24, at 9:00 a.m.) between meals. During an interview on 5/14/24 at 11:40 a.m., dietary director (DD)-F was informed residents on the memory care unit went 15 hours between their dinner meal on 5/13/24, to breakfast on 5/14/24. DD-F stated residents received a big snack on 5/13/24, around 7:30 p.m. Snacks observed on the snack cart consisted in part of individual packages of crackers, cookies, peanut butter crackers and pudding. During an interview on 5/15/24 at 9:21 a.m., registered dietician (RD)-H was informed of observations for meal service on the memory care unit exceeding 14 hours. RD-H stated it would be acceptable if a substantial snack was offered. RD-H defined a substantial snack as one with a protein and a carbohydrate. During an interview on 5/15/24 at 9:33 a.m., with DD-F and RD-H, DD-F confirmed that on the memory care unit, dinner was served at 6:00 p.m., and breakfast at 9:00 p.m., and stated residents received a substantial snack in the evening, however, admitted residents were offered a carbohydrate, but no protein. RD-H suggested the facility may need to alter mealtimes if residents could not be offered a substantial snack after dinner and before bedtime. During an interview on 5/15/24 at 5:55 p.m., the director of nursing (DON) stated she had been informed by DD-F of the 15-hour lapse between dinner and breakfast the next day. The DON was aware the time between dinner and breakfast should not exceed 14 hours without residents being offered a substantial snack, and stated this would be discussed with the leadership team.

Based on interview and document review, the facility failed to develop and implement a comprehensive antibiotic stewardship program with established monitoring to help reduce unnecessary antibiotic use and reduce potential drug resistance for 12 of 20 residents (R40, R32, R35, R37, R18, R12, R45, R34, R27, R33, R23, R38) reviewed for antibiotic use. The lack of a program had potential to affect all 53 residents residing in the facility. Findings include: During an interview on 5/15/24 at 1:43 p.m., the director of nursing (DON), who was identified as infection preventionist, shared the infection and antibiotic tracking log. The log included resident name, admit date , infection type, body system of infection, symptoms, onset date, test date, result (organism colony counts for urine), antibiotic name, dose, and frequency along with start and end dates, if on transmission based precautions and date symptoms resolved. January and March 2024 did not have any infections listed. The DON indicated the previous person doing infection prevention (IP) was no longer at the facility and she had just taken over so it was not completed. The DON was not sure why March log was not completed. Review of February, and April 2024 included: February 2024 log included 10 residents with antibiotics. - R40 was listed as having a urinary tract infection (UTI) with onset date of 3/1/24. Culture result was listed as Hospital. Antibiotic name, dose, route and frequency were not completed. Date of resolution of symptoms was not completed. -R32 was listed as having a UTI with onset date of 2/20/24. Results of urine culture indicated hospital name and not culture result. Antibiotic included cephalexin (antibiotic), 500 mg orally three times day, started on 2/20/24 and stopped on 2/26/24. Date symptoms resolved was blank. April 2024 log included 10 residents (R35, R37, R18, R12, R45, R34, R27, R33, R23, R38) with infections and on antibiotics. All were missing symptoms resolution date. In addition: - R23 was listed as upper respiratory infection with symptom of shortness of breath. Results indicated hospital order. Antibiotic included amoxicillin/Clavulanic (antibiotic), no dose, twice a day with starts date as 4/4/24 and end date of 4/13/24. R33 was listed as UTI with date of onset left blank. Culture results was documented as a local hospital with no culture result present. Antibiotic included cephalexin (antibiotic) 500 mg twice a day starting 4/2/24 and ending 4/8/24. R33 was listed again with UTI with onset left blank. Culture results was documented as physician order with no culture result present. Antibiotic included cephalexin 1000 mg twice a day starting 4/27/24 and ending 5/10/24. R38 was listed as shortness of breath. Culture results was documented as pneumonia/respiratory failure. No antibiotic was listed. Review of medical record indicated R38 was receiving Mycamine (used to treat fungal infections) 100 mg intravenous every 24 hours. During interview on 5/15/24 at 2:05 p.m., the DON indicated the charge nurse looks at culture reports when the results come in and they don't always get scanned in timely for her to track the results timely. The DON confirmed the date of onset, culture results, and symptoms resolved lacked documentation for appropriate antibiotic tracking and analysis. The facility Antibiotic Stewardship Program policy dated 3/13/23, included: 1. The infection preventionist, along with the consultant pharmacist, will monitor antibiotic use by utilizing a facility approved infection/antibiotic surveillance tracking form and through monthly medication reviews. The information gathered will include: resident name, unit and room number, date symptoms appeared, name of antibiotic, started date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy outcome and adverse events if applicable. 2. Appropriate indications for antibiotic use include pathogen susceptibility, based on culture and sensitivity to antimicrobial. 3. If a resident is admitted to the facility with orders for antibiotic therapy, the orders will be reviewed for appropriateness and completeness. Any pertinent supporting documentation will also be reviewed and obtained for the medical record.

Based on interview and document review, the facility failed to follow manufacturer's instructions for cleaning and sanitizing 1 of 1 ice machines used for resident consumption. This had the potential to affect all 53 residents who resided in the facility. Findings include: During an interview on 5/14/24 at 9:08 a.m., maintenance director (MD)-A, stated the facility had one ice machine used for resident consumption and identified its location near the dining room. MD-A stated he cleaned the ice machine once a year using distilled water. The manufacturer's user's manual was requested. During an observation on 5/14/24 at 9:12 a.m., the ice machine was observed to be in a small room off the main dining room. It was a Scotsman brand, counter-top style ice machine. The manufacturer's user's manual provided by MD-A was reviewed for Scotsman brand ice machine, model number HID540. The recommended time between cleanings was a minimum of six months. The recommended process to clean the ice machine included use of hot water (110-120 degrees Fahrenheit) and a solution of an ice machine scale remover. To sanitize the ice machine, the recommended process was to mix a sanitizing solution with warm water to a concentration of 100 parts per million (ppm). During an interview 05/14/24 at 2:00 p.m., with MD-A and corporate maintenance director (CMD-G), MD-A stated he had been in his role for about three years and had been instructed by his former supervisor how to clean the ice machine and to clean it annually. MD-A admitted he had not followed the manufacturer's recommendations. CMD-G stated he would assist MD-A to implement cleaning and sanitization of the ice machine