**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure a comprehensive care plan was developed and implemented to include of post-traumatic stress disorder (PTSD) triggers and interventions for 2 of 2 residents (R10 and R23) who had a diagnosis of PTSD. Findings include: R23's face sheet printed 5/14/25, included diagnoses of Parkinson's disease (progressive neurodegenerative disorder that affects movement), psychological trauma, dementia, and major depressive disorder. R23's annual Minimum Data Set (MDS) dated [DATE], indicated R23 had moderate cognitive impairment, no behaviors and required moderate assist to stand, toileting substantial to maximal assist of 1 and was able to walk 150 feet with touching and standby by assist. PTSD was not checked as an active diagnosis. Medications included antipsychotic and antidepressant use. R23's plan of care dated 8/6/24, included a potential for mood deficit related to dementia, Parkinson's disease, depression and anxiety. Interventions included keep resident and family updated, encourage participation in activities of interest, support visits for mood and adjustment, mental health provider visits routinely, allow resident to verbalize and express feelings and frustrations. Medicate with Pristiq (antidepressant), Seroquel (antipsychotic), Remeron (antidepressant), Wellbutrin (antidepressant), Effexor (antidepressant, antianxiety), testosterone injection, olanzapine (antipsychotic) and melatonin (hormone that plays a role in sleep) per MD orders. R23's care plan failed to indicate PTSD triggers and interventions. On 5/13/25 at 12:51 p.m., registered nurse RN-C stated she was not aware of R23's history of trauma. RN-C stated R23 has a lot of anxiety and does not like being at the facility. RN-C is not aware of any triggers and confirmed there is no plan of care for PTSD. On 5/13/25 at 12:59 p.m., nursing assistant (NE)-E stated she was aware of R23's history of PTSD but was not aware of triggers. NA-E stated she felt R23 had more anxiousness than PTSD and when he is anxious she goes and gets the nurse. On 5/13/25 at 1:07 p.m., NA-F stated she was not aware of R23's history of PTSD but is aware he has a lot of anxiousness. NA-F could not state what triggers the PTSD or periods of anxiousness. NA-F stated we try to distract him by taking him outside or to an activity or we go get the nurse. On 5/13/25 at 12:06 p.m., the director of nursing (DON) confirmed she was aware of R23's history of PTSD but the comprehensive plan of care did not include PTSD including triggers and trauma informed care. R10's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment, required substantial/maximal assistance with personal hygiene, utilized a walker and wheelchair, diagnoses included non-traumatic brain dysfunction, anxiety, depression, and post-traumatic stress disorder (PTSD), and antipsychotics were received on a routine basis. R10's care plan dated 5/10/25, indicated cognition: alteration in thought process r/t (related to) dementia in severe loss range, family kept updated and makes decisions on her behalf, family also consulted for history of needs and background information to assist with daily needs provide cues for her to participate with completing ADL (activity of daily living) needs with schedule she is comfortable with and supervision throughout the day to be sure any independent decisions are appropriate, observe for any changes with cognition or level of alertness and report if; activities: alteration in lifestyle r/t dementia in severe loss range, anxiety, chronic disease process, new environment needs assistance to, from and during activities of her preferences, shows signs of increased agitation, wanting to go home having things to do with difficulty in redirection, needs staff assistance to divert energy and attention to validate feelings, staff will encourage and assist to, from and during activities of her preference, in attempts to ward off onset of agitation, provide meaningful 1:1 visits of conversations, attempts at reminiscing, picture books, sensory, validate feelings to resident when she is agitated and attempt to find quiet, calming activities with safe items or materials. R10's care plan failed to indicate PTSD triggers and interventions. On 5/12/25 at 3:43 p.m., during a telephone interview family member (FM)-D stated R10 had a history of PTSD. On 5/13/25 at 8:51 a.m., NA-G stated she was uncertain if R10 had a history of trauma or PTSD and would need to look in R10's chart. NA-G stated, maybe the nurse would know. On 5/13/25 at 9:48 a.m., RN-B stated she was verbally informed of R10's PTSD history. RN-B stated the care plan was expected to include R10's PTSD and confirmed R10's care plan did not include or identify PTSD triggers or interventions. On 5/13/25 at 10:26 a.m. NA-H stated she was aware R10 had a history of PTSD, but was unsure of specific triggers and stated she would expect the triggers indicated on the care plan. NA-H stated she used the care plan located in the paper chart. NA-H was observed and looked at R10's paper chart and confirmed R10's record did not identify PTSD triggers or interventions. NA-H stated she was uncertain where to find R10's PTSD related information. On 5/13/25 at 12:06 p.m., during an interview with the DON and social services (SS)-A the DON confirmed R10's care plan did not include information related to PTSD as expected. Facility Trauma Informed Care policy dated 8/24, indicated : Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. Facility Interdisciplinary Resident Care Plan policy dated 5/22, indicated: 1. The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal Representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. Assessment of residents are ongoing and care plans are revised as information about The residents and the residents' condition change. 4. The resident care plan is reviewed every 90 days by all member of the Interdisciplinary team. 5. Changes are made as needed on the care plan by all team members. 6. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate is encouraged to participate in the development of and revisions of the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure accuracy of measured weights for 1 of 1 resident (R29) reviewed for nutrition. Findings include: R29's face sheet printed on 5/14/25, included diagnoses of diabetes, high blood pressure, and history of stroke. R29's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, clear speech, could understand and be understood. No weight loss and no difficulty swallowing. R29 required substantial assistance or was dependent upon staff for activities of daily living. R29's physician orders dated 12/12/23, indicated regular diet. R29 was not on a diuretic (a medication that increases urine output). R29's care plan dated 3/26/25, indicated R29 had an altered nutritional status related to diabetes and history of stroke. A goal for R29 dated 3/15/24, indicated R29 would have stable weights by estimated date of 6/24/25. Intervention dated 12/18/23, indicated to monitor weight and intake. (The frequency was not defined). Intervention dated 3/26/25, indicated R29 was independent with eating after meal set up and staff would encourage and assist. Nursing progress note dated 3/7/25, indicated family member (FM)-A was concerned about R29's eating; stated R29 ate slower and was easily distracted. Dietician progress note dated 3/24/25, indicated: 8# (pound) weight gain in past 6 months. Not significant. Continued regular diet, ate 50-75% for breakfast, and 75-100% of lunch and dinner. No chewing or swallowing difficulties. Cognitive status decreased further this quarter. Will continue to monitor intakes, weights, dehydration and nutrition risk. Continue with care plan. During record review noted potential discrepancies in measured weights. Twenty-two weights were reviewed for six months, from 11/5/24, through 5/6/25. Three incidences appeared potentially inaccurate: 12/17/24: 134# (pounds) 12/31/24: 142# (increase of 8#) 1/7/25: 135 # (decrease of 7#) 2/25/25: 148# 3/4/25: 129# (decrease of 19#) 3/7/25: 130# 3/11/25: 142# (increase of 12#) 3/18/13: 132# (decrease of 10#) During an interview on 5/13/25 at 8:52 a.m., nursing assistant (NA)-A stated residents were weighed on their bath day. While standing in the tub room on first floor, NA-A demonstrated how residents were weighed using the chair in the tub that slid out and onto an [NAME] Mobile Digital Scale. NA-A stated staff pressed the ON/ZERO button which displayed the residents weight. NA-A stated NA's recorded the weight in the electronic medical record (EMR). When entering a new weight, NA-A stated they did not see the previous weight, would need to go to a different part of the EMR. During an interview on 5/13/25 at 3:57 p.m., R29's weights for the past six months were reviewed with the director of nursing (DON). The DON acknowledged they were likely inaccurate. The DON stated she had posted the [NAME] Mobile Digital Scale Operations instructions in the nurses station on first floor for staff reference. The instructions indicated how to operate the scale. The DON provided a copy of the instructions which were page 51 of the operations manual dated November 2017. The DON stated if staff didn't zero out the scale, the reading of the weight could be inaccurate. Further, the DON stated the resident could not have their feet on the foot rests of scale or on the floor - they had to hold them off the floor to get an accurate weight. While the instructions indicated the residents feet could not be on the foot rests, it did not indicate the feet had to be off the floor. The DON stated NA's had not received formal training on the use of the scale and no competency had been conducted to ensure NA's knew how to use it properly. Further, the DON stated there was no auto-alert in the EMR when staff recorded a weight significantly higher or lower than the last recorded weight. The DON stated she would expect licensed nursing staff to be aware of weight fluctuations and to follow-up on them. During an interview on 5/14/25 at 7:31 a.m., licensed practical nurse (LPN)-A stated she was aware NA's had been having problems with the scale. LPN-A stated if she noted significant weight fluctuations, she would ask the NA to re-weigh the resident. LPN-A stated R29 had been having some issues eating - not remembering how to feed herself, and that it took her a long time to eat. LPN-A stated staff had started taking her to the dining room earlier, so she had more time to eat, and staff sat next to her to encourage and/or feed her. LPN-A looked in the EMR and verified the significant weight fluctuations and did not believe them to be accurate. LPN-A stated the EMR did not provide an auto-alert to indicate when a residents weight was significantly different from the previous weight so it could go unnoticed. During an interview on 5/14/25 at 8:12 a.m., NA-C stated she had training on the [NAME] scale when she was hired and knew a residents feet had to be off the foot rests of the scale and off the floor. NA-C stated they did not have to zero out the scale, just turn it on and it was ready to go. NA-C stated NA's entered the weight into the EMR but could not see the previous weight. During an interview on 5/14/25 at 9:02 a.m., NA-D stated she fed R29 breakfast and R29 ate everything. With NA-D and NA-C together, NA-C stated R29 could eat snacks in her room independently that her family brought in but was not able to feed herself with a fork -- she mainly played with her food and stacked cups on her plate. Registered nurse (RN)-A provided copies of orientation checklists for NA-A (dated 8/9/24), NA-B (dated 1/17/25), NA-C (dated 12/23/23). The checklists did not include orientation to the [NAME] mobile digital scale. For NA-D, RN-A provided a competency checklist from 2019-2020 which include how to weigh a resident accurately (balance the scale, feet off the floor). Facility Weight Monitoring policy dated 3/24/23, indicated weight could be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. A weight monitoring schedule would be developed upon admission for all residents. Newly admitted residents - monitor weight weekly for 4 weeks. Residents with weight loss - monitor weight weekly. If clinically indicated - monitor weight daily. All others - monitor weight monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure staff were following manufacturer's guidelines with continuous positive airway pressure (CPAP) machine with daily maintenance and weekly cleaning for 1 of 1 resident (R23) reviewed for respiratory care and treatments. Findings include: R23's face sheet printed 5/14/25, included diagnoses of Parkinson's disease (progressive neurodegenerative disorder that affects movement), and obstructive sleep apnea (breathing repeatedly stops or become significantly reduced during sleep often due to collapse of the upper airway). R23's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R23 had moderate cognitive impairment, and required moderate assist to stand, toileting substantial to maximal assist of 1 and was able to walk 150 feet with touching and standby