**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide a dignified dining experience for 1 of 1 resident (R37) observed for dignity. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R37's diagnoses included Alzheimer's disease, aphasia, dementia, depression, polyneuropathy ( is a condition in which a person ' s peripheral nerves are damaged, and low back pain. R37's care plan, indicated R37 needed assistance with eating, however lacked plastic silverware had been used for R37. During observation on 11/19/24, at 5:10 p.m., R37 was sitting in his wheelchair at a table in the middle of dining room with three other residents. Staff had placed regular silverware in front of the other three residents sitting at the table and placed a plastic spoon and fork on the table in front of R37. Staff assisted R37 with eating while staff utilizing a plastic fork. At 5:42 p.m., staff continued feeding R37 with plastic silverware. During observation on 11/20/24 at 12:07 p.m., R37 was seated at a table in the middle of dining room with three other residents. Staff assisted R37 with eating utilizing plastic silverware. During observation on 11/21/24 at 12:18 p.m., R37 was seated at a table in the middle of dining room with three other residents. Staff assisted R37 with eating utilizing plastic silverware. During interview on 11/19/24 at 2:30 p.m., family member (FM-A) stated R37 had a problem with collecting silverware due to his time in Vietnam where silverware was scarce. FM-A stated facility gave R37 plastic silverware to eat with due to the hoarding of silverware where R37 would take silverware and place in his shirt pocket where he would have six to eight pieces of silverware at a time. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated R37 needed assistance with eating with staff having to feed him. NA-E stated R37 had been utilizing plastic silverware due to him collecting them. NA-E stated staff use plastic silverware when assisting R37 with eating. During interview on 11/21/24 at 10:54 a.m., licensed practical nurse (LPN)-A stated R37 had a history of stealing silverware. LPN-A stated R37 had worked as a jailor so not sure if that behavior correlated with his past occupation. LPN-A stated R37 had one incident in the past year, awhile ago, where he held a knife up to a nurse and due to that incident, R37 had been given plastic silverware ever since. LPN-A stated he is not aware of any other incidents regarding silverware. During interview on 11/21/24 at 11:39 a.m., registered nurse (RN)-A stated R37 was obsessed with collecting of silverware. RN-A stated R37 was a retired police officer, served in the army and also worked at a corrections facility where he would go and remove items from inmates. RN-A stated R37 had one incident a while ago where held a regular butter knife towards a nurse, so plastic silverware was initiated for R37 for the safety of the staff. RN-A stated she is not aware of any other incidents since. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated R37 liked to hold onto utensils and not give them up. ADON stated R37 previously attempted, within last year or so, to jab out with a knife towards staff so plastic silverware was initiated to make it less likely to cause injury to staff. ADON stated R37 had several episodes since then utilizing the plastic silverware but stated it had been quite a while since she was made aware or heard anything regarding incidents with silverware. ADON confirmed that R37 was assisted by staff with eating at all times due to R37's increased confusion. ADON stated she would expect behaviors to be assessed and characterized quarterly coordinating with MDS assessments. ADON stated an on-going quarterly assessment should have been completed for use of plastic silverware and behaviors and confirmed they were not completed. ADON stated a trial of regular silverware should have been completed to see if R37 was still demonstrating previous behaviors and confirmed trial had not been completed. ADON stated trial and reassessment were important as utilizing plastic silverware could affect R37's dignity and also how he eats and also percentage of how much R37 eats. The facility Dignity and Respect policy, dated 7/24, indicated facility will make sure that everyone is treated with dignity and respect. Every resident has the right to be treated with dignity and respect. Facility provides services and supports in a way that respects and considers personal preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R32) reviewed and observed for self-administration of medications. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R32's physician orders included order for Ipratropium-Albuterol inhalation solution 0.5 - 2.5 (3) mg(milligram)/ml(milliliter) - 3 mL inhale orally two times a day related to mild intermittent asthma. R32's medical record was reviewed and lacked evidence of self-administration of medications order had been obtained for R32. During observation and interview on 11/18/24 at 3:17 p.m., R32 stated she used the nebulizer machine twice daily and has been on it for long-term management of asthma. R32 stated nurse will bring medication into room, pour medicated solution into the canister of the nebulizer mask, apply nebulizer mask to resident's face, will turn on nebulizer machine and will then leave her room. R32 stated the nurse will sometimes come back to her room, at a later time, to make sure nebulizer machine is turned off. Nebulizer mask with canister was standing up in nebulizer machine and contained approximately ¼ inch of clear solution in canister. During observation on 11/19/24 at 12:49 P.M., nebulizer mask with canister was standing up in nebulizer machine and the canister was full of clear solution. During observation on 11/19/24 at 6:44 p.m., nebulizer mask with canister was standing up in nebulizer machine and contained approximately ¼ inch of clear solution in canister. During observation on 11/20/24 at 8:47 a.m., nebulizer mask with canister was standing up in nebulizer machine and contained approximately ¼ inch of clear solution in canister. During observation on 11/20/24 at 3:43 p.m., R32 was sitting in room with the nebulizer mask on her face and the nebulizer machine running. No staff were present in R32's room. During observation on 11/21/24 at 9:45 a.m., nebulizer mask with canister was standing up in nebulizer machine and contained approximately ¼ inch of clear solution in canister. During record review on 11/20/24, the self-administration of medications (SAM) assessment was completed on 4/16/24, identified R32 was physically unable to self-administer medications and was not a candidate for self-administration of medication. During interview on 11/20/24 at 9:57 a.m., licensed practical nurse (LPN)-B stated there was only one resident that resided in facility who had an order to self-administer medications and confirmed R32 was not the resident. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated the nurse sets the nebulizer up, applies fluid into canister, applies mask to R32's face and then leaves the room. NA-E stated nurse will come back at a later time to shut machine off. During interview on 11/20/24 at 10:16 a.m., LPN C stated there was only one resident who had a SAM order and LPN-C confirmed it was not R32. LPN-C stated if a resident had a SAM order, a little blue person with a circle around would be displayed in R32's electronic medication record (EMR). LPN-C reviewed R32's EMR and confirmed R32 did not have an order for self-administration of medications. During interview on 11/20/24 at 10:36 a.m., LPN-B confirmed R32 did not have an order to self-administer medications. LPN-B stated the nurse would take nebulizer solution into R32's room, set nebulizer up, apply mask and then would go back into R32's room [ROOM NUMBER]-20 minutes later to check on resident and shut machine off. When surveyor asked if R32 should have a self-administer order for nebulizer's, LPN-C stated, I don't know, this is just something we have always done. During interview on 11/21/24 at 10:48 a.m., LPN-A stated when a resident has a nebulizer treatment, the nurses set up the solution, apply the mask and would then leave room and come back later to check on resident. LPN-A stated R32 does her nebulizer treatment independently and confirmed had R32 had no SAM order. During interview on 11/21/24 at 11:39 a.m., registered nurse (RN)-A stated there was only one resident in the facility that had an order to self-administer medications and confirmed R32 did not have a SAM order. RN-A stated the nurse sets up the solution, signs it out in the MAR, fills canister in nebulizer mask with nebulizer solution, applies mask to resident's face and then would come back 15 minutes later to check on resident. When surveyor asked if a nebulizer treatment should be assessed for self-administration and an order obtained, RN-A stated she could understand and how it would be important to assess the resident for a self-administration order. RN-A stated if a resident was confused, the straps could be a safety risk if resident could not get the mask off their face and to also ensure the resident is able to self-administer medications safely. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated a resident should have a self-administration assessment completed to ensure the resident could reliably and accurately self-administer medications. ADON stated her expectation would be for nebulizer's to be assessed for self-administration of medication after set-up if staff are leaving the room during the treatment. ADON confirmed R32 did not have any SAM orders and stated an assessment should have been completed and an order should have been obtained. ADON stated it was important to ensure that the resident can correctly, accurately, and safely self-administer medications and that the provider agrees with the resident self-administering medications. ADON stated the resident should be reassessed quarterly to ensure there are no changes in resident's cognitive or physical status. The facility Self-Administration of Drugs policy, dated 7/24, identified residents in the facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. As part of their overall evaluation, the RN and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. In addition to general evaluation of decision-making capacity, the RN and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: 1. Ability to read and understand medication labels, 2. Comprehension of the purpose and proper dosage and administration time for his or her medications, 3. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) them, and 4. Ability to recognize risks and major adverse consequences of his or her medications. If the RN determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. The RN and practitioner review quarterly and as needed a resident's ability to continue to self-administer medications.