according to manufacturer's recommendations. MD-A was aware failure to clean and disinfect the ice machine according to manufacturer's recommendations could result in residents consuming contaminated ice. Scotsman Ice Systems Installation and User's Manual for Meridian Ice Maker-Dispensers for model HID540 with date of March 2015, pages 18 and 19, indicated the following, in part: Recommended minimum time between cleanings was six months. Remove both front panels. Push On/Off button to shut ice making off. Shut water supply off. Drain water from ice making system. Remove reservoir cover and fill with hot water .mix a solution of four ounces of ice machine scale remover and 16 ounces of potable water. Use solution to washout the water reservoir cover, ice discharge chute, ice chute cover, ice delivery chute, storage bin cover and inside of the ice storage bin. Wash the sink / drip tray and grill with solution. To sanitize, mix a two-gallon solution of sanitizer. A recommended sanitizer solution is one two-ounce packet of Stera Sheen [NAME] Label and two gallons of warm potable water, or an equivalent sanitizer at a concentration of 100 parts per ppm. The facility Sanitization policy with revised date of October 2008, indicated: Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer ' s instructions and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Hand hygiene On 5/15/24 at 7:32 a.m. NA-H was observed on hall two and exited room [ROOM NUMBER] wearing blue plastic gloves and entered room [ROOM NUMBER] without removing the gloves or completing hand hygiene. NA-H then exited room [ROOM NUMBER] and reentered room [ROOM NUMBER] with the same gloves and failed to perform hand hygiene and then exited room [ROOM NUMBER] and carried a clear plastic bag of soiled linen with the same gloves. NA-H discarded the plastic bag in the soiled room at the other end of the hall. NA-H exited the soiled utility room with the same gloves and then entered room [ROOM NUMBER] and was observed to start morning cares with R11 and failed to complete hand hygiene throughout the observation. On 5/15/24 at 10:54 a.m., NA-H confirmed he had worn gloves from room to room without changing the gloves or completion of hand hygiene. NA-H stated the gloves were expected to have been removed prior to entering another resident room and hand hygiene was expected prior to entering and when exiting a resident room. On 5/15/24 at 12:13 p.m., the DON stated staff should not wear gloves from room to room and stated staff were expected to wash hand after handling soiled linen. The DON stated staff were expected to disinfect hands prior to entering and exiting a resident room. The facility Handwashing policy dated 2/24, indicated: Proper hand washing techniques should be used to protect the spread of infection. Hand washing shall be completed: After changing incontinent products or cleaning up after someone who has used the toilet After touching garbage Hand washing and Gloves - When conducting a procedure requiring the use of gloves, proper hand washing shall be completed before donning gloves and after removing gloves Based on observation and interview staff failed to ensure a mechanical transfer lift was cleaned after resident used for 1 of 1 residents (R23) observed for infection control practices. In addition, the facility failed to ensure proper glove use and hand hygiene was preformed between resident use and proper infection prevention practices was observed when sorting soiled laundry. Findings Include: Mechanical lift R23's face sheet printed 5/15/24 included diagnoses of right humerus (upper arm), diabetes mellitus and heart failure. R23's plan of care indicated assist with transfer using 2 assist and patient lift. During observation on 5/15/24 at 7:35 a.m., nursing assistant (NA)-D and NA-C with the assist of a mechanical lift, transferred R23 from her bed to her chair. NA-D removed the lift from the room and parked it in hallway along the wall. NA-D did not clean the lift with sanitizer. NA-D then went into another resident room. NA-C exited R23's room and went to the dirty utility room. During interview on 5/15/24 at 7:36 a.m., registered nurse (RN)-D indicated all lifts should be sanitized after each use and for sure before parking in the hallway otherwise it could contaminate anyone who touches it (lift). During interview on 5/15/24 at 7:50 a.m., NA-D confirmed he didn't disinfect the lift after use but should have. Laundry During observation and interview on 5/15/24 at 7:10 a.m., housekeeping (H)-A was observed in the room off the main laundry room where dirty laundry requiring laundering was brought and placed in bins. H-A was wearing gloves that covered her hands and no gown and was placing dirty laundry in colored and white containers. Multiple times H-A touched her clothing with the dirty linen while sorting. H-A then brought sorted laundry into the main laundry room and placed her hand and arm into multiple pieces of dirty clothes to ensure sleeves and pant legs were not inside out before being put in the washer. During this process, H-A arms were not covered from wrist to above her elbow. H-A also touched her clothing multiple times with the dirty clothes. H-A indicated she does not wear a gown when sorting clothes unless they have the flu or infections in the building. Hand hygiene was not observed throughout the sorting and placing clothes in the washer. During observation on 5/15/24 at 8:13 a.m., H-A was picking up dirty laundry from a bath/shower room. The dirty linen was in hampers and was bagged. H-A was wearing gloves but no gown and picked up dirty clothes, towels and washcloths one by one from the hamper bag and was placing them in a cart. H-A then went across the hall to the dirty utility room and again picked up dirty linens one by one out of the hamper bags and placed in her cart. H-A then took dirty unbagged laundry to the laundry room. During interview on 5/15/24 at 1:43 p.m., the director of nursing confirmed all patient lifts should be disinfected after use if going to be placed in the patient hallway. The DON confirmed laundry staff should be wearing a gown when sorting dirty laundry and laundry should be transported in plastic bags to the laundry room and not sorted in the patient care area. Review of the Infection Prevention and Control Program, dated 3/13/24 included the facility has established policies and procedures regarding infection control and the facility provides personal protective equipment and checks for its proper use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide a dignified atmosphere for 1 of 1 resident (R9) observed to have an uncovered catheter bag which was visible to others. Findings include: R9's Face Sheet, printed 4/20/23, indicated R9 had a diagnosis of benign prostatic hyperplasia (enlarged prostrate)with lower urinary tract symptoms. R9's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R9 was cognitively intact, requires extensive assistant of 2 persons and has an indwelling catheter. During observation on 4/18/23, at 8:20 a.m. nursing assistant (NA)-C assisted R9 using EZ stand to his wheelchair and placed the Foley catheter bag under the wheelchair, next to the catheter bag cover. R9 wheeled himself through the hallway past main entrance of the facility and into the dining room where 9 other residents were having breakfast. Catheter bag was visible under wheelchair draining clear yellow