by assist. Special treatments included CPAP. R23's plan of care dated 3/11/24, did not include a respiratory plan of care or the use of a CPAP machine. R23's physician orders dated 1/24/25, included rinse CPAP mask and hose with gentle soap and water. Hang to dry, weekly on Friday's at noon. An order dated 2/29/24, included CPAP at bedtime. ResMed AirSense manual, undated, included empty the humidifier tub daily and wipe it thoroughly with a clean disposable cloth and allow to dry out of direct sunlight. Weekly included clean the humidifier tub, air tubing and outlet connector in warm water using household dishwashing liquid or wash the humidifier tub and outlet connector in a solution of 1 part vinegar and 9 parts water. Rinse each component thoroughly in water and allow to dry out of direct sunlight or heat. Wipe the exterior of the device with a dry cloth. During an observation and interview on 5/12/25 at 3:52 p.m., R23's [NAME] ResMed CPAP machine was on his bedside table, with the mask and tubing hooked around grab bar on his bed still hooked to the machine. A gallon jug of distilled water was present on bedside table. The water reservoir was 1/4 full of water. R23 stated staff don't ever clean the CPAP machine, face mask, tubing or empty out the water when he removes the CPAP mask in the mornings. R23 stated he has the So Clean machine, (on bedside table) but has never seen staff use it. On observation 5/13/25 at 1:38 p.m., water reservoir of CPAP machine was approximately 1/4 full of water. Tubing and mask was hooked around grab bar on bed. On interview 5/13/25 at 12:59 p.m., nursing assistant (NA)-E stated day shift staff don't do anything with the CPAP machine. That would be the night shift. On interview 5/13/25 at 1:07 p.m., NA-F stated she has never cleaned the mask or tubing for R23's CPAP machine and she has never emptied out the CPAP reservoirs. NA-F stated that is generally the night shift who does that. On interview 5/14/25 at 8:40 a.m., NA-G stated day shift does not do anything with R23's CPAP machine, mask or hose. NA-G stated she is unsure what night shift does. On interview and observation 5/14/25 at 9:11 a.m., R23 stated staff have never cleaned his machine since he has been at facility. R23 stated he has the So Clean machine (device to clean CPAP masks and hoses that kills 99.9% of microorganisms) on his bedside but staff haven't used it since he brought it here. R23 stated he has never seen staff disconnect the tubing and mask and wash it with soap and water. R23 stated staff never empty the water out of the machine and just fill it up when it needs more water. Mask and tubing were hooked onto the grab rail of the bed. On interview and observation 5/14/25 at 9:43 a.m., registered nurse (RN)-C stated she hasn't actually done anything with R23's CPAP machine and added the NA's would empty the water reservoir and clean the mask and tubing per orders. RN-C confirmed there was water in the reservoir and likely wasn't emptied this morning. RN-C stated she is unsure how the So Clean machine works. On interview 5/14/25 at 10:25 a.m., the director of nursing (DON) stated she would expect staff to use the So Clean machine weekly to clean the tubing and mask and added she wasn't aware staff were not using the machine. The DON stated she would expect whoever takes the mask off and turns off the machine would empty the water reservoir after each use. Facility CPAP-BIPAP cleaning policy dated 5/2025 included: - It is the policy of this facility to clean CPAP/BIPAP equipment in accordance with current CDC guidelines and manufacturer recommendations in order to prevent eh occurrence or spread of infection. -CPAP/BIPAP equipment may vary by manufacturer. Common equipment includes the machine, tubing, mask, headgear/straps, disposable/non-disposable filters, and humidifier chamber. -Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections. -Staff shall perform hand hygiene and wear gloves whenever touching the CPAP/BIPAP equipment. -Dust the machine when needed, and wipe clean with a damp cloth and mild detergent. -If humidification is required, distilled or sterile water will be used to fill the humidifier chamber. Empty the chamber completely after each use and wipe dry. -Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. -Weekly cleaning activities (specify day of week): Wash headgear/straps in warm, soapy water and air dry. Wash tubing with warm, soapy water and air dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to identify and document the trauma-related history, post-traumatic stress disorder (PTSD), known triggers and lacked a system or process for completing trauma assessments for 2 of 2 residents (R10 and R23) with a known history of PTSD. Findings include: R23's face sheet printed 5/14/25, included diagnoses of Parkinson's disease (progressive neurodegenerative disorder that affects movement), psychological trauma, dementia, and major depressive disorder. R23's annual Minimum Data Set (MDS) dated [DATE], indicated R23 had moderate cognitive impairment, no behaviors and required moderate assist to stand, toileting substantial to maximal assist of 1 and was able to walk 150 feet with touching and standby by assist. PTSD was not checked as an active diagnosis. Medications included antipsychotic and antidepressant use. R23's plan of care dated 8/6/24, included a potential for mood deficit related to dementia, Parkinson's disease, depression and anxiety. Interventions included keep resident and family updated, encourage participation in activities of interest, support visits for mood and adjustment, mental health provider visits routinely, allow resident to verbalize and express his feelings and frustrations. Medicate with Pristiq (antidepressant), Seroquel (antipsychotic), Remeron (antidepressant), Wellbutrin (antidepressant), Effexor (antidepressant, antianxiety), testosterone injection, olanzapine (antipsychotic) and melatonin (hormone that plays a role in sleep) per MD orders. The plan of care did not include trauma informed care or interventions. R23's document review failed to include a trauma assessment or evaluation of R23's PTSD. On interview 5/13/25 at 12:06 p.m., the director of nursing (DON) confirmed she was aware of R23's history of PTSD. DON confirmed R23's plan of care lacked comprehensive trauma assessment and plan of care for triggers and trauma informed care. On interview 5/13/25 at 12:51 p.m., registered nurse RN-C stated she was not aware of R23's history of trauma. RN-C stated R23 has a lot of anxiety and does not like being at the