Based on interview and document review, the facility failed to provide the required written Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) forms to 2 of 3 residents (R7 and R16) reviewed whose Medicare A coverage ended and then remained in the facility. Findings include: R7's undated Census Records listing identified on 7/9/24, R7's payer source changed from Medicare Part A to Private Pay, and remained in the facility. R7's medical records lacked evidence that a SNFABN and/or the NOMNC forms were completed and/or reviewed with resident/representative. R16's undated Census Records listing identified on 9/7/24, R16's payer source changed from Medicare Part A to Medicaid, and remained in the facility. R16's medical records lacked evidence that a SNFABN and/or the NOMNC forms were completed and/or reviewed with resident/representative. During interview on 11/20/24 at 2:09 p.m., social worker (SW) stated the facility could not locate any forms for R16. During interview on 11/21/24 at 11:22 a.m., SW stated the facility could not locate any forms for R7. During interview on 11/21/24 at 11:30 a.m., registered nurse (RN)-A stated forms are discussed at the facilities daily stand-up meetings and the MDS coordinator completed them. RN-A stated the MDS coordinator is on medical leave and the director of nursing (DON), assistant director of nursing (ADON) and herself have been splitting the MDS coordinator's tasks between the three of them and completes them. RN-A confirmed she could not locate any forms for R7 or R16. During interview on 11/21/24 at 12:59 p.m., ADON stated the facility could not locate any forms for R16. ADON stated it was important to complete and keep the notices to prove a discussion had been had with the resident and/or representative regarding the services and benefits that are ending. Important for the discussion and review of forms are completed with enough notice so the resident/representative could appeal if they do not agree with the discontinuation of services and they are aware of the daily rate they would be responsible for after coming off Medicare part A. During interview on 11/21/24 at 1:53 p.m., ADON stated the facility could not locate any forms for R7. ADON stated she could not confirm if they had been completed or not. The facility Beneficiary notices policy and procedure was requested but was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to reassess behaviors and intervention of potential wandering to ensure safety and prevent possible elopement for 2 of 2 residents (R37 and R33) reviewed for accidents. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R37's diagnoses included Alzheimer's disease, aphasia, dementia, depression, polyneuropathy, and low back pain. MDS indicated wandering was not exhibited. R37's initial Elopement Risk Assessment, dated 7/14/23, indicated R37 was an elopement risk. However, R37's medical record was reviewed and lacked evidence R37 had been comprehensively reassessed quarterly for wandering or a potential elopement risk. R37's order summary, indicated order to check placement of wander guard (alerts when attempting to leave an area or building) on left wrist every shift. R37's care plan, indicated R37 was at risk for eloping and wandering due to history of attempts at home and attempts at eloping rom facility since admission. R37's progress note, dated 10/16/24 at 10:30 a.m., identified wander guard in place due to history of wandering and elopement. R37's progress note, dated 6/11/24 at 5:26 p.m., indicated R37 wandered down hallway during dinner, pushed on the south emergency exit door, and exited the building. Door alarm and wander guard sounded alerting staff that R37 had exited the building. Staff were able to redirect resident back inside. During observation on 11/18/24 at 3:57 p.m., R37 was seated in his wheelchair in the common living room area and was self-propelling self around room reaching out for imaginary items. R37 had a wander guard device on his left wrist. During observation on 11/21/24 at 10:43 a.m., R37 was seated in his wheelchair in the common living room area and was self-propelling self around room. R37 was seated by the front door for several minutes before beginning to wander around area. During observation on 11/21/24 at 1:33 p.m., R37 was seated in his wheelchair in the common living room area and was self-propelling self around room. During interview on 11/20/24 at 9:57 a.m., licensed practical nurse (LPN)-B stated R37 wandered throughout facility. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated R37 was very active and restless, wanders around facility, and requires one on one staff monitoring frequently for safety. During interview on 11/21/24 at 11:14 a.m., social worker (SW)-A stated wandering and elopement assessments are completed by either herself or nursing staff. SW-A stated she is usually the one responsible for completing these assessments. SW-A stated elopement assessments are completed quarterly along with the resident's quarterly assessments. SW-A confirmed R37's last elopement assessment was completed on 7/14/23. SW-A stated quarterly reassessments are important to ensure interventions in place are still appropriate, wander guard was still appropriate, and if there was still an elopement risk/concern. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated elopement/wandering assessments are to be completed quarterly. ADON confirmed R37 last elopement assessment was completed on 7/14/23. ADON stated it should have been reassessed quarterly. ADON stated it was important to reassess resident quarterly for safety reasons, to determine if resident was still at continued risk for elopement and ensure wander guard is still appropriate as it could be a dignity concern for a resident who no longer needs a wander guard. ADON stated the elopement assessment would help determine if the resident was having increased wandering and may need to be transferred to the memory care unit for their safety. R33's quarterly MDS dated [DATE], identified R33 had severe cognitive impairment, required extensive assistance with care, R33 wore a wander/elopement alarm. R33's medical diagnoses included parkinsons, dementia, post traumatic stress disorder (PTSD), anxiety, edema, repeated falls, cerebrovascular disease, visual hallucinations, and restless legs. R33's Wandering Risk Assessment done 8/22/23, identified R33 did not understand surroundings or what is being said and had a history of wandering. Wandering Risk Assessment score was 14 indicating R33 was at a high risk of wandering behavior R33's care plan dated 11/02/24, identified R33 was an elopement risk/wanderer due to history of attempts to leave facility unattended. Interventions included redirect from wandering by offering pleasant diversions, structured activities, food, and conversation and wanderguard on wrist. On 11/19/24, at 6:58 p.m. R33 was observed in common area watching television (tv) no attempts to wander. R33 was observed on 11/20/24, at 10:13 a.m. self propelling wheelchair in common area, no attempt to approach front door. on 11/20/24, at 1:43 p.m. R33 was observed self propelling wheelchair down hallway, no attempt to approach front door, no attempts to enter other resident rooms. On 11/21/24, at 9:16 a.m. R33 was observed self-propelling wheelchair from dining room to common area with no attempt to go towards front door. When interviewed on 11/21/24, at 9:20 a.m. nursing assistant (NA)-B stated R33 wandered down hallways, did not enter other residents rooms and had not attempted to leave the building in a long time When interviewed on 11/21/24, on 10:03 a.m. licesed practical nurse (LPN)-A stated in R33s head he has somewhere to go. He hasn't done any exit seeking in a very long time, he goes up and down the halls looking for something, never enters other rooms. During interview on 11/21/24, at 10:49 a.m. assistant director of nursing (ADON) stated wandering/elopment assessments were completed at admission and quarterly. ADON confiremd a wandering risk assessment was last completed on 8/22/23, the assessment should be completed quarterly to ensure the wanderguard is still an appropriate intervention. When interviewed on 11/21/24, at 11:14 a.m. social worker - A stated wandering and elopement assessment were completed between social services and nursing. Risk assessments are coordinated with the quarterly assessments. social worker confirmed that lastwandering risk assessment was completed on 8/22/23. Important to assess to determine interventions in place are still appropriate for them. The facility Wandering, Unsafe Resident policy, dated 7/2024, identified the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). Nursing staff will assess residents quarterly for risk factors related to unsafe wandering. If determined to be at risk, nursing will consult with social services. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. If wander guard is determined to be needed, consent will be obtained from family for device use. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the Administrator and Director of Nursing immediately and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and documentation review the facility failed to provide assistance with facial hair removal for 2 of 3 residents (R32 and R37) with grooming needs who was dependent upon staff for assistance. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R32's diagnoses included heart failure, hypertension, orthostatic hypotension, renal failure, Alzheimer's disease, stroke, dementia, depression, and asthma. R32's care plan lacked evidence of resident's shaving preferences. During observation on 11/19/24 at 6:44 p.m., R32 was sitting in wheelchair in her room. R32 had white facial hair on chin approximately 1 inch long. During observation on 11/20/24 at 8:47 a.m., R32 continued to have facial hair on chin. During observation on 11/20/24 at 3:43 p.m., R32 continued to have facial hair on chin. During observation on 11/21/24 at 9:45 a.m., R32 continued to have facial hair on chin. R37 R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R37's diagnoses included Alzheimer's disease, aphasia, dementia, depression, polyneuropathy, and low back pain. R37's care plan lacked evidence of resident's shaving preferences. During observation on 11/18/24 at 2:53 p.m., R37 had facial hair located on face located on his check extended down chin and neck approximately one fourth inch to one half inch long. During observation on 11/19/24 at 12:39 p.m., R37 continued to have facial hair on face. During observation on 11/20/24 at 1:04 p.m., R37 continued to have facial hair on face. During observation on 11/21/24 at 10:43 a.m., R37 continued to have facial hair on face. During interview on 11/19/24 at 2:25 p.m., family member (FM)-A stated R37 was very particular with being clean shaven and had detailed hygiene practices he had performed daily. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated if a resident had facial hair and needed to be shaved, she would automatically shave resident with morning cares. During interview on 11/20/24 at 10:16 p.m., licensed practical nurse (LPN)-C stated nursing assistants perform shaving when doing morning cares with residents. LPN-C confirmed R32 and R37 had facial hair and should have been shaved. During interview on 11/21/24 at 10:48 a.m., LPN-A stated nursing assistants shave residents on bath days but if facial hair is noted, nursing assistants would shave residents when needed. LPN-A confirmed there was a few scruffy residents at this time who should be shaved. LPN-A confirmed R32 and R37 had facial hair and should have been shaved. During interview on 11/21/24 at 11:39 a.m., registered nurse (RN)-A stated when a resident is admitted , their shaving preference is asked. Shaving is performed by the nursing assistants on the resident's bath day or as needed or based on their preferences. RN-A stated staff should be asking R32 if she would like her chin hairs shaved and that R37 should be shaved daily. RN-A stated we encourage daily grooming for the residents. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated the nursing assistants should be assisting residents with shaving. ADON stated the resident's shaving preferences should be located on the resident's care plan. ADON stated her expectation is shaving should occur daily with grooming and for staff to ask the resident if they would like to be shaved if facial hair is noted. ADON stated it was a commonsense thing and is important for the resident to be shaved for the dignity of the resident and their sense of self. The facility Shaving the Resident Policy, dated 7/24, indicated shaving residents is to promote cleanliness and to provide skin care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure proper treatment was provided to maintain hearing for 1 of 1 resident (R8) reviewed for hearing. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], identified R8 had intact cognition and required assistance with all activities of daily living (ADL)'s. MDS indicated R8 had minimal difficulty with the ability to hear and wore hearing aids. R8's Communication Care Area Assessment (CAA) dated 9/19/24, indicated R8 had the potential for communication deficits related to his hearing impairment. Identified R8 had poor hearing in both ears and R8 had a history of cerumen (wax) build up. R8's care plan, indicated R8 has a communication problem related to hearing deficit and he wore bilateral hearing aids. R8's electronic health record (EHR) lacked evidence R8 was offered an audiology appointment. R8's physician's orders identified an order to flush both ears until wax clears every 24 hours as needed for wax buildup. During observation on 11/18/24 at 3:20 p.m., R8 had hearing aid in the left ear but none in the right ear. During observation and interview on 11/18/24 at 3:21 p.m., R8 stated he took his hearing aides out as they are not working well. R8 stated if a new battery is replaced into hearing aids, his hearing improved for a couple of hours and then went back to him not being able to hear. During observation on 11/19/24 at 12:37 p.m., R8 did not have hearing aids present in ears. During observation on 11/19/24 at 7:53 p.m., R8 was sitting out in the common area playing cards with another resident. R8 did not have hearing aids present in ears. R8 was speaking very loudly to another resident. During observation on 11/20/24 at 8:44 a.m., R8 was sitting in common area talking loudly to another resident. R8 did not have hearing aids present in ears. During observation on 11/20/24 at 3:22 p.m., R8 was sitting in common area talking loudly to another resident. R8 did not have hearing aids present in ears. During observation on 11/21/24 at 9:21 a.m., R8 did not have hearing aids present in ears. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated resident had hearing aids, but thought they were broken and she does not know what exactly is going on with them. NA-E stated R8 may have wax buildup in ears and may need his ears flushed as he has a history of wax buildup. NA-E confirmed she has noticed an increase in hearing impairment for R8. During interview on 11/21/24 at 10:48 a.m., licensed practical nurse (LPN)-A stated R8 wore hearing aids but thinks that they do now work very well. LPN-A stated staff assist R8 with changing the batteries. LPN-A stated nursing could check R8's ears for wax if resident has complaints of pressure or staff notices his hearing is worse. LPN-A confirmed R8's hearing has been notably worse in the past month or so. Confirmed R8 had an order to flush ears. During interview on 11/21/24 at 11:39 a.m., registered nurse (RN)-A stated R8 has difficulty hearing and wore hearing aids in both ears. RN-A stated if staff notice a decrease in hearing, nursing should assess R8's ears with an otoscope to check for wax buildup. RN-A confirmed R8 had an order for flushing ears due to wax buildup and stated since R8 had that order in place, it should have been done to see if his hearing would improve at all after flushing. RN-A stated the provider reviewed orders every 30-60 days so due to it being an order, it should be tried to check for hearing improvement. RN-A confirmed flushing of R8's ears had not been completed in the past 6 months as it would be documents on the mediation administration record (EMR). During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated she would expect staff to process the standing order for Debrox (wax softening) ear drops and then to flush ears after drops were initiated. ADON stated she expects the nurse to check for wax buildup when there is an increase in hearing difficulty noted in a resident. ADON stated this was important for the resident to be able to communicate and for staff to be able to communicate with him as this could lead to dignity concerns for the resident. The facility Care of the Hearing-Impaired Resident policy, dated 7/24, indicated the purpose of this procedure is to provide guidelines when providing care to the resident with hearing impairment. The facility to evaluate resident's progress and adjustment at regular intervals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 (R37) resident reviewed who had a history of past traumatic experiences. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R37's diagnoses included Alzheimer's disease, aphasia, dementia, depression, polyneuropathy, and low back pain. R37's care plan, print date of 11/19/24, lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization. R37's trauma questionnaire dated 7/6/23, indicated R37 had trauma in his past. However, no additional information was obtained to determine triggers and/or coping mechanisms. During interview on 11/19/24 at 2:30 p.m., family member (FM)-A stated R37 had post-traumatic stress disorder (PTSD) and behaviors had gotten worse. FM-A stated R37 would see imaginary people coming out of the television and standing outside the windows, would take things apart and remove batteries from items as he disassembled bombs during his time in Vietnam, would sleep during the day and would be awake all night as he would stand in the bedroom or sit in chair in living room where he could see both doors on guard like he was on guard duty, and collected silverware due to limited silverware during his time in Vietnam. FM-A stated facility gave R37 plastic silverware to eat with due to R37 taking the regular silverware, putting them in his shirt pocket and would have six to eight pieces of silverware at a time. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated she was not aware of any past trauma in R37's life. NA-E stated it would be important to know if a resident went to war or had certain triggers so if they exhibit behaviors we know how to respond. NA-E stated if resident had a history of trauma, it would be on resident's care plan. During interview on 11/20/24 at 10:25 a.m., social worker (SW) stated she is responsible for completing assessments for trauma, elopement, and mood/depression. SW stated on the trauma assessments, if a resident answers yes to a question, she would have to talk in detail about triggers and what interventions are effective and put triggers/interventions in the resident's care plan. SW stated she completed the assessments for all residents, no matter what the resident's cognitive level is. SW stated for a resident with severe cognitive impairment, she would interview the resident and may get family input at care conference. SW stated she would be notified by staff with any issues resident may be experiencing and would follow up with resident to determine what could be offered or what interventions could be implemented. During interview on 11/21/24 at 9:15 a.m., SW stated trauma assessments are completed upon resident's admission and uses the information from the assessment to implement in care plan. SW confirmed she completed trauma assessment for R37 when R37 was admitted in 2023. SW stated when a resident has a decline or a change, it is discussed at Tuesday staff meetings and then she would reassess resident and determine what to do next. SW stated if a resident displayed behaviors, they would watch and chart behaviors. Facility has offered small groups for veterans, cognitive bins, real babies, and coordination with therapy for tasks to keep resident busy. During interview on 11/21/24 at 10:45 a.m., licensed practical nurse (LPN)-C stated she was not aware of any past trauma in R37's life. During interview on 11/21/24 at 10:46 a.m., LPN-A stated he was not aware of any past trauma in R37's life. During interview on 11/21/24 at 10:31 a.m., SW confirmed she completed the trauma assessment with R37, who had a severe cognitive impairment, and put information on care plan. SW reviewed R37's record and confirmed trauma was not on care plan. SW stated she should have asked about possible triggers and implement interventions to support the resident the best the facility can. SW stated it was important to include trauma on resident's care plan so staff know how to care for the resident and can provide interventions when needed. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated that when a resident is admitted , they are asked about past trauma and trauma informed care questionnaire would be completed by the social worker. ADON stated trauma assessments should be assessed quarterly due to new or changing behaviors. ADON stated R37's care plan should have included behavior monitoring, PTSD/trauma triggers, how staff would avoid those triggers and interventions to be used if R37 was triggered. ADON confirmed R37 did not have behavior monitoring or a care plan that addressed R37's past trauma and the last trauma assessment completed was on 7/6/23. A facility Trauma Informed Care policy, dated 7/2024, indicated the facility would demonstrate a culturally competent and trauma informed practice; integrate residents' preferences into care plans and understand the three core principles of Trauma Informed Care. The impact of adversity is not a choice; understanding adversity helps us make sense out of a behavior and prior adversity is not a [NAME]. The facility is to ensure that all those involved in the organization understand the general impact of trauma; paths to recovery and identify signs and symptoms of trauma in resident, families, staff and to incorporate practices that prevents re-traumatization. The facility will incorporate the 4 R's of a Trauma Informed Approach: - Realization: Ensure that all those involved in facility comprehend that trauma can affect individual's families, staff, and the community. - Recognition: Staff will recognize signs and symptoms of trauma and have access to trauma screening tools. - Responding: Staff will respond by using the Trauma informed Approach. - Resisting Re-traumatization: Ensure that practices and behaviors do not create a disruptive environment and re-traumatize.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure side rails were assessed to determine appropriate and safe to use for 2 of 5 residents (R8 and R19) who were observed to have a side rail affixed to their beds. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], identified R8 had intact cognition and required assistance with all activities of daily living (ADL)'s. R8's diagnoses included dislocation of internal left hip prosthesis, coronary artery disease, GERD, obstructive uropathy, arthritis, presence of cardiac pacemaker, pain in right shoulder, pain in left shoulder, generalized muscle weakness and other abnormalities of gait and mobility. MDS did not identify use of side rails. R8's care plan, included R8 required limited assist of one staff for bed mobility (to go from lying to sitting/sitting to lying) but was able to turn and reposition in bed himself in bed. Care plan indicated R8 had two half upper side rails to assist with bed mobility and for staff to observe for injury or entrapment related to side rail use. During observation on 11/18/24 at 3:27 p.m., R8's bed had a ¼ side rail affixed to the head of bed on both sides of bed. R8's medical record lacked evidence that an assessment had been completed timely to determine necessity and whether R8 could safely use side rails. Last side rail assessment was completed on 6/25/24. Additionally, R8s medical record lacked evidence alternatives were tried prior to installing the side rails. R19's annual Minimum Data Set (MDS) dated [DATE], identified R19 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R19's diagnoses included stroke, hemiplegia following cerebral infarction affecting right dominant side, atrial fibrillation, coronary artery disease, heart failure, hypertension, thyroid disorder, depression, dysphagia following cerebral infarction and Barrett's esophagus without dysplasia. MDS did not identify use of side rails. R19's care plan, print date of 11/20/24, included that R19 required limited assist of one staff for bed mobility. Care plan indicated R19 had two half side rails on both sides of her bed to help her turn and transfer easier. During observation on 11/19/24 at 12:39 p.m., R19's bed had a ¼ side rail affixed to the head of bed on both sides of bed. R19's medical record lacked evidence that an assessment had been completed timely to determine necessity and whether R19 could safely use side rails. Last side rail assessment was completed on 8/21/23. Additionally, R19s medical record lacked evidence alternatives were tried prior to installing the side rails. During interview on 11/18/24 at 3:27 p.m., R8 stated he used side rails to reposition himself in bed and to assist him with getting into bed. R8 stated the side rails were in my way when he had to get up to use restroom at night. R8 stated he told staff several times but the staff told resident that it is something I guess I have to have. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated she has seen R8 utilize the side rails on his bed with turning and repositioning NA-E stated she has seen R19 utilize the side rails on her bed with repositioning and to assist her from sitting to standing. During interview on 11/21/24 at 10:48 a.m., licensed practical nurse (LPN)-B stated R8 utilized bed rails to aid in turning and repositioning in bed. LPN-B stated he was not aware R8 was having trouble getting out of bed at night due to the side rails and stated R8 is not supposed to get out of bed on his own anyway's as R8 tends to self-transfer. During interview on 11/21/24 at 11:39 a.m., registered nurse (RN)-A stated side rail assessments are completed quarterly and annually by the MDS nurse. RN-A stated the MDS nurse has been out of medical leave for the past several months and her duties were being completed by director of nursing (DON), assistant director of nursing (ADON) and herself. RN-A confirmed R8's last side rail assessment was completed on 6/25/24 and R8 should have had another assessment completed in September. RN-A confirmed R19's last side rail assessment was started on 8/28/24 but it was not started/completed and the last completed assessment was completed on 8/31/23. RN-A stated facility does not assess the resident for what type of grab bar/side rail would be appropriate for resident but for whatever device is on the bed in the room that the resident was admitted to is what the resident received. RN-A stated some residents get side rails and some get grab bars. RN-A stated she did not assess side rails based on the resident's condition or need, only assessed on if resident wanted them. RN-A was not aware of what alternative methods could be assessed and/or trialed regarding side rails. RN-A stated assessment of side rails is important to ensure resident still wanted to use side rails, determine if resident still needed them and that they are able to still use them safely. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated side rail assessments are competed quarterly. ADON stated whatever is on the bed in the room the resident was admitted to is what the resident was assessed for. ADON stated the facility treated grab bars and side rails the same. ADON stated assessment of side rails are important to ensure the resident has side rails for the right reasons, that they are still safe for the resident, and that the resident is not having ill effects from having side rails on bed. The facility Assessing the Safety of Side Rails policy, dated 8/2024, indicated staff will alert the RN if a client has any type of side rail or similar equipment and the RN will then evaluate whether the side rails appear to be safe for the client. The RN will educate the client, the client's representative and/or family members about the risks related to side rails, and if the client's side rail does not appear to meet FDA standards, the RN will recommend to the client, the client's representative, the client's involved family members that the side rail be removed and will recommend alternative options to reduce the risk of a fall out of bed. The RN will document these conversations and recommendations. 1. The RN will train staff to be alert for any side rail or equipment that resembles a side rail that a client may be using or considering using and to notify the RN immediately about the side rail or equipment. 2. When notified that a client has a side rail, the RN will assess and evaluate what the client's needs are and assess to determine if the client can safely utilize the side rail/equipment and determine whether the side rail/equipment meets the FDA standards for side rails. 3. The RN will provide for any client who has a side rail or is considering obtaining one and, if appropriate, the RN will educate the client's representative and/or the client's family regarding side rail safety and risks including potential death due to falls, entrapment, and asphyxiation. If the RN determines that the client is not able to safely use a side rail, or that the client's side rail does not meet the FDA or most current safety guidelines, the RN will recommend that the side rail should be removed and will document this recommendation, will document to whom the education was directed and will document the person who was given the recommendation to remove the side rail. 4. If the RN determines that the side rails are not a safe device for the client, the RN will provide options and alternatives for reducing fall or positioning self to the client, the client's representative and/or the client's family. The RN will document these recommended options and the response from the client, client's family, and client's representative to the RN's recommendations. 5. The RN may not remove a side rail that is the property of the client, the client's representative or the client's family. If the RN determines that a client's side rail is unsafe, and the client, the client's representative or the client's family does not remove it, the RN will notify the client's physician and consider whether to notify the Common Entry Point. Side rails can be very helpful in assisting individuals in transferring out of bed or repositioning in bed. It is important to recognize that the dangers exist regardless of the purpose for using the side rails. Nursing staff should assess an individual's capabilities for using side rails safely.

Based on interview and document review, the facility failed to ensure the services of a registered nurse (RN) were available onsite for 8 consecutive hours seven days a week. This had the potential to affect all 41 residents who reside at the facility. Review of the facility staffing schedules dated 4/1/24 through 6/30/24, identified there was not eight consecutive hours of RN coverage for 6/2/24, 6/15/24 and 6/16/24. During interview on 11/21/24 at 12:59 p.m., the assistant director of nursing (ADON) verified there was no RN on for eight consecutive hours on 6/2/24, 6/15/24 and 6/16/24. The ADON stated the facility policy and practice was to have a RN on duty in the building eight consecutive hours but had call-ins for those dates and not sure what happened. The facility Departmental Supervision policy, dated 7/2024, indicated the nursing services department shall be under the direct supervision of a Registered or Licensed Practical/Vocational nurse at all times. 1. A Registered or Licensed Practical/Vocational Nurse (RN/LPN/LVN) is on duty twenty-four hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A Registered Nurse (RN) is employed as the Director of Nursing Services (DNS). The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, the Assistant Director of Nursing (ADON), then a RN Care Coordinator (RNCC) is responsible for the supervision of all nursing department activities including the supervision of direct care staff. During the absence of those Registered Nurses (Weekends and holidays), a registered nurse will be scheduled to be on duty, in the facility, 8 hours out of every 24 hour period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure adverse event monitoring was completed for 1 of 4 residents (R37) and failed to monitor adverse behaviors for 1 of 4 residents (R37) reviewed for unnecessary medication use and were taking an antipsychotic medication. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R37's diagnoses included Alzheimer's disease, aphasia, dementia, depression, polyneuropathy, and low back pain. R37's Order Summary Report, print date 11/19/24, identified R37's current physician ordered medications and treatments at the nursing home. These included orders for haloperidol (an antipsychotic) 1.5 mL (3 mg) three times daily for anxiety/restlessness/agitation. R37's care plan, print date of 11/19/24, lacked evidence for behavior and/or side effect monitoring with use of an antipsychotic medication. R37's medication record, identified the order for haloperidol and recorded R37 received the medication, as ordered, on a daily basis. However, the record lacked evidence staff monitored for adverse effects of the medications. In addition, the record lacked behavioral symptoms to monitor, and track. R37's medical record lacked evidence R37's behaviors were monitored, assessed, and reviewed to justify the daily medication administration and that R37 was being assessed or evaluated for adverse effects as ordered by the physician. During interview on 11/21/24 at 11:39 a.m., registered nurse (RN)-A stated a resident who receives an antipsychotic medication should have the following monitoring: behavioral and adverse effect monitoring, and an abnormal involuntary movements assessment should be completed. RN-A stated antipsychotic monitoring should be included in the resident's care plan. RN-A confirmed R37 did not have an order for side effects monitoring, behavior monitoring and that it was not listed on R37's care plan. RN-A stated it was important for the antipsychotic medication to be listed on the care plan as it is another way for staff to be aware of what types of medication is receiving and it is another way to monitor for side effects. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated when a resident is receiving an antipsychotic medication, side effect and target behavior monitoring should be completed. ADON stated the antipsychotic medication would be stated in the care plan with what side effects to monitor and interventions for behaviors. ADON stated it was important for the well-being of the resident and if resident was experiencing side effects from medication it could mean than resident may need a dose reduction and/or an alternative medication. The facility Antipsychotic Medication Use policy, dated 7/2024, identified antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition. Staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms, and risks. Nursing staff will document in detail an individual's target symptom(s). The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. Based on assessing the resident's symptoms and overall situation, the Physician will determine whether to continue, adjust, or stop existing antipsychotic medications. Nursing staff shall monitor and report any of the following side effects to the Attending Physician: A) Sedation; B) Orthostatic hypotension; C) Lightheadedness; D) Dry mouth; E) Blurred vision; F) Constipation; G) Urinary retention; H) Increased psychotic symptoms (atropine psychosis); I) Extrapyramidal effects; J) Akathisia; K) Dystonia; L) Tremor; M) Rigidity; N) Akinesia; or tardive dyskinesia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R21 R21's quarterly Minimum Data Set (MDS) dated [DATE] indicated R21 had significant cognitive impairment and an indwelling catheter. R21's diagnosis list included: obstructive and reflux uropathy (a disorder limiting the flow of urine), urinary retention (difficulty emptying the bladder) R21's orders included: change urinary catheter every 28 days, change urine collection bag every Thursday, and document catheter output every shift. R21's careplan indicated R21 had urinary catheter. R21's catheter assessment dated [DATE] indicated R21 has an indwelling catheter since 11/4/22. Catheter was last changed 8/24/24. During interview on 11/19/24 at 1:10 p.m., R21's family member (FM) -D indicated R21 has had a urinary catheter for 2 years. During observation on 11/19/24 at 1:28 p.m., no enhanced barrier precautions signage or protective equipment (PPE) were noted outside R21's room. There were no bins to dispose of PPE noted inside R21's room. During interview on 11/19/24 at 7:26 p.m., nursing assistant (NA)-A stated staff receive infection prevention training once a year. NA-A stated when residents are on precautions, signage is placed on the door and carts containing PPE are placed outside the rooms. Precautions are also indicated on the resident's care sheet. NA-A stated they were not familiar with EBP. R21's care sheet indicated R21 has urinary catheter however lacks indication of EBP. During observation and interview on 11/20/24 at 9:02 a.m., R21 was lying in bed with urinary drainage bag attached to the bedframe. NA-B entered room, sanitized hands, and applied gloves. NA-B was not wearing isolation gown gown. NA-B obtained R21's daytime urinary bag from bathroom and brought it to the bedside. NA-B removed R21's sweatpants and opened R21's incontinent brief. NA-B provided catheter care, disconnected drainage bag, wiped ends of catheter tubing with alcohol wipes, and attached daytime drainage bag. NA-B placed night drainage bag in the bathroom and removed gloves. NA-B assisted R21 to the edge of the bed and applied gait belt. NA-B assisted R21 to standing position and transferred R21 to the wheelchair. NA-B returned to the bathroom, applied gloves, and placed a paper towel on the bathroom floor. NA-B placed graduate (container used to measure fluids) on paper towel, emptied drainage bag, measured amount and disposed in the toilet. NA-B was not wearing gown. NA-B stated they were not familiar with EBP and had never been instructed to use it. When surveyor explained what EBP was, NA-B stated they never heard of it. The facilities Enhanced Barrier Precautions policy was requested but was not received. Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene and donning/doffing of personal protective equipment (PPE) was performed in order to prevent the spread of infection for 3 of 3 residents (R8, R32, and R21) observed for enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Findings include: ENHANCED BARRIER PRECAUTIONS, PPE USE AND HAND HYGIENE Review of CDC guidance dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions (EBP) include: Dressing, Bathing/showering, Transferring, Providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R8's annual Minimum Data Set (MDS) dated [DATE], identified R8 had intact cognition and required assistance with all activities of daily living (ADL)'s and had an indwelling catheter. R8's diagnoses included dislocation of internal left hip prosthesis, coronary artery disease, gastroesophageal reflux disease, obstructive uropathy (excess urine accumulation in kidneys that causes swelling of kidneys), arthritis, presence of cardiac pacemaker, pain in right shoulder, pain in left shoulder, generalized muscle weakness and other abnormalities of gait and mobility. R8's care plan, print date of 11/20/24, indicated R8 required staff assistance with all ADL's and had an indwelling catheter. During observation on 11/18/24 at 3:33 p.m., R8 did not have cart with PPE or hand hygiene in or outside of room, nor did not have signage posted indicating that R8 was on enhanced barrier precautions. R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R32's diagnoses included heart failure, hypertension, dysphagia (difficulty in swallowing), dyskinesia of esophagus (painful and abnormal contractions of the esophagus (food pipe) that do not lead to wave-like movement (peristalsis) to push the food to the stomach), orthostatic hypotension (form of low blood pressure that occurs when standing after sitting or lying down), renal failure (one or both of the kidneys no long function well on their own), Alzheimer's disease, stroke, dementia, depression, and asthma. MDS indicated R32 received tube feedings. R32's care plan, print date of 11/20/24, indicated R32 required staff assistance with all ADL's and received tube feeding related to dysphagia and dyskinesia of esophagus. During observation on 11/18/24 at 3:14 p.m., R32 did not have cart with PPE or hand hygiene in or outside of room, nor did not have signage posted indicating that R32 was on enhanced barrier precautions. During interview on 11/20/24 at 9:57 a.m., licensed practical nurse (LPN)-B stated if a resident was on precautions, there would be a sign posted outside of resident's door, PPE carts would be placed outside resident's room in hallway, and garbage cans/bins would be kept in resident's room to dispose of PPE before exiting room after cares. LPN-B stated for residents with catheters or tube feedings, PPE that is used are gloves. LPN-B was not aware of what EBP precautions were and stated they have not been trained on them. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated they are notified in report if resident goes on precautions. NA-E stated a bin for PPE would be placed outside of resident's room and three bins would be placed inside resident's room for garbage and linens. NA-E stated she was not aware of what enhanced barrier precautions were. During interview on 11/20/24 at 10:16 a.m., LPN-C stated if a resident was on precautions there would be a sign posted on resident's doors, a PPE cart would be in place outside of resident's room, and garbage cans in resident's room. LPN-C stated when caring for the catheter an/or tube feeding, PPE used are gloves and mask. LPN-C was not aware of what EBP precautions were. During interview on 11/21/24 at 10:29 a.m., assistant director of nursing (ADON) stated when a resident is on precautions, PPE cart would be placed outside of resident's room with a signed posted on resident's door directing staff what PPE is needed before caring for resident. ADON stated precautions would also be posted on the resident's home page in the electronic health record. ADON stated standard precautions are used for residents with catheters and/or has tube feedings. ADON stated she had heard about EBP precautions but was not familiar with them and confirmed that EBP precautions are not in place in facility. ADON stated EBP had not been implements and confirmed R8 and R32 should be on EVP due to R8 having a catheter and R32 receiving tube feedings. ADON stated EBP precautions are important for the resident and staff safety.