urine. During observation and interview on 4/18/23, at 9:07 a.m., R9 left the dining room and wheeled himself back to his room past the main entrance area and through the hallway. Catheter bag remained uncovered with cover hanging next to the catheter bag. R9 indicated he is thankful he has the Foley catheter and when questioned about the urinary bag uncovered stated I guess it doesn't bother me too much, but added he isn't sure how other people feel about looking at it. During observation on 4/18/23, at 1:02 p.m., physical therapist (PT)-A assisted R9 from the bed using the EZ stand and placed R9 in his wheelchair. Catheter bag was hung under R9's wheelchair and was not covered. R9 was wheeled down the hallway to the therapy room. During interview on 4/19/23, at 3:50 p.m. assistant director of nursing (ADON) indicated catheter bags should always be covered and buried under the chair if resident is out of their room. During interview on 4/20/23, at 8:11 a.m. the director of nursing confirmed all catheter bags should be covered stating it is a dignity issue. The DON indicated if residents have a room mate it should be covered in their room also. The DON stated its like toileting, you close the door. A policy and procedure related to ensuring catheter bags are covered was requested and not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to meet professional standards of care when the NA (nursing assistant) applied prescribed medication cream for 1 of 1 resident (R9). Findings include: R9's Face Sheet, printed 4/20/23, included diagnoses of aneurysm (bulging) of artery of lower extremity and osteoarthritis of left knee. R9's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R9 was cognitively intact, understands and is understood and required extensive assistance from staff with transfers, dressing, toilet use, and personal hygiene. R9's physician order dated 3/8/23, indicated R9 had an order for topical analgesic rub/cream at bedside and may use per self as needed. A care plan dated 1/31/23, indicated R9 could self administer medications that included Aspercreme, Icy Hot, Biofreeze and other topical analgesic rubs at bedside and is appropriate to administer to self per assessment. A self-administration of medication assessment was completed on 1/31/23, and R9 was deemed safe to self-administer topical analgesic rubs. During observation on 4/18/23, at 8:09 a.m. nursing assistant (NA)-C, upon request from R9, unwrapped right lower leg from vascular boot and applied Pain Relief rub cream to R9's lower leg and foot. Trained medication assistant (TMA)-A was present in the room and unwrapped ace wrap from left lower leg. NA-C applied cream to left foot and TMA-A rewrapped left lower leg. NA-C then placed vascular boot back on right lower leg. NA-C was not able to state what the pain relief medication contained just that he gets it from the Veterans Administration. Review of Pain Relieving Rub ingredients included methyl salicylate (aspirin)15.% (a nonsteroidal anti-inflammatory drug). During interview on 4/18/23, at 1:03 p.m. NA-C indicated nursing assistants are able to apply R9's pain relief rub because it is an over the counter lotion. NA-C indicated R9 is capable of doing it himself but he likes staff to do it for him. NA-C indicated she has not had any training on application of pain relief creams but has on barrier creams and lotions. During interview on 4/18/23, at 1:05 p.m. registered nurse (RN)-B indicated NA's are able to apply over the counter creams. RN-B added she will usually do Aspercreme, but NA's can do moisture barriers. RN-B indicated she had not observed NA's apply pain relief cream but indicated R9 is capable of putting it on himself. During interview on 4/19/23, at 2:44 p.m. RN-A indicated since there is an order for R9 to have his pain relief cream at the beside, the NA's are able to apply the cream. RN-A added the medication comes directly to him from the Veterans Administration and is a generic Aspercreme. During interview on 4/19/23, at 4:22 p.m. Pharmacist (P)-D indicated nursing assistants should not be applying pain relief creams unless they have specific training related to the cream. P-D indicated they don't know the effects of the medications, and what side effects to monitor for. During interview 4/20/23, at 9:15 a.m. the director of nursing (DON) indicated NA's should not be applying aspirin based creams unless they have additional training, which has not been completed. Trained medication aides (TMA's) are allowed to apply the creams otherwise it is a licensed nurse role. The DON added aspirin based creams are considered a medication regardless if it is over the counter or not. Requested policy and procedure for medication administration and none was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility to ensure provider order was present for use of ace wraps for 1 of 1 resident (R9) reviewed for skin. Findings include: R9's face sheet printed 4/20/23, indicated a recent hospitalization from 3/16/23 until 3/27/23 with diagnosis including aneurysm of artery of lower extremity and bifascicular block(conduction abnormality of the heart). R9's significant change Minimum Data Set, dated [DATE] indicated R9 had intact cognition, had recent surgery and required extensive assist of 2 for personal hygiene, toileting and transfers. R9's care plan dated 3/28/23, indicated R9 has an alternation in activities of daily living. Interventions included weight bearing as tolerated to right lower extremity, no lifting greater than 10 pounds, pulling or pushing for 4-6 weeks post operative and right foot ankle foot orthoses (provide support and proper joint alignment of foot and ankle). No mention of an ace wrap was present on the plan of care. Review of provider orders 4/7/23, indicated to elevate legs and feet as resident allows every shift but no order for ace wrap was present to left lower extremity. During interview and observation on 4/18/23, at 8:09 a.m. R9 was lying in bed with both feet elevated. R9's left ankle and foot had an ace wrap present. Trained medication aide (TMA)-A removed the ace wrap and nursing assistant (NA)-A applied pain cream per R9's request. R9's skin on lower leg had multiple creases present. Skin was warm to the touch per TMA-A. TMA-A then reapplied ace wrap to R9's left lower leg. R9 indicated he just woke up and slept with the ace wrap on his foot. Upon review of R9's treatment administration record (TAR) and medication administration record on 4/18/23, at 8:36 a.m. identified no instructions were present for application or removal of ace wraps. During interview on 4/19/23, at 2:00 p.m., licensed practical nurse (LPN)-A indicated there was no order for the ace wrap in the electronic medical record. LPN-A indicated we generally take ace wraps off on nights but usually have instructions on the order with when to put it on and take it of. During interview on 4/19/23, at 2:07 p.m., registered nurse (RN)-A was not able to locate an order for ace wrap on left lower leg for R9. RN-A indicated generally we would remove them at night. RN-A added resident likely returned from the hospital with the ace wrap in place. During interview on 4/19/23, at 2:10 p.m. R9 indicated no one removed the ace wrap last night. During interview on 4/20/23, at 9:15 a.m., the director of nursing indicated ace wraps should be put on in the morning and taken off at bedtime. An order is required for use of