facility. RN-C not aware of any triggers and confirmed there is no plan of care for PTSD. On interview 5/13/25 at 12:59 p.m., nursing assistant (NE)-E stated she was aware of R23's history of PTSD but was not aware of triggers. NA-E stated she felt R23 had more anxiousness than PTSD and when he is anxious she goes and gets the nurse. On interview, 5/13/25 at 1:07 p.m., NA-F stated she was not aware of R23's history of PTSD but is aware he has a lot of anxiousness. NA-F could not state what triggers R23's PTSD or periods of anxiousness. NA-F stated we try to distract him by taking him outside or to an activity or we go get the nurse. On interview and observation on 5/14/25 at 9:11 a.m., R23 was sitting in his chair in his room watching television. R23 stated he was in the military but doesn't feel he has PTSD. On interview 5/14/25 at 9:54 a.m., the DON stated during conversations, R23 has said he was shot at and people around him were killed when he was in Vietnam. The DON stated on memorial day during the last program at the facility, R23 was emotional and crying. The DON stated R23 likely didn't want to talk about his history when he stated he doesn't have PTSD. R10's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment, required substantial/maximal assistance with personal hygiene, utilized a walker and wheelchair, diagnoses included non-traumatic brain dysfunction, anxiety, depression, and post-traumatic stress disorder (PTSD), and antipsychotics were received on a routine basis. R10's care plan dated 5/10/25, indicated cognition: alteration in thought process r/t (related to) dementia in severe loss range, family kept updated and makes decisions on her behalf, family, provide cues for her to participate with completing ADL (activity of daily living) needs with schedule she is comfortable with and supervision throughout the day to be sure any independent decisions are appropriate, observe for any changes with cognition or level of alertness and report if; activities: alteration in lifestyle r/t dementia in severe loss range, anxiety, chronic disease process, new environment needs assistance to, from and during activities of her preferences, shows signs of increased agitation, wanting to go home having things to do with difficulty in redirection, needs staff assistance to divert energy and attention to validate feelings, staff will encourage and assist to, from and during activities of her preference, in attempts to ward off onset of agitation, provide meaningful 1:1 visits of conversations, attempts at reminiscing, picture books, sensory, validate feelings to resident when she is agitated and attempt to find quiet, calming activities with safe items or materials. R10's document review failed to include a trauma assessment or evaluation of R10's PTSD. On 5/12/25 at 3:43 p.m., during a telephone interview family member (FM)-D stated R10 had a history of PTSD. On 5/12/25 at 6:15 p.m., R10 was observed seated in a wheelchair in the day area and completing a puzzle. On 5/13/25 at 8:07 a.m., R10 was seated in a wheelchair in the day area and was completing a puzzle. On 5/13/25 at 8:51 a.m., NA-G stated she was uncertain if R10 had a history of trauma or PTSD and would need to look in R10's chart. NA-G stated, maybe the nurse would know. NA-G stated education was not provided on R10's PTSD triggers or interventions and stated she utilized interventions for dementia and agitation which included distraction, puzzles, coloring and talking about family. On 5/13/25 at 9:48 a.m., RN-B stated she was verbally informed of R10's PTSD history. RN-B stated the care plan was expected to include R10's PTSD and confirmed R10's care plan did not include or identify PTSD triggers or interventions. RN-B stated she was not aware of trauma assessments completed for residents at the facility. On 5/13/25 at 10:26 a.m., NA-H stated she was aware R10 had a history of PTSD, but was unsure of specific triggers and stated she would expect the triggers indicated on the care plan. NA-H stated she used the care plan located in the paper chart. NA-H was observed and looked at R10's paper chart and confirmed R10's record did not identify PTSD triggers or interventions. NA-H stated she was uncertain where to find R10's PTSD related information. On 5/13/25 at 12:06 p.m., during an interview with the DON and social services (SS)-A, the DON confirmed awareness of the R10's PTSD and stated a trauma assessment was not done as expected. The DON and SS-A stated a trauma assessment was important to identify triggers and interventions and include that information on the care plan. The DON and SS-A confirmed there was no current process in place to for identifying or addressing trauma related needs including trauma related triggers and interventions. Facility Trauma Informed Care policy dated 8/24 included: - The facility will use a multi-disciplinary approach to identifying a resident ' s history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others. - St [NAME] ' s will collaborate with resident trauma survivors, and as appropriate, the resident ' s family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. - In some cases, if the facility has more than one trauma survivor, social services will make a good faith effort at establishing a support group that is run by a qualified professional, or allow a support group to meet in the facility. If a group cannot be run/meet at facility, social services will assist the resident in locating a support group in the community as appropriate and feasible. -The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident ' s exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident ' s care plan. While most triggers are highly individualized, some common triggers may include, but are not limited to: a. Experiencing a lack of privacy or confinement in a crowded or small space. b. Exposure to loud noises, or bright/flashing lights. c. Certain sights, such as objects that are associated with their abuser. d. Sounds, smells, and physical touch. -Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. -The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understand if interventions must be modified. - In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 5/13/25 at 1:11 p.m., on first floor, NA-A stated staff carried soiled laundry, including resident clothing, bed linens and towels, from resident rooms by hand, down the hallway to a hamper in the tub room if it was soiled resident clothing, or the utility room if it was soiled bed linens or towels. NA-A stated she would do this even