Based on interview and record review, the facility failed to submit complete and/or accurate data for staffing information based on payroll and other verifiable data during 1 of 1 quarter (Quarter 3) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Review of the Payroll Based Journal (PBJ) [NAME] Report 1705D identified the facility had excessively low weekend staffing during the third quarter of the fiscal year 2024, which included dates between April 1st to June 30th. Review of daily staff schedules and facility staffing report during quarter three indicated adequate levels of staff on weekends. Therefore, the data submitted in the PBJ to CMS was inaccurate. During interview on 11/21/24 at 3:09 p.m. the administrator stated the facility staffing levels did not change from weekdays to weekends. Administrator stated the business office completed and submits the PBJ data based on information off the schedule and daily staff postings. Administrator stated it was important to ensure accurate data is submitted based on requirements. The facility Payroll Based Journal (PBJ) Reporting policy, dated 7/2024, indicated staff and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Direct-care staffing information will include staff hired directly by the facility, those hired through an agency, and contact employees. Providers who are employed by the facility (including physicians) will be included in direct-care staffing information, providers who bill Medicare directly will not be included. For auditing purposes, reported staffing information will be based on payroll records, or other verifiable information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure special instructions for wound care were transcribed and followed for 1 of 2 residents (R2) reviewed for pressure ulcers. Findings include: R2's quarterly minimum data set (MDS) dated [DATE], indicated R2 was moderately cognitively impaired, required 1-to-2-person physical assistance for most activities of daily living (ADLs). R2's diagnoses include dementia, urinary tract infection (UTI), local infection of the skin and subcutaneous tissue, urge incontinence and carrier of methicillin resistant staphylococcus aureus (MRSA-an antibiotic resistant bacterial infection). R2's care plan (CP) last reviewed 10/16/23, indicated R2 had impaired skin integrity related to arterial/pressure ulcer to right lateral ankle and instructed staff to administer treatments as ordered. The CP further indicated R2 was incontinent of bladder with a history of multiple UTIs and had an ADL self-care performance deficit and required assistance with bathing. R2's bath days were listed as Tuesday, Thursday, and Saturday. R2's wound care order dated 6/27/23, written by physician assistant (PA) indicated, step by step wound care and dressing change instructions for every other day and as needed if the dressing gets wet. The wound order included additional instructions, Please keep the wound and dressing DRY in the shower - using a cast bag, plastic bag or plastic wrap to keep the wound and dressing dry, if it gets wet, please change it according to the instructions above. The order was marked as noted by registered nurse (RN)-C on 6/28/23. R2's wound care order dated 9/20/23, written by PA indicated, step by step wound care and dressing change instructions for every other day and as needed if the dressing gets wet. The wound order included additional instructions, Please keep the wound and dressing DRY in the shower - using a cast bag, plastic bag or plastic wrap to keep the wound and dressing dry, if it gets wet, please change it according to the instructions above. The order was marked as noted by RN-C on 9/21/23. R2's bath task dated 10/11/22, indicated, Bathing: TUESDAY & THURSDAY AM; SATURDAY PM. The bath task was edited by RN-C on 10/17/23, to include, Please cover right ankle wound with water-proof dressing during showers. During observation and interview on 10/17/23 at 10:22 a.m., R2 stated she had a shower earlier this morning and her wound dressing was wet from the shower. R2 stated they normally change her dressing every other day but could not remember the last time it was changed. The dressing was wet and was not dated. R2 stated she gets three showers a week and they never cover the dressing, so it always got wet in the shower. During observation on 10/17/23 at 10:45 a.m., license practical nurse (LPN)-B entered R2's room and removed the nebulizer treatment and did not address the wet dressing. During interview on 10/17/23 at 11:24 a.m., nursing assistant (NA)-A stated assisted R2 with her shower this morning and did not cover the dressing to keep it dry. NA-A stated worked with R2 regularly and had never been instructed to cover her dressing. NA-A stated plastic limb protectors were available and used on other residents. NA-A further stated thought the nurse was supposed to change the dressing every day so did not think it was concerning that the dressing was wet. During interview on 10/17/23 at 11:28 a.m., LPN-B stated R2's dressing was supposed to be changed every other day and as needed. LPN-B stated was not aware of any order or instruction to keep R2's dressing dry during a shower. LPN-B stated would expect such instructions to have been transcribed and listed in R2's electronic medical record (EMR) where the NAs would see it so they would know to cover the dressing during her shower. During observation on 10/17/23 at 11:38 a.m., LPN-B provided wound care and changed R2's dressing. During interview 10/17/23 at 2:00 p.m., RN-C stated was the one who reviewed and noted R2's wound orders but agreed the specific instructions were not entered into R2's EMR. RN-C stated assumed staff knew to cover a dressing during a shower. RN-C stated the specific instructions should have been transcribed into R2's EMR so staff were aware and would cover the dressing during showers. RN-C added the instructions to R2's bathing task in her EMR so NAs would see and complete going forward. During interview on 10/17/23 at 2:05 p.m., assistant director of nursing (ADON) stated PA typically ordered all dressings to be covered during showers and thought it was standard practice. ADON stated R2's dressing should be covered during showers. During interview on 10/17/23 at 2:27 p.m., PA stated he always orders wounds and dressings on lower extremities in particular to be covered during showers since the water could pass from pretty dirty areas like a resident's bottom and possibly transfer E-coli (Escherichia coli-a type of bacteria that normally lives in intestines) or something like that down to a wound causing an infection. PA further stated he had ordered R2's dressing be covered during showers and expected that was being done. During interview on 10/18/23 at 1:13 p.m., director of nursing (DON) stated expectation for orders to be transcribed into the EMR appropriately. DON stated expectation special instructions for during a shower would be entered where the NAs would see them and would expect the NAs to follow the instructions. DON stated R2's dressing should be covered during showers to decrease the chance of the wound becoming infected. During follow up interview on 10/19/23 at 10:47 a.m., DON stated R2 did have an infection in her wound in June and the bacteria cultured included E-coli but could not confirm how R2 contracted the infection. DON further stated R2 suffered from frequent UTIs and had just recently recovered from one. DON stated NAs should be notifying the nurse when a dressing got wet regardless whether it was covered. Facility policy Shower/Tub Bath undated, lacked instruction for wound/dressing coverage to protect from becoming wet. Facility policy Wound Care dated May, 2022, instructed staff to verify physician orders for specific procedure and review resident's care plan for special needs of the resident. The policy lacked instruction for wound/dressing coverage during showers to protect from becoming wet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to consistently assess and report changes in wound condition for 1 of 1 residents (R4) observed for pressure ulcers which had the potential for a worsening condition to go unnoticed. Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], included cognitively intact with diagnosis including diabetes mellitus, stage 3 PU of sacral region, (Stage III pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) non-pressure chronic ulcer of right and left calf, and peripheral vascular disease. R4 required extensive assistance with most activities of daily living (ADL's). R4's care plan included a problem area dated 12/9/21, and indicated one sacrum pressure ulcer (PU). PU will show signs of healing and remain free from infection. R4 was admitted with PU on 12/3/21. R4's care plan included administering treatments as ordered, monitoring for effectiveness, and documenting assessment weekly. R4's physician orders dated 12/9/21, indicated R4 receive weekly skin and health assessment every evening shift on Thursdays and to document in progress note. R4's wound documentation identified wound measurements were taken on: 12/3/21, 12/10/21, 1/19/22, and 2/18/22. In the electronic health record (EHR) wound assessment, the system provided the following prompt, wounds, bruises, dimensions and characteristics (YOU MUST MEASURE); however, on dates 12/23/21, 12/30/21, 1/6/22, 1/13/22, 1/27/22, 2/3/22, 2/10/22, 2/17/22, 2/24/22, 3/3/22, and 3/10/22 no measurements were found. During observation on 3/16/22, at 1:17 p.m. registered nurse (RN)-C was observed changing the dressing on R4's sacrum. RN-C did not measure dimensions of PU at the time. RN-C stated RN-A was responsible for measuring PU on Friday's and that she was unaware of where skin and wound notes were documented. When interviewed on 3/17/22, at 10:26 a.m. RN-A stated she was responsible for monitoring PU weekly on Friday's. RN-A stated facility has a wound application on phone that automatically creates a skin and wound evaluation in EHR. RN-A stated she saw wounds weekly but no documentation was provided. RN-A stated last measurements of PU were taken on 2/18/22. When interviewed on 3/17/22, at 