ace wraps. The DON added she would hope the nursing staff would catch the order was missing. A policy and procedure was requested for ace wrap use and none was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure an eye doctor appointment was scheduled for 1 of 2 residents (R8), reviewed for treatment to maintain hearing and vision. Findings include: R8's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R8 had intact cognition and was able to communicate needs and wishes without difficulty. R8's medical diagnoses included diabetes mellitus type 2, and hypertension (high blood pressure). R8's care plan revised 9/3/20, indicated R8 has adequate vision. R8 has eye glasses but was not wearing them for assessment and was able to read 14 point print on the assessment chart. R8 said she could see 12 point print, but it was blurry. The care plan directed staff to to assist R8 as needed if she wishes to wear/use her eye glasses. During interview and observation on 4/17/23 at 10:44 a.m., R8 was in her room sitting in front of her television with no glasses on. R8 indicated she needs an eye appointment for glasses and went once but hasn't gone back as no one has made her an appointment. R8 indicated she did not currently have any eye glasses. An After Visit Summary dated 5/19/22, indicated R8 was seen by ophthalmology for type 2 diabetes mellitus, intermediate stage age related macular degeneration (results in blurred or no vision in the center of the visual field) of both eyes, cataract (clouding of the lens) of both eyes, glaucoma (damage to the optic nerve causing loss of vision) suspected, bilateral and myopia with stigmatism (optical defect where vision is blurred) and presbyopia (loss of near focusing ability), bilateral. Discharge instructions included return in about 3 months around 8/19/22 for HVF (Humphrey Visual Field, a test that measures the entire area of peripheral vision while the eye is focused on a central point). During interview on 4/18/23, at 8:54 a.m. R8 indicated she can't see very far anymore. R8 indicated she has to sit in front of the television to see it and can not read things further than 10 feet. R8 added she sometimes get headaches from trying to read things afar. R8 indicated she requested an eye doctor appointment at the last care conference meeting in March but she hasn't been informed if an appointment has been scheduled. A progress note dated 3/22/23, indicated a care conference was held and R8 expressed interest in an eye exam. Health unit coordinator will set up appointment. During interview on 4/18/23 at 9:10 a.m. registered nurse (RN)-A checked in appointment book and indicated nothing is currently scheduled for R8. During interview on 4/18/23, at 9:15 a.m. health unit coordinator (HUC) indicated she believes R8 was seen by ophthalmology a couple months ago. The HUC confirmed nothing currently scheduled for R8 to see an eye doctor. The HUC then indicated she does remember being told to schedule an eye doctor appointment after her last care conference, but it slipped her mind and the appointment was not made. During interview on 4/18/23, at 9:30 a.m. director of nursing (DON) indicated R8 should have had a follow up appointment with the ophthalmologist scheduled last August but it was missed. The DON added it is our job not to miss things. During interview on 4/20/23, at 8:11 a.m. the DON confirmed eye doctor and ophthalmology appointments were not scheduled per follow-up and request, but should have been. A facility policy regarding resident assessment for vision and coordination of appointments was requested, but none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to provide exercises to maintain strength and mobility for 1 of 4 residents (R18) reviewed for range of motion (ROM). Findings include: R18's face sheet printed 4/19/23, indicated admitted [DATE], diagnoses of hemiplegia affecting left nondominant side (loss of strength and weakness on half of the body) and cerebral infarction (stroke). R18's significant change in status Minimum Data Set (MDS) assessment dated [DATE], identified severe cognitive impairment, one person physical assist with bed mobility, transfer, walk in room, dressing, toilet use, personal hygiene; upper impairment on one side; utilized wheelchair; and restorative nursing range of motion was not performed. R18's care plan dated 3/22/23, indicated alteration in ability to complete activities of daily living related to decline in mobility, post non traumatic intercranial hemorrhage, diabetes and depression. PT/OT (physical therapy/occupational therapy) as ordered, assist of 1 for pivot transfers with belt, FWW(front wheeled walker)/grab bars wheel to toilet no ambulating at this time and interventions indicated: complete attached exercises 3x (times) week, ambulate to/from bathroom with FWW and gait belt, verbal cues for resident to push up with hands and turn completely before sitting down in the chair, wheelchair as needed if too fatigued or unsafe to walk, and refer to therapy updates/notes/documentation for current status or changes R18's OT Discharge summary dated [DATE], indicated R18 was discharged from OT on 3/30/23, with recommendations staff continue green t-band (resistance band used for strength) 4-5/week. R18's therapy referral to nursing dated 3/30/23, indicated OT therapy completed instructions to nursing exercises continue with green t-ban exercises 4-5x/week. R18's [NAME] dated 4/20/23, indicated PT: continue with green t-band exercises 4-5x week complete exercise 3x. R18's task history indicated on 3/30/23, task for aide cares was entered and indicated PT: continue with green t-band exercises 4-5x week complete exercise 3x. R18's point of care audit report printed 4/20/23, identified R18 continue with green t-band exercise 4-5x/week the and the report identified exercises were documented completed 4/17/23, 4/12/,23, 4/10/23, 47/7/23, 4/5/23, and 4/3/23; and not applicable on 4/19/23. However, interview and observation confirmed the exercise were not completed as documented. On 4/18/23, at 10:36 a.m. R18 was observed seated in recliner, left foot elevated on the bed, and ROM (range of motion) exercise instructions and pictures were posted on R18's closet door. R18 indicated exercises with a green band were not completed routinely with staff. On 4/19/23, at 5:58 p.m. during an interview nursing assistant (NA)-D indicated R18 had ROM orders and NA staff were expected to complete the ROM as ordered. NA-D further indicated staff did not always have time to complete R18's ROM. NA-D verified not applicable was documented for R18's ROM exercises today (4/19/23) due to unawareness of the specific exercises R18 had ordered. On 4/19/23, at 6:12 p.m. NA-E indicated ROM exercises were not ordered for R18. NA-E confirmed he documented the exercises on 4/17/23, 4/12/,23, 4/10/23, and verified the exercises were not completed as documented. NA-E indicated unaware of a green band or exercise instructions posted in R18's room. R18's room was observed with NA-E and confirmed the exercise instructions were posted on the closet door and were expected completed when documented completed On 4/19/23, at 6:19 p.m. licensed practical nurse (LPN)-D indicated was aware R18 had orders for exercises and was not aware of the specifics of the order. LPN-D stated was not aware of a green band in R18's room. LPN-D stated nursing was responsible to ensure the NA's completed the ROM