if there were a small amount of BM (bowel movement) on the laundry. NA-A stated staff did not place soiled laundry in bags first before carrying it to the hampers. NA-A stated she was careful not to let soiled laundry touch her uniform. Further, NA-A stated she had done that as long as she had worked at the facility. Review of NA-A's orientation checklist dated 8/9/24, did not include instruction on transporting soiled laundry. During an interview on 5/13/25 at 1:29 p.m., on second floor, NA-F stated soiled laundry was carried by hand to either the utility room or tub room, such as resident clothing, towels, washcloths and bed linen. NA-F stated soiled laundry was not placed in a bag first before carrying it to the hampers. NA-F stated if something was heavily soiled and if there were extra bags in the residents wastebasket, she would place the soiled items in the bag. NA-F stated she was careful not to let the soiled items touch her uniform. During an interview on 5/13/25 at 2:45 p.m., registered nurse (RN)-A, who was also the infection preventionist, stated staff were to transport soiled laundry from resident rooms to the utility room or tub room hampers in a bag and away from their uniform. RN-A was informed of observation and interviews. During an interview on 5/14/25 at 12:29 p.m., the director of nursing (DON) was informed of observation and interviews regarding nursing staff carrying soiled laundry by hand, from resident rooms to the tub room or utility room to place in hampers. The DON stated staff could take the hampers to the resident rooms instead of carrying the laundry to the hampers. The DON acknowledged that still had the potential for staff to carry soiled items a distance. The DON stated if they (staff) did not do that, she would expect them to place soiled laundry in bags to carry to the hampers. The DON could not recall if nursing staff had received training on the expected way to transfer soiled laundry. Facility Infection Prevention and Control Program policy dated 2/2025, indicated the facility had established and maintained 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 as per accepted national standards and guidelines. Direct care staff would handle, store, process, and transport linens to prevent spread of infection. Soiled linen would be collected at the bedside and placed in a linen bag. When the task was complete, the bag would be closed securely and placed in the soiled utility room. Based on observation, and interview the facility failed to ensure proper infection prevention practices was observed when transporting soiled linen when staff were observed to transport soiled linen unbagged and ungloved throughout the River Haven unit hallway. This had the potential to impact all 11 residents residing in the unit. Finding include: R35's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, required substantial/maximal assistance with personal hygiene, lower body dressing, and toileting hygiene and diagnoses included non-traumatic brain dysfunction and non-Alzheimer's dementia. R35's care plan dated 5/14/25, indicated ADL's (activity of daily living: alteration in self care r/t (related to) dementia, Parkinson's, poor balance, falls, weak with exertion, chronic disease process, arthritic changes substantial max to partial moderate assist with personal hygiene partial to moderate assist with dressing upper extremities and substantial max to dependent with lower extremities and footwear. On 5/13/25 8:15 a.m., nursing assistant (NA)-G exited R35's room and was observed carrying linen in her bare hands without placing the linen in a bag and without wearing gloves. NA-G proceeded through the hallway ungloved while carrying the unbagged linen and entered the tub room. In the tub room NA-G unwrapped the linen with her bare hands, revealing a brief mixed with the linens. NA-G separated the brief from the linen using her bare hands and placed the linen into the soiled linen hamper and the brief into a trash receptacle. NA-G stated she was not sure if the linen needed to be bagged when carried throughout the hallways and confirmed she did not wear gloves in the hallway while carrying the soiled linen. NA-G stated gloves were not allowed worn in the hallways. NA-G stated that the brief had been worn by the resident but was not visibly soiled with urine or feces and acknowledged the clothing was also worn. NA-G was observed washing her hands with soap and water for 21 seconds.

Based on observation, interview, and document review the facility failed to ensure the kitchen ceiling tiles were kept in a clean and sanitary manner and free of dust and debris. This had the potential to affect all 46 residents residing in the facility. Findings include: On 5/13/25 at 9:08 a.m., two ceiling tiles located approximately six feet from the steam table were observed with gray, fuzzy material hanging from them. Directly beneath these ceiling tiles were two metal meal carts. At the time of observation, cook (C)-A was interviewed and confirmed the presence of the gray fuzzy material on the ceiling tiles, acknowledging the condition was unclean and unacceptable. C-A stated that kitchen staff were responsible for cleaning the ceiling tiles and further confirmed that plated food trays were placed on the metal carts located under the affected ceiling area before being delivered to residents. On 5/13/25 at 10:45 a.m., dietary aide (DA)-A was observed placing plated food onto meal trays located on metal carts situated directly beneath the ceiling tiles with visible gray material. On 5/13/25 at 11:09 a.m., maintenance director (MD)-A stated the kitchen staff were responsible to clean the kitchen ceiling tiles. On 5/13/25 at 12:17 p.m., the dietary director (DD)-C confirmed that the ceiling tiles were not included on the routine cleaning checklist. DD-C stated ceiling tiles above food preparation and tray assembly areas were expected to be clean and free of debris and would expect maintenance to clean the tiles when dirty. DD-C provided the kitchen cleaning schedule, which did not include ceiling tile cleaning. On 5/14/25 at 10:15 a.m., the administrator stated that kitchen ceiling tiles were expected to remain clean and free from debris. The administrator further stated that when debris is observed, both kitchen staff and maintenance are expected to coordinate to ensure cleanliness of the ceiling tiles Facility Cleaning and Sanitation of Dining and Food Service Area policy dated 2017, indicated: The nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The director of food and nutrition