12:33 p.m. licensed practical nurse (LPN)-A stated RN-A is responsible for measuring all PU and RN-B was responsible for measuring during RN-A's absence. When interviewed on 3/17/22, at 12:35 p.m. RN-A stated measurements of all pressure ulcers should be completed weekly. RN-A stated that RN-B will complete measurements in her absence. RN-A stated floor nurses should be measuring during weekly skin checks. RN-A stated she should be better at gathering measurements and charting them into EHR. On 3/17/22, at 12:35 p.m. a message was left for DON who did not return the call. When interviewed on 3/17/22, at 1:07 p.m. the administrator stated RN-A, RN-B, and DON were responsible for weekly measurements. Administrator stated expectation for PU to be measured weekly as there could be the potential of worsening condition. When interviewed on 3/17/22, at 3:08 p.m. RN-B stated RN-A was responsible for measuring pressure ulcers. RN-B stated the director of nursing (DON) and herself were responsible for measurements when RN-A was absent. RN-B stated it was not discussed who would complete R4's measurements during RN-A's absence. DON completed wound measurements during R4's telehealth appointment on 3/3/22, but no documentation was provided. On 3/17/22, at 3:18 p.m. a message was left for DON who did not return the call. The policy titled Pressure Ulcer Risk Assessment not dated specified skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Nurses will conduct skin assessments at least weekly to identify changes. The policy titled Pressure Ulcer Treatment not dated indicated the following information should be recorded in the resident's medical record: All assessment data (i.e., color, size, pain, drainage, etc.) when inspecting the wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure consulting pharmacist recommendations were acted upon, addressed, and documented in the medical record for 1 of 5 residents (R5) reviewed for unnecessary medication use. Findings include: R5's quarterly Minimum Data Set (MDS), dated [DATE], identified R5 had diagnoses of Bipolar II Disorder and Schizoaffective Disorder. R5's Physician Order Sheet printed 3/17/22, identified R5's current medication regimen with their corresponding start dates. This included an order for Zyprexa (an antipsychotic used to treat Bipolar Disorder) 20 milligrams (mg) by mouth one time a day. This medication was last dose adjusted on 12/2/21. R5's monthly Consultant's Pharmacist's Medication Review, dated 1/7/22, identified a review of available data in the medical record - nursing recommendation to update Abnormal Involuntary Movement Scale (AIMS) (used to assess the severity of involuntary movements) exam if not recently done. R5's monthly Consultant's Pharmacist's Medication Review, dated 2/7/22, identified a review of available data in the medical record, nursing recommendation to update AIMS exam and clarify dose of Reserpine. R5's monthly Consultant's Pharmacist's Medication Review, dated 3/7/22, identified a review of available data in the medical record, nursing recommendation to assess AIMS or Dyskinesia Identification System:Condensed User Scale (DISCUS) (used to rate tardive dyskinesia symptoms) exam. R5's medical record was reviewed and lacked evidence the consulting pharmacist's recommendation on R5's AIMS Assessment had been forwarded, reviewed and/or acted upon by the facility despite the recommendation being made for the previous 3 months. When interviewed on 3/16/22, at 12:59 p.m. registered nurse care coordinator (RNCC)-A stated she was responsible to follow-up on the pharmacy recommendations for all residents. RNCC-A reviewed R5's medical record and verified the pharmacist recommendations dated 1/7/22, 2/7/22 and 3/7/22 had not been addressed at this time. On 3/17/22, at 10:47 a.m. facility administrator stated pharmacy recommendations are sent to the director of nursing and the RNCC-A and the RNCC-A is responsible for follow up of said recommendations. Furthermore, the administrator stated the expectation was that pharmacy recommendations should be addressed right away. On 3/17/22, at 11:55 a.m. the Consultant Pharmacist (CP) was interviewed and explained AIMS Assessments should be completed every 6 months and pharmacy recommendations should generally be addressed when made. CP verified her records showed R5's recommendations had not yet been addressed and the last AIMS completed was 6/22/21. Further, CP stated while R5's recommendation not being addressed was likely not a significant issue, it was a clinical recommendation and should have been acted upon as symptoms can develop over time the longer a resident is on the medication. Facility policy titled Pharmacy Recommendation Procedure, dated 10/1/21 indicated the pharmacist emails the pharmacy recommendations to the director of nursing, the RNCC or designee and the medical provider. The RNCC then reviews the pharmacy recommendations and completes/addresses what nursing recommendations are requested, document in a follow-up progress note from the pharmacist's note, file in the pharmacy recommendation binder and fax back to pharmacy. Facility policy titled Antipsychotic Medication Use, dated 3/2021 indicated nursing staff shall monitor and report any of the following side effects to the Attending Physician as well as complete an AIMS assessment every 6 months and the physician shall respond appropriately.

Based on observation, interview, and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 1 of 3 residents (R23) who had concerns with food temperatures. Finding include: During an observation on 03/14/22, at 12:38 p.m. Cook-A provided a tour of the kitchen. During this tour the cook-A was unable to produce documentation on how they monitor food temperatures. During observation and interview on 03/14/22, at 12:48 p.m. DC reported the facility did not have a certified dietary manager (CDM). The DC stated they did not have access to the blank log sheets that the temperatures would be recorded on. DC stated they were no longer recording food temperatures because of this. During an interview on 03/14/22, at 4:59 p.m. the facility administrator stated the certified dietary manager (CDM) had been gone for about a month. They had another dietary manager (DM) who had been covering and came in around once a week. The administrator also reported they had hired a new CDM who was going to be training soon. When interviewed on 3/14/22, at 6:02 p.m. R23 stated the food is often very cold. R23 received meal tray service in their room. During observation on 03/17/22, at 11:53 a.m. an extra tray was requested for the lunch meal. Dietary aid (DA)-A loaded the insulated food cart along with the sample tray at 12:14 p.m. DA-A began to pass the room trays at 12:18 p.m. At 12:34 p.m. the last tray was provided to a resident. At 12:37 p.m. temperatures were taken on the sample tray along with DC. The following was found: ham and cabbage were 97.0 degrees Fahrenheit (F), potatoes 95 degrees F and carrots 94 degrees F. The food was also tasted and was found to be cold. DC reported, The food is cold because the plate is cold, our warmer needs help. Maybe I'll need to get a new plate warmer, or warm plates in oven. DC confirmed they had complaints about cold room trays and stated, they were going to talk to the administrator about ways of keeping the plates warmer before sending them out. When interviewed on 03/17/22, at 1:05 p.m. R23 stated, her corned beef, cabbage and potatoes were very cold and had refused to eat it. R23 was eating peanut butter toast instead. On 3/17/22, at 1:46 p.m. a message was left for registered dietician who did not return the call. The facility policy titled Food Temperatures, undated, included, all hot food items would be served at or above 150 degrees. Record food temperature reading on Food Temperature Record.

Based on observation, interview and document review, the facility failed to follow standard precautions while processing laundry including the use of (PPE) personal protective equipment. The lapses in infection control had the potential to impact all residents who had their laundry washed by the facility. Findings include: During an observation of the soiled laundry area of the facility on 3/15/22, at 7:30 a.m. a laundry aide (LA)-A was observed wearing gloves, mask and eye protection, but was not wearing a protective gown over her personal uniform while sorting soiled personal laundry from three large bins and from an open wired basket used to transport linens to units. LA-A stated she was not trained to wear a gown while sorting soiled laundry. LA-A stated she sorts the dirty laundry by color without using a gown to cover her personal clothing. LA-A stated she was the person responsible for washing the soiled clothing and folding the clean clothing after it was done. LA-A stated two other housekeeping aides will perform laundry if she is absent. During an observation on 3/16/22, at 8:10 a.m. LA-A was observed passing clean laundry on Sunny Lane hallway wearing the same uniform she had worn while sorting soiled laundry. Clean towels were observed touching LA-A's uniform before being placed into clean utility room. During an observation on 3/16/22, at 8:22 a.m. LA-A was observed passing clean laundry on Western Trails hallway wearing the same uniform she had worn while sorting soiled laundry. During an observation on 3/16/22, at 10:49 a.m. LA-A was observed passing clean laundry on River Crossing hallway wearing the same uniform she had worn while sorting soiled laundry. When interviewed on 3/17/22, at 12:19 p.m. the administrator stated the expectation would be to wear all PPE which includes a nonpermeable gown when sorting dirty laundry as all laundry is considered infectious and personal clothing could become contaminated when going from soiled to clean. The facility policy titled Laundry and Bedding, Soiled not dated specified soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. -Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely). -The Environmental Services Director or supervisor will ensure that forceps/tongs or similar safe sorting devices are available for sorting laundry.