exercises . On 4/19/23, at 7:47 p.m. the director of nursing (DON), assistant director of nursing (ADON), and administrator indicated staff were expected to complete resident's ROM exercises as ordered and nursing assistants should follow up with nurse, DON, or charge nurse if concerns and expected supplies in the residents room. On 4/20/23, at 8:12 a.m. LPN-C indicated a binder was located on each of the three resident's hallway and available for staff; and included resident's ROM exercise orders from OT/PT. LPN-C stated staff were expected to review the binder for instructions for resident's OT/PT orders and included resident specific ROM orders. LPN-C stated when residents were discharged from OT/PT a communication paper order was placed in the binder, and the HUC (health unit coordinator) or charge nurse placed the order as a task in the EMR (electronic medical record) for NA's or nursing. LPN-C stated pictures and instructions of exercises were placed on the resident' s closet doors by OT and PT. LPN-C indicated unaware R18 had ROM exercises order with a green band, and confirmed the binder did not include an order from OT. R18's room was observed with LPN-C and the green band was located in R18's bedside drawer. LPN-C indicated was not aware or familiar with the policy or procedure for nursing restorative care or ROM. LPN-C indicated R18's ROM was not on the nursing treatment order, and was on the NA's task list. On 4/20/23, at 8:28 a.m. NA-C and NA-F indicated R18's computer orders or hallway binder did not indicate ROM exercises, and further stated they were not aware of the green band R18 was to use for ROM exercises. Observed NA-F access the EMR and indicated R18 ROM was not a task NA's were responsible to complete. NA-F confirmed R18's ROM instructions were located R18's closet door, but had not seen a communication note from therapy. On 4/20/23, at 9:18 a.m. occupational therapy assistant (OTA)-G indicated R18 was discharged from OT on 3/30/23 and copies of order were placed in the hallway binder, with the charge nurse to enter the order in the EMR, and with the DON. OTA-G indicated staff were expected to assist R18 with the green t-band exercises 4-5 times per week and document completion. Facility policy titled Contracture Prevention and Management, dated 2017, indicated - Prevent or reduce contractures/deformity/atrophy - Increase and/or maintain individually determined normal range of motion. - Prevent progression of further joint mobility limitation and loss of function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to conduct a comprehensive reassessment after a resident sustained an injury to identify root cause and ensure new interventions were implemented to prevent further injuries for 1 of 1 resident (R37) reviewed for accidents. Findings include: R37's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, required one person physical assist with bed mobility, transfers, eating, dressing, toileting, and personal hygiene, unsteady, only able to stabilize with staff assistance when moved from seated to standing position; upper and lower extremity impairment on one side, utilized a wheelchair and walker, and diagnoses indicated arthritis, other fracture, lesion of ulnar nerve right upper limb (an abnormal change in structure of the right upper limb). R37's care plan dated, 3/20/23 indicated trigger for ADL's (activities of daily living); interventions included no weight bearing restrictions, independent for eating with set up and clean up, try L (left) angled silverware and feed self with R (right) hand, ext.(extensive) assist for all transfers with use of EZ stand (mechanical device), assistance to transfer on/off toilet, totally dependent for bathing/shower, extensive staff assist with personal hygiene and grooming, need limited assist with oral cares, require extensive assistance of staff to dress/undress; nutrition potential for alteration; interventions indicated use divided plate and left curved utensils for eating r/t (related to) distal radial fracture; bladder and bowel monitoring: able to use the call light to call for assistance to the bathroom, walks with 4 wheel walker, transfer belt and 1, client is requesting that EZ stand up lift be used, it is too hard for her to transfer and pivot to the commode at bedside. R37's care plan revised 3/20/23, failed to indicate revised transfer, mobility, and assistance following R37's right distal radial fracture(wrist break) to prevent prevent reoccurrence and future avoid accidents during transfers with R37. R37's progress notes indicated: -3/6/23, at 7:48 p.m. R37 bumped her right arm, c/o (complaints of) pain of 8, able to flex and extend elbow, move wrist up and down, twist arm over palm up and down, can wiggle fingers, fell asleep and resting quietly. -3/6/26, at 10:23 p.m. R37 has been using arm and now sleeping. -3/7/23, at 4:41 a.m. R37 was assisted to the BR (bathroom) during the noc. (night) and c/o pain on rt. (right) forearm but no swelling or redness noted. -3/7/23, at 9:11 a.m. R37's family was called due to rt arm pain after bumping it on the doorframe in room last pm 3/6/23, Xray was suggested and FM-I in agreement, arrangements being made for R37 transported for Xray. -3/7/23, at 1:37 p.m. R37 returned to facility with Xray showing a distal radial fracture, wear a splint 24 hours a day, elevate her arm, and ice it as needed, Tylenol is to be given for pain as needed, Xray to be done 1-2 weeks to recheck. -3/8/23, at 3:57 a.m. right hand, continue splint, with wrap, elevated, no complaints of pain, CMS present, resident rested tonight -3/9/23, at 5:10 a.m. ice pack to left wrist, elevated during night. -4/17/23, at 1:08 p.m. Dr. appointment resident was seen for right arm fracture, continue with right arm splint and f/u (follow-up) in 2 weeks. Document titled Physician orders dated 3/7/23, located in R37's medical record and RN-B indicated R37 bumped her right elbow on a door frame while being transferred from bathroom last p.m. 3/6/23, she had c/o pain in rt. forearm since then, ROM in elbow flex and extend without pain, moves wrist up and down, no co/o pain with pressure, no bruising, slight swelling noted inner wrist. Xray report dated 3/7/23, indicated R37 had acute, impacted, nondisplaced, transverse fracture of the distal radius (broken wrist). Office visit report dated 3/7/23, indicated R37 presented with FM-I for concerns of right wrist pain, that started yesterday (3/6/23) after she had hit her arm while being transferred from the bathroom, she had slight deformity in the distal right wrist area, this is the area of pain, and mild swelling in this area, and the plan indicated distal radial fracture: R37 was placed in a volar splint(device applied to immobilize the wrist and hand), recommended follow up in 1-2 weeks for repeat assessment and x-ray, continue Tylenol for pain, elevate and ice as need for comfort. Office visit report dated 4/17/23, indicated R37 had distal radial fracture: x-ray today reviewed, there was continue distal radial fracture of the right wrist, splint for 2 more weeks. Physical therapy progress report indicated: -3/22/23, referred to PT services due to right distal radius fracture, R37 bumped her arm during a transfer on the door frame. EZ stand no issues until recently bumped arm on doorframe during transfer with subsequent distal radius fracture, EZ stand with right radial fracture still tolerates