services will determine all cleaning and sanitation task needed for the departments. Staff will be trained on frequency of cleaning as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure basic infection control measures were followed when 1 of 1 resident (R41's) urinary drainage bag was observed resting on the floor. Findings include: R41's diagnosis list printed on 4/17/24, included history of pulmonary emboli (when arteries are blocked by a blood clot). R41's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and dependency upon staff for most activities of daily living. R41's physician orders dated 9/8/23, indicated indwelling urinary catheter. R41's care plan dated 9/15/23, indicated Foley (describes the type of catheter) catheter management per MD (medical doctor) orders and facility protocol. During an observation on 4/15/24 at 1:39 p.m., observed R41's urinary drainage bag hooked to the side pocket of his cloth recliner, resulting in the bottom of the bag, including the urinary drainage valve, to rest on the floor. During an observation on 4/16/24 at 8:18 a.m., R41 was in his recliner eating breakfast. Observed R41's urinary drainage bag hooked to the side pocket of his recliner, resulting in the bottom of the bag, including the urinary drainage valve, to rest on the floor. During an interview and observation on 4/16/24 at 9:05 p.m., together with licensed practical nurse (LPN)-A looked at the location of R41's urinary drainage bag. LPN-A stated the bag was supposed to be kept off the floor to prevent the possibility of a urinary tract infection (UTI). LPN-A asked nursing assistant (NA)-A to obtain a pouch in which to put R41's bag. During an interview and observation on 4/16/24 at 9:07 a.m., together with NA-A, looked at the location of R41's urinary drainage bag. NA-A stated that was not where she would hang R41's bag and acknowledged the bag should not rest on the floor due to the possibility of bacteria entering the bag. NA-A placed the urinary drainage bag in a cloth pouch and set the pouch in the side pocket of the recliner. During an interview on 4/16/24 at 12:30 p.m., registered nurse (RN)-A who was also the infection preventionist, stated staff were trained to keep a urinary drainage bag off the floor and acknowledged the potential for bacterial growth if the bag was on the floor. During an interview on 4/17/24 at 11:24 a.m., the director of nursing (DON) was informed of observations of R41's urinary drainage bag resting on the floor. The DON stated she would expect staff to position the bag so that it would not rest on the floor or to place it in a cloth pouch or a plastic basin. The facility Catheter Care - Urinary policy dated 5/24/22, indicated the purpose of the procedure was to prevent catheter-associated urinary tract infection. The policy did not address how staff should position the urinary drainage bag when the resident was in bed, in a chair, or a wheelchair.

Based on observation, 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 49 residents who resided in the facility. Findings include: During an observation on 4/16/24 at 10:39 a.m., noted a Manitowoc brand, counter-top style ice machine in the first floor resident ice machine. During an interview on 4/15/24 at 11:35 a.m., dietary supervisor (DS)-B stated dietary staff wiped down the outside of the ice machine located in the first-floor dining room but did not clean the inside. During an interview on 4/17/24 at 11:17 a.m., dietary aide (DA)-A stated she cleaned the ice machine using hot water and a long narrow brush to clean a long, narrow PVC pipe laying horizontal alongside the bottom of the ice machine. DA-A stated dietary staff did not clean the inside of the ice machine; didn't empty out the ice or do anything else to it. DA-A verified the ice machine was used for resident consumption. Reviewed Manitowoc ice machine Use & Care Manual, received from plant operations director (POD)-A. The manual identified three separate cleaning procedures: 1) Preventative Maintenance Cleaning Procedure - recommended monthly; 2) Cleaning/Sanitizing, recommended a minimum of once every six months; 3) Heavily Scaled Cleaning Procedure if the ice machine had certain symptoms. During an interview on 4/17/24 at 11:40 a.m., POD-A stated plant operations staff did not clean the ice machine; dietary staff took care of that. POD-A was informed dietary staff was not cleaning the ice machine according to manufacture instructions in order to prevent the growth of bacteria. POD-A acknowledged no one in the facility was cleaning the ice machine according to manufacture instructions. Manufacturer's instructions for Manitowoc RNS12 & RNS20 Model Nugget Ice Machines Installation, Use & Care Manual, dated 10/13. Cleaning and Sanitizing - the facility is responsible for maintaining the ice machine in accordance with the instructions in this manual. Clean and sanitize the ice machine every six months for efficient operation. The Manitowoc Ice Machine has three separate cleaning procedures: 1. Preventative Maintenance Cleaning Procedure. Perform this procedure as required for water conditions. Recommended monthly. Allows cleaning the ice machine without removing all the ice from the bin. Removes mineral deposits from areas or surfaces that are in direct contact with water during the freeze cycle (reservoir, evaporator, auger, drain lines). 2. Cleaning/Sanitizing Procedure. This procedure must be performed a minimum of once every six months. All ice must be removed from the bin. The ice machine and bin must be disassembled, cleaned, and sanitized. The ice machine produces ice with the cleaner and sanitizer solutions. All ice produced during the cleaning and sanitizing procedures must be discarded. 