transfer well, will assess for room safety, including considering padding to door frames to decrease risk of further injury. -4/11/23, R37 able to respond to vc's (voice commands) for RUE (right upper extremity) placement to prevent further injury/pain during E/Z stand transfers. -4/17/23, instructed R37 in upright posture during EZ stand transfers recliner, toilet., holds only with left upper extremity, discussed with nursing staff how transfers have been going and they report ok but need to remind pt to stand tall and keep legs still as pt sometimes pushes with legs pushing his backward as they raise EZ stand. R37's medical record lacked any evidence of a comprehensive assessment to identify root cause analysis or implementation of any new interventions to prevent future injuries/accidents. On 4/17/23, at 12:47 p.m. R37 was seated in a wheelchair and splinted right arm extended from hand to the elbow. R37 stated approximately one month ago while transferred by one staff with an EZ stand lift from her bathroom toilet to the bed, her right arm caught the bathroom door frame. R37 further indicated she voiced to the staff her arm was broken. R37 indicated a day or two later, FM-I transported her to the doctor and was determined her right arm was broke. R37 indicated no surgery was needed and required the bandage at all times. R37 stated difficulty with eating and brushing her teeth due to her inability to use her right hand. On 4/18/23, at 8:34 a.m. licensed practical nurse (LPN)-B indicated uncertain how R37 broke her wrist, and stated new orders included splint on 24/7, wiggle fingers, and R37 continued to transfer with EZ stand with one person, and was unaware of any new interventions to prevent injury. On 04/18/23, at 8:49 a.m. director of nursing (DON) indicated on 3/7/23, she became aware of R37's arm pain, and immediately had the resident assessed with a provider and the Xray indicated a pathological fracture (spontaneous break in a bone). When asked if the fracture occurred on 3/6/23, when R37 bumped her arm on the doorframe, DON indicated the injury was from age and how R37 positioned herself on her right side in her wheelchair and in bed. The DON indicated she would provider further information from the Xray report. On 4/19/23, at 12:52 p.m. registered nurse (RN)-B indicated on 3/6/23, during evening shift report LPN-B reported R37 had bumped her elbow on the bathroom doorframe. RN-B indicated R37 was immediately assessed and R37 indicated her right arm was bumped on the doorframe, reported pain, no redness, swelling, or bruising was observed. RN-B stated the information LPN-B reported included R37's elbow was bumped, but not the forearm. RN-B indicated R37's reported pain at the forearm area. RN-B indicated the end of her shift was 3/6/23, at 11:00 p.m. and R37 had no changes with assessment throughout the shift. RN-B stated on 3/7/23, started her shift and around 7:00 a.m. observed R37's right arm swollen, and notified FM-I and suggested an x-ray to rule out injury, and further notified the provider. RN-B indicated R37 sustained a right radial fracture, and assumed was caused when R37 bumped her arm on the doorframe the previous evening. RN-B further indicated an incident report was not filled out at the time or after learning of the fracture, and indicated had worked at the facility for a month and had not received education on the procedure for incident reports. RN-B indicated was not aware of any interventions implemented to prevent further injuries with R37. On 4/19/23, at 1:08 p.m. during an interview RN-A indicated risk management implementation was expected when an injury occurred with a transfer and stated any type of skin concern, fall, or accident required a risk management and required the nurse complete a form in the EMR (electronic medical record). RN-A indicated the risk management provided the steps and procedures for the expectations of a nurse when an injury occurs, and a risk management would include an incident report embedded in the form. On 4/19/23, at 1:53 p.m. NA-C via telephone interview stated on 3/6/23, immediately after supper assisted R37 to the toilet and transferred with an EZ-stand out of the bathroom, NA-C indicated the support strap cushion of the EZ-stand was bulky and caused R37's arms to go outside of the strap and enabled R37 to keep her arms next to her body while transferred, and caused R37 arm to bump the bathroom doorframe. NA-C indicated R37 immediately grabbed her elbow, and the incident was immediately reported to LPN-B. NA-C indicated R37 stated arm was painful, and was holding her arm at the elbow. NA-C stated she observed R37's elbow and found no open areas, no blood and no swelling, NA-C indicated on the morning of 3/7/23, reported the incident to the DON and observed the DON record the information. NA-C indicated she then proceed to find a different sling to use with R37 and placed a sling with less cushion to prevent R37's elbows from extending outward. On 4/19/23, at 1:34 p.m. during a follow up interview the DON confirmed the Xray indicated the fracture was not pathological, when asked how the injury occurred the DON indicated a risk management form through the EMR was expected to assist the facility with the root cause of the injury. The DON indicated the implementation of risk management form was expected with an injury or an accident to ensure a cause was investigated. The DON stated the risk management procedure mimicked a fall incident report, and provided the nurse the steps to ensure a comprehensive assessment was completed, and included a causal analysis and updated care plan with interventions to prevent reoccurrence. The DON verified no new interventions were implemented after R37's diagnosis of right radial fracture on 3/7/23. The DON indicated on the spot education was completed with NA-C on 3/6/23, in regards with safe transfers. On 4/20/23, at 8:38 a.m. LPN-C indicated R37 sustained an injury during a transfer, when her arm bumped the doorframe. LPN-C indicated unaware of any formal interventions implemented to prevent reoccurrence. LPN-C indicated R37 used the EZ-stand with the small sling after the incident, and stated the care plan did not reflect R37's sling size. LPN-C indicated the care plan was expected to indicate transfer specifics for residents to assist staff. On 4/20/23, at 8:58 a.m. physical therapist (PT)-G indicated R37 sustained an injury when her arm bumped the doorframe during a transfer. PT-G indicated therapy looked at options for padding at the doorway, and have not been able to find anything to stay in door way, and assisted with R37's positioning in EZ-stand and alignment. PT-G indicated education with nursing about slowing down with transfer or use the commode to eliminate the reoccurrence of injury, however R37 preferred to use the bathroom to toilet. Policy titled Mechanical Lifts dated 3/18, indicated: 7. All adverse events involving a mechanical lift will have a root cause analysis completed and reported on at the QA&A/QAPI meeting. Incident Report Guide dated 12/11, indicated Injury-no fall -complete incident report P&P -Place on 24 hour report. - Complete appropriate assessments. -Witnessed-obtain witness statements. -If significant injury.