3. Heavily Scaled Cleaning Procedure. Perform this procedure if have some or all these symptoms: Grinding, popping or squealing noises from the evaporator. Grinding noise from gearbox. Ice machine stops on Safety Shutdown. Your water has a high concentration of minerals. The ice machine has not been on a regular maintenance schedule. Run a cleaning procedure as described above after this procedure is complete. NOTE: A Sanitizing Procedure must be performed after all cleaning procedures have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, observation and document review, the facility failed to document and monitor weight status for 1 of 1 resident (R28) who has a history of edema and fluid retention. Findings include: R28's face sheet printed on 3/8/23, included diagnoses of chronic obstructive pulmonary disease (progressive lung disease with airflow limitations and variable respiratory symptoms), aortic valve stenosis (narrowing of heart valve that separates the pumping chamber of the heart to the rest of the body), and hypertensive heart failure (high blood pressure causing thickening of the heart muscle). R28's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R28 had moderate cognitive impairment, no weight loss or gain, uses oxygen therapy and takes a diuretic daily. R28 required extensive assist of 1 to 2 persons for activities of daily living. R28's care plan dated 8/11/22, indicated R28 had a potential for alteration in tissue perfusion related to heart failure, aortic stenosis, diabetes, and respiratory failure. Interventions included observe for changes in edema, weigh 2 times weekly and give medications including Lasix (diuretic) per physician orders. R28's physician orders dated 1/17/22, indicated R28's weight was to be obtained twice a week on Tuesday and Friday and to contact primary care provider for 2 pound increase in 2 days or 5 pound increase in a week. During observation on 3/7/23, at 12:39 p.m. R28 was sitting in recliner with legs elevated with elastic stockings on. R28 had minimal to no edema present on lower extremities. R28 had loose sounding cough. Review of R28's weights from 9/1/22 through 3/3/23 included opportunities for 70 weights with 19 not completed. Gaps in weights included: 9/19/22 to 9/26/22, one missed 9/26/22 to 10/3/22, one missed 10/3/22 to 10/19/22, four missed 10/25/22 to 11/4/22, two missed 11/11/22 to 11/18/22, one missed 11/22/22 to 12/2/22, two missed 12/16/22 to 12/23/22, one missed 12/23/22 to 12/30/22, one missed 12/30/22 to 1/6/23, one missed 1/20/23 to 1/27/23, one missed 2/10/23 to 2/17/23, one missed 2/17/23 to 3/3/23, three missed During interview on 3/8/23, at 1:36 p.m. nursing assistant (NA)-B indicated R28 is weighed on Tuesdays and Fridays. NA's report the weight to the nurse who documents it. NA-B provided an aide sheet that included weights to be completed on Tuesday and Friday. During interview on 3/8/23, at 1:50 p.m., registered nurse (RN)-A reviewed plan of care and indicated R28 is to be weighed Tuesday and Fridays. During interview on 3/08/23, at 1:53 p.m., the director of nursing (DON) evaluated weights and confirmed there were multiple missing weights. During interview on 3/8/23 at 2:15 p.m., the DON was able to locate 2 weights after 2/17/23 and added the unit was having difficulty with the scale around 2/24/23. Facility policy and procedure dated 10/28/22, for weight monitoring included: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates this is not possible or resident preferences indicate otherwise -weights should be recorded at the time obtained if clinically indicated, monitor weight daily or as directed by medical provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure 1 of 2 residents (R24) received assistance with hand splints to prevent worsening of range of motion. Findings include: R24's Diagnosis Report printed 3/8/23, included diagnosis of hemiplegia and hemiparesis (total or nearly complete paralysis on one side of the body), speech and language deficits, and Alzheimer's disease. R24's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R24 had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. The MDS further identified R24 required extensive to total assistance for activities of daily living (ADL's) and had no rejection of cares. Functional limitation in range of motion (ROM) of upper (shoulder, elbow, wrist, and hand) showed R24 had impairment on one side and and lower extremities (hip, knee, ankle, and foot) with impairment on both sides. R24's care plan dated 10/24/19, included R24 required total assist with ADL's and had an alteration in mobility. Interventions included passive range of motion to right upper extremity. R24 was last evaluated by occupational therapy on 5/3/22 for wheelchair positioning deficits related to sliding out of her chair. R24 was previously evaluated and treated 12/2/20 through 2/6/21 for joint mobility for range of motion deficits to right upper extremity (RUE). Goal included patient will trial various splints to determine most appropriate for day or night use to prevent further spasticity and contracture in RUE. Discharge plans and instructions included apply splint at appropriate times and if patient flings off no need to put it back on. During observation and interview on 3/6/23, at 4:23 p.m. R24 was lying in bed. Right arm was lying by her side and right thumb was tucked under her fingers which were curled in towards the palm of her hand. A family member (FM)-A indicated he doesn't believe R24 has ever had a splint for her right hand. During observation on 3/7/23, at 8:10 a.m. R24 was sitting in her Broda chair (positioning wheelchair) in dining room. No splint was present on her right hand and right fingers curled in towards palm. During observation and interview on 3/7/23, at 12:28 p.m. nursing assistant (NA)-A was assisting R24 with lunch. R24's right arm was on the armrest of the chair. R24 would move her arm which flopped down towards the side of the wheelchair. R24 did not move her right hand and no splint was present. NA-A indicated R24 frequently will move her right arm so it falls off the arm of the chair but has not seen her move her right hand or fingers at all. NA-A asked R24 to move her fingers with no movement noted. R24's thumb was tucked into her palm with fingers curled over the thumb but not touching the palm. NA-A indicated R24 does not have a splint for her right hand. During observation on 3/8/23, at 7:20 a.m., R24 was asleep in bed. No hand splint was present on right hand. During interview on 3/8/23, at 9:35 a.m., NA-B indicated it has been a few years since R24 last wore a splint. NA-B added they do range of motion (ROM) twice a day and are able to move her fingers, but R24 says owie the whole time. R24's right hand is paralyzed but she can move her right arm. During interview on 3/8/23, at 8:21 a.m., registered nurse (RN)-A indicated R24 does not have a hand splint. During observation on 3/8/23, at 1:27 p.m., R24 was asleep in bed with no hand splint on right hand. During interview on 3/8/23, at 8:28 a.m. occupational therapist (OT)-A indicated the last occupational therapy evaluation for R24 was for positioning in wheelchair and nothing was mentioned about her right hand. The last time R24 was seen for her right hand was February 2021 for hand splint use. OT-A indicated therapy should be notified if staff are going to stop using a hand splint so other options can be evaluated. Staff should not just discontinue use of a splint. During interview on 3/8/23, at 2:08 p.m., the director of nursing (DON) indicated she evaluated R24 and she was able to open her right hand without R24 saying ouch. After looking through R24's electronic medical record (EMR), the DON indicated the last notes she could locate were from January 2021 and R24 was to wear the splint at night but the resident would remove the right hand splint herself. The DON added she doesn't know what happened with the splint and would look for it in R24's room. A progress note dated 1/26/21, at 5:56 a.m. included staff reported that R24 had hand splint on approximately 2 hours, then removed it herself. A progress note dated 1/26/21, at 2:40 p.m. indicated R24 takes splint off a short time after putting it on. A progress note dated 1/31/21, at 5:07 a.m. included overnight staff reported R24 removed hand splint shortly after putting it on. Facility policy and procedure titled Functional Maintenance Policy, undated, included implement of a functional maintenance program may occur following a course of physical, occupational or speech therapy. In these cases, the therapist will provide resident specific training to the appropriate staff members, assist nursing in establishing initial goals and suggest interventions and approaches. The interdisciplinary team will determine when to discontinue the functional maintenance program and develop the follow-up interventions to be provided by general nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to prepare food in accordance with resident needs for 1 of 2 residents (R28) who was identified as on a mechanically altered (cut up meats) diet. Findings include: R28's face sheet printed 3/8/23, included diagnosis of dysphagia (difficulty in swallowing food or liquid), pneumonia and diabetes mellitus. R28's signed physician orders dated 10/19/2022, indicated a diabetic diet, and cut meat into bite size pieces. R28's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R28 understands and is understood, has moderate cognitive impairment, requires supervision with eating, able to feed self and has no swallowing difficulties. R28's plan of care dated 2/5/23, included an alternation in nutritional status related to diabetes and history of cerebral infarction with right sided weakness and dysphagia. R28 requires adaptive eating utensils and staff to cut meat. Interventions included eats meals at nurses station, R28 to feed himself after meal is setup by staff and meat is cut up and resident will follow guidelines set up by speech therapy on 2/11/22. Black handled weighted silverware to aid with self feeding. A speech therapy discharge note dated 2/11/22, indicated R28 was discharged to continue with current diet, and cut up solids. Patient should continue to utilize cue card to help with recall and use of taught safe swallow strategies. During interview and observation on 3/6/23, at 3:22 p.m. R28 was sitting in his recliner in his room. A sign on the wall next to the recliner stated Safe Swallow Strategies which included small single sips of liquid, eat slow, cut up solids into small bites, alternate between food and liquid and was dated 1/21/22 from speech therapy. R28 indicated no one ever cuts up his food and denied any issues with chewing or swallowing. During observation on 3/7/23, at 12:09 p.m. R28 was eating lunch in the dining room. R28 had beef tips with gravy and mashed potatoes. Beef tips were not cut into bite size pieces. R28 ate without any choking incidents. There was no cue card present. During observation on 3/8/23, at 7:50 a.m. R28 was in the dining room with a round sausage whole patty and boiled egg on his plate. Neither were cut into bite size pieces. There was no cue card present on the table. During observation on 3/8/23, at 11:20 a.m. dietary aide (DA)-A was preparing meals for delivery to the residents on floor 2. DA-A placed a hamburger on a bun and potato wedges on R28's plate. Review of meal sheet indicated R28 was on diabetic diet with 1/2 dessert portions. During observation on 3/8/23, at 12:10 p.m. R28 was on floor 2 in dining area with a hamburger on a bun and potato wedges present. Food was not cut into bite size pieces. R28 ate 1/3 of his hamburger and 1/2 of potato wedges. There was no cue card present at R28's table. During interview on 3/8/23 at 12:15 p.m. nursing assistant (NA)-C indicated normally the kitchen cuts up R28's food. When questioned why R28's hamburger wasn't cut into bite size pieces, NA-C indicated R28 can eat sandwiches without being cut up, but meats like turkey need to be cut up. During interview on 12/8/23, at 12:18 p.m. registered nurse (RN)-A indicated R28 has a tendency to chew his food too fast and had been seen by speech therapy who told him to slow down when eating. RN-A indicated staff will ask R28 if he wants his food cut up or not. During interview on 3/8/23, at 12:20 p.m. R28 stated everything is supposed to be cut up but they never do it. R28 denied choking on his food. R28 further stated no one asks him if he wants his food cut up or not. During interview on 3/8/23 at 12:30 p.m. cook (C)-A indicated R28 is on a carbohydrate consistent, regular texture thin liquids diet with 1/2 portion of dessert. There was no mention of meat being cut up on the diet order the kitchen had but will discuss it with the registered dietician (RD). During interview on 3/8/23 at 1:27 p.m. RD indicated the kitchen did not receive notification to the change in diet order. Requested to see sign/recommendations speech therapy (ST) posted in R28's room, which she then reviewed. After reviewing sign and ST notes, the RD indicated somehow communication did not occur between ST, nursing and the kitchen. The RD added per current standards a Dysphagia easy to chew, level 7 diet would be appropriate which includes moistened tender meats, thin-sliced deli meats (cut up or chopped). During interview and observation on 3/8/23 at 1:35 p.m. NA-B approached the RD and indicated she found R28's swallowing strategies card on another table and will tape it to R28's table so it doesn't get moved again. During interview on 3/8/23 at 2:40 p.m. the director of nursing (DON) confirmed the diet order was missed. Facility policy and procedure titled Standard Diets dated 3/2018, included diet order terminology will be used to assure consistency and accuracy in providing the diets per physician order. Clarification will be requested by the dietician or charge nurse to the physician on diet orders noted in the standard terminology.