-(fracture, laceration, large hematoma etc.) Investigation must occur per protocol. -Immediate notification NHA, DON, Social services notification per facility protocol. If her physical injuries sustained which could not be explained. Report filed with state agencies per protocol. ,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for a Foley catheter for 1 of 1 resident (R9) reviewed for catheter cares. Findings include: R9's face sheet, printed 4/20/23, included diagnosis of benign prostatic hyperplasia (swelling) with lower urinary tract symptoms). R9's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R9 had intact cognition, required extensive assistance with activities of daily living. The MDS indicated R9 had a Foley catheter. R9's care plan dated 3/28/23, identified R9 had a indwelling Foley catheter with interventions including keep catheter tubing free of kinks, keep drainage bag below bladder level, maintain a closed catheter drainage system, and monitor patency of catheter. During an observation on 4/18/23, at 7:45 a.m. R9 was lying in bed asleep. Catheter bag was lying on the floor next to the bed. During interview on 4/18/23, at 8:18 a.m. nursing assistant (NA)-C, indicated she wasn't aware the catheter bag was lying on the floor and added night shift must have done that. NA-C indicated she always hooks the catheter bag to the bed and had not noticed it was on the floor this morning. During observation on 4/19/23, at 1:34 p.m. R9 was asleep in his chair next to his bed. The catheter bag was lying on the floor next to the chair. During interview on 4/19/23, at 2:00 p.m. licensed practical nurse (LPN)-A indicated catheter bags should not be on the floor and entered R9's room and hooked the catheter bag under the chair off the floor. During interview on 4/19/23, at 3:50 p.m. assistant director of nursing (ADON), indicated catheter bags should not be laying on the floor due to increase risk of infection. The ADON indicated staff should know better. During interview on 4/20/23, at 8:11 a.m. the director of nursing confirmed catheter bags should not be laying on the floor. If no hook is present on the catheter bag, then it should be put in a wash basin so it isn't on the floor. The DON added that is the standard of nursing practice. Facility policy and procedure titled Indwelling urinary catheter (Foley) Care and Management from Lippincott procedures, dated 11/28/22 included: - Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of catheter associate urinary tract infection (CAUTI). However, don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to coordinate services between the facility and the hospice agency to ensure coordination of care for 1 of 1 resident (R25) reviewed for hospice care. Findings include: R25's face sheet printed on 4/20/23, included diagnosis of cerebral infraction (stroke). R25's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R25 was cognitively intact and required limited assistance of one staff for most activities of daily living (ADL's). R25's physician order dated 4/6/23, indicated a referral to hospice. R25's care plan with revised date of 4/11/23, indicated R25 was at end stage of life and utilizing hospice services. Intervention included to coordinate care with hospice. Further, the care plan indicated R25 had a terminal diagnosis of acute CVA (cerebral vascular accident) with less than six month terminal diagnosis. Interventions included: hospice patient -- see hospice care plan. During an interview and observation on 4/17/23, at 1:17 p.m., R25 was sitting in a chair in her room, well groomed and alert. When asked if she was receiving hospice services, R25 replied, I think I have that kind of insurance; I don't know if it pays well though. Further questioning revealed R25 did not realize she had been receiving care from a hospice agency. During interview and record review on 4/19/23, at 1:03 p.m., while in the nurses station looking through the hospice binder for R25 and not seeing a hospice plan of care, the health unit coordinator (HUC) stated they had not received a hospice care plan yet for R25 who had been enrolled in hospice 12 days ago. When asked where to find hospice nurses notes, the HUC provided a hard copy of R25's hospice nurses notes dated 4/17/23, and stated she would be scanning it into the EMR (electronic medical record). The HUC stated that was the only hospice nurses note that had to be scanned for R25. During an interview on 4/19/23, at 4:24 p.m., the director of nursing (DON) was asked for R25's hospice plan of care. The DON provided a copy of R25's POLST (physician orders for life-sustaining treatment), hospice acknowledgement of services and medicare notice, plus other non-clinical documents, but not the hospice plan of care. When informed these documents did not include the hospice plan of care, the DON stated that was all she could find. During an interview on 4/20/23, at 10:09 a.m., when asked where to find R25's hospice plan of care and hospice nurses notes, licensed practical nurse (LPN)-C looked at progress notes in the EMR. Not finding any hospice nurses notes, LPN-C stated she did not know where hospice agency documented their notes. Regarding the hospice care plan, LPN-C stated that would be in the hospice binder at the charge desk (nurses station). During an interview on 4/20/23, at 10:19 a.m., the DON was informed there was no hospice care plan or hospice nurses notes for R25, except for one nurses note dated 4/17/23. The DON admitted the facility did not have either and would need to contact the hospice agency to get them. The DON acknowledged hospice nurses notes and hospice plan of care were important for communication between the hospice agency and the facility and for continuation of care for R25. During an interview on 4/20/23, at 1:03 p.m., the assistant director of nurses (ADON) stated R25's hospice nurses notes were emailed to her by the hospice agency. When she received one, she printed it and gave it to the HUC. The notes were first reviewed by the charge nurse, then given to the HUC to be scanned into the EMR. The ADON looked through her emails and did not locate additional hospice nurses notes for R25. During an interview and observation on 4/20/23, at 1:08 p.m., the HUC again confirmed the only hospice nurses notes waiting to be scanned was a hospice nurse visit from 4/17/23. During a telephone interview on 4/20/23, at 1:26 p.m., hospice agency receptionist ([NAME]) stated R25 had been seen by a nurse on 4/7, 4/8, 4/11, and 4/17/23. [NAME] did not know how hospice nurses notes were provided to this facility, adding it varied by facility. Facility policy titled Hospice Policy and Procedure, with revised dated of 8/2013, indicated when a resident was enrolled in hospice, the nursing home would establish a coordinated plan of care. The facility would work with the hospice team in integrating the hospice practice for medical records, including documentation of visits. The facility care plan would include the most recent hospice care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Laundry On 4/18/23, at 7:12 a.m. nursing assistant (NA)-B was observed to exit R42's room and used ungloved hands and carried unbagged soiled linen against her clothing. NA-B carried unbagged dirty linens through the memory care resident hallway, and a white cloth dropped on the hallway floor. NA-B picked the dirty wash cloth with a bare hand. NA-B when interviewed stated dirty laundry was expected bagged prior to the exit of a resident's room and transported bagged in the hallways. The memory unit dirty linen utility room was observed with NA-B and compartments for the linen were observed with unbagged linen. NA-B indicated the linen was expected bagged prior to placing in the compartments and confirmed she did not follow the procedure for transportation of dirty linen. On 4/20/23, at 9:37 a.m. during an interview assistant director of nursing (ADON) indicated awareness staff carrying soiled laundry unbagged in the facility and stated staff were expected to bag laundry prior to the removal from a resident's room. ADON indicated she had provided staff on various occasions education on the transportation of soiled laundry expectations. Facility policy titled Infection Prevention and Control Manual Environmental Services/Housekeeping Laundry Handling Lines to Prevent and Control Infection, dated 2020, indicated: Purpose: All potentially contaminated lined to be handled with appropriate measures to prevent cross transmission. 4. Soiled laundry/linen should be bagged or contained where collected. 5. Carry soiled linen away from/body/uniform to prevent self-contamination. 6. Do not place soiled linen on furniture, floor, or other surfaces. Based on observation, interview and document review, the facility failed to ensure facility-wide infection prevention and control program (IPCP) policies and procedures were reviewed at least annually. In addition, staff failed to properly transport soiled linen. This had the potential to impact all 49 residents residing in the facility. Findings include: Infection Prevention and Control Program Upon entrance on 4/17/23, infection prevention and control program standards, policies and procedures were requested in writing and was informed these policies and procedures were in the survey-readiness binder. The survey readiness binder had multiple individual policies, including surveillance program, antibiotic stewardship, Covid-19 immunization policy, and influenza vaccine program. However, there was no policy addressing the facility-wide infection prevention and control program. Furthermore, the policies provided had not been updated annually, with most dated 2019, or 2021. During an interview on 4/18/23, at 10:30 a.m., the director of nursing (DON) was asked for the policy addressing the facility-wide infection prevention and control program. The DON stated the infection prevention and control program policies and procedures were all online and provided a six-page index titled Infection Prevention and Control Manual, dated 2020. During an interview on 4/20/23, at 11:31 a.m., the facility corporate nurse consult was asked to provide evidence that the corporate infection prevention and control polices and procedures were updated annually. On 4/20/2023, at 2:02 p.m. via email, the corporate nurse consult provided a document with Pathway Health letterhead and titled Preface - Infection Prevention and Control Manual 2020. The document indicated in part: In health care, the only constant is change. Staying on top of the most recent Infection Prevention and Control material is a never-ending job. The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. In addition, page three of the document indicated: This manual was written based on the most recent federal regulatory requirements (OSHA [Occupational Safety and Health Administration], CMS [Centers for Medicare & Medicaid Services]), and the most recent Best Practice Guidelines written by various organizations, such as the Center for Disease Control (CDC), and the National Institute for Occupational Safety and Health (NIOSH). When implementing this manual, make certain that your organization meets state and local regulatory requirements. Check with state specific infection control requirements and with regional Department of Public Health entities. Be sure to update policies and procedures as it relates to any new/updated guidance from CDC, OSHA, CMS and State/Local resources. This manual is intended to be a resource for quality assurance purposes only. The document did not indicate it would be or was updated annually. The facility assessment dated [DATE], indicated the facility utilized the Pathway Health Services, Infection Prevention and Control manual as the main infection prevention and control resource.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident bathroom call light cords were within reach from the bathroom floor for 3 of 3 residents (R25, R11, R14), reviewed for call lights. Findings include: R25 R25's admission Minimum Data Set (MDS) assessment dated [DATE], included diagnosis of cerebral infarction (stroke). R25 was cognitively intact and required limited assistance of one staff for walking and toileting. During an observation on 4/17/23, at 12:53 p.m., observed the end of the call light cord in R25's bathroom (which was shared by three other female residents), approximately 18 inches off the floor. During an observation on 4/17/23, at 12:59 p.m., a staff member was observed assisting R25 to the bathroom and then left the room. R25 was observed on the toilet by herself. R11 R11's quarterly MDS assessment dated [DATE], included diagnosis of epilepsy (a disorder causing seizures). R11 was cognitively intact and required supervision of one staff for set-up help when walking and toileting. During an observation on 4/17/23, at 10:30 a.m., observed the end of the call light cord in R11's bathroom appropriately two feet from the floor. During an interview and observation on 4/19/23, at 12:44 p.m., R11 was walking in her room by herself, with the aide of a cane. R11 stated she used the bathroom independently. R14 R14's significant change MDS assessment dated [DATE], included diagnoses of acute and chronic respiratory failure and morbid (severe) obesity. R14 was cognitively intact and required extensive assistance of one staff for walking and toileting. During an observation on 4/17/23, at 2:29 p.m., observed the end of the call light cord in R14's bathroom approximately 18 inches from the floor. During an observation on 4/18/23, at 8:14 a.m., observed a staff member ambulate R14 to the bathroom and leave the room. During an interview and observation on 4/18/23, at 12:39 p.m., the administrator stated he was not aware call light cords in resident bathrooms needed to extend to the floor to be accessible to a resident lying on the floor. Together went to R25, R11 and R14's bathrooms to observe the length of the call cord lengths. The administrator agreed residents would not be able to reach them if lying on the floor, and stated he would ask maintenance to address it. During an interview and observation on 4/18/23, at 12:50 p.m. in R11's room, the maintenance director measured the call cord at 23 inches from the floor. The other two bathrooms were occupied. During an interview on 4/18/23, at 1:36 p.m., the maintenance director reported the end of the call light cord in R14's room was 19 inches from the floor, and in R25's room was 14 inches from the floor. The maintenance director stated he had already changed the call light cords and would add it to routine maintenance audits to ensure sustained compliance. Facility policy regarding resident call lights was requested and a one page document titled Logbook Documentation, dated 3/24/23, was received. The document listed instructions how to conduct a nurse call system test. Instructions included: check call cords in bathrooms and shower rooms. Ensure call cord length is no more than six inches from the floor. Repair as necessary.