**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and facility policy review the facility failed to document a summary of the resident's repeated grievances regarding showers and any corrective actions and follow-up for the grievances for one (1) of 14 sampled residents. Resident #39. Findings include: Review of the facility policy titled, Resident and Family Grievances, with a review date of 2/3/2023 revealed, Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. D .The Grievance official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. An interview on 5/28/24 at 10:35 AM, Resident #39 revealed he is supposed to get his showers on Tuesday, Thursday, and Saturday but is lucky if he gets a shower two times a week. He revealed, I didn't get one this past Saturday and usually don't get them if Certified Nurse Aide (CNA) #3 is not here. CNA#3 is the shower aide but misses a lot because of her sick child. I've been telling the Social Services Director/Grievance Officer and Registered Nurse (RN) #2 but nobody has come to discuss this with me. I complain about it all the time to everyone, they know it's a problem. An interview on 5/29/24 at 12:45 PM, Resident #39 revealed, that he has talked with the Administrator (ADM) and the Social Worker/Grievance Officer multiple times about not getting his showers as scheduled. During an interview on 5/29/24 at 2:10 PM, RN #1 revealed she developed a sign-off sheet for showers and confirmed through review of the documented sign-off sheets that Resident #39 did not always get his three showers a week. During an interview on 5/29/24 at 3:15 PM, CNA #1 and CNA #2 both confirmed Resident #39 had complained about not getting his showers in the past. CNA #1 and CNA #2 confirmed if Resident #39 told you he didn't get a shower Saturday or was only getting showers two times a week then he was being truthful with you and stated, He shoots it straight. In an interview on 5/29/24 at 3:20 PM, the Social Services Director revealed she is also the Grievance Officer and revealed Resident #39 has voiced not getting showers many times. She confirmed that she did not fill out a formal grievance form and therefore it was not followed up on and validated therefore was no resolution to his grievance. During an interview on 5/29/24 at 3:30 PM, RN #2 stated, I don't think there's a soul in this building that Resident #39 hasn't told about not getting his showers. An interview on 5/29/24 at 4:05 PM, the Director of Nurses (DON) revealed she was unaware that Resident #39 was making specific complaints about his showers and confirmed if he was specifically complaining to staff about his lack of showers then he should have had a grievance filled out so his concerns could have been appropriately addressed and followed up on. During an interview on 5/29/24 at 4:25 PM, the Administrator revealed she was aware of the bathing concerns with Resident #39 and confirmed that it was not properly addressed through the grievance process and that there was no resolution or follow-up done for the complaint for Resident #39. Record review of the Face Sheet revealed Resident #39 was admitted to the facility on [DATE] with diagnoses that included Encephalopathy, Disorder of the skin and subcutaneous tissue, and Dementia. Record Review of Resident #39's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/21/24 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interviews, and facility policy review the facility failed to protect a resident's right to privacy in her room for one (1) of 54 residents reviewed for resident rights. Resident #39 Findings include: Review of the facility policy titled, Resident Rights, with a copyright date of 2018, revealed 1. Resident rights. The resident has the right to a dignified existence . 9. Safe environment. The resident has a right to a safe, clean, comfortable and Homelike environment, including but not limited to receiving treatment and support for daily living safely. An interview on 4/18/23 at 4:00 PM, with Resident #39, during the Resident Council Meeting, revealed Resident #36 had wandered into her room and she did not want uninvited men in her room. She revealed it makes her very uncomfortable for him to be in her room, she feels he was intruding in her private space. She revealed the staff would hear her tell him to get out and would come to convince him to leave. She shared that she would not want to be on the toilet or getting out of her clothes, and he was to come in her room. She revealed that she wanted the staff to assure her that she had the right to her private space, and that she would be comfortable and safe by not having to always watch for him to keep him out of her room. An interview on 4/19/23 at 1:10 PM, with the Registered Nurse (RN) Supervisor confirmed that Resident #36 exhibited wandering behaviors and had wandered in and out of other residents' rooms. She noted that she could not confirm or deny that the male resident had wandered into Resident #39's room before. An interview on 4/19/23 at 1:30 PM, with the Administrator, revealed she had a conversation with Resident #39 some time ago about Resident #36 when he entered her room, and that Resident #39 wanted the Administrator to tell her she would stop Resident #36 from coming in her room. She noted that she informed Resident #39 that she would do all that she could to keep Resident #36 out of her room but could not promise that he would not enter her room again. She confirmed Resident #39 had the right to privacy, that her right to privacy had been violated. An interview on 4/19/23 at 1:45 PM, with Social Services, confirmed Resident #39's complaint that Resident #36 unwantedly entered her room. She revealed that she did not think Resident #39's rights had been violated because Resident #39 did not present the complaint to her in that manner, that it was not a major occurrence with Resident #36 going into her room, and that she informed Resident #39 that Resident #36's mind does not function like hers anymore and he was not aware of what he was doing. An interview on 4/19/23 at 2:34 PM, with Licensed Practical Nurse, (LPN) #2, confirmed that Resident #36 did exhibit wandering behaviors and had been wandering in and out of different residents' rooms. An interview on 4/19/23 at 4:40 PM, with the Director of Nursing (DON), confirmed Resident #36 did wander in and out of other residents' rooms and that there had been residents that did not like him coming into their rooms. Record review of the Face Sheet for Resident #39 revealed an admission date of 12/03/21 and a diagnosis of Adjustment disorder with Mixed Anxiety and Depressed Mood. Record review of the Patient Progress Note, from Resident #36's physician dated 2/10/23, revealed . [AGE] year-old out and about in the facility in his wheelchair . he's been a little agitated, going in and out of folks room but so far, he's been redirected. Impression: . 2. Dementia. Record review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 2/14/23, for Resident #39, revealed an interview dated 2/13/23 with a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #39 is cognitively intact.

Based on resident interview, staff interviews, record review, and facility policy review, the facility failed to record, initiate, and resolve a grievance for a resident, for one (1) of five (5) residents reviewed for grievances in Resident Council. Resident #39 Findings include: Review of the facility policy titled, Resident and Family Grievances, with the date implemented of March 1, 2019, revealed . Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance . 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. d. Verbal complaint during resident or family council meetings. 10. Procedure: . b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance from or assist the resident or family member to complete the form; . 11. Take any immediate actions needed to prevent further potential violations of any resident right . d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. 12. The facility will make prompt efforts to resolve grievances. During a Resident Council Meeting, on 4/18/23 at 4:00 PM, an interview with Resident #39 revealed that Resident #36 had wandered into her room. She did not want uninvited men in her room. It made her very uncomfortable for him to be in her room and she felt he was intruding in her private space. The staff would hear her tell him to get out, because they would come to her room to convince him to leave. She confirmed that she had spoken to the Administrator and the Social Worker about it, and nothing had been done. She revealed she knew nothing about a grievance being written up for this complaint and no one had come back to her to talk about it. On 4/19/23 at 1:30 PM, during an interview with the Administrator, confirmed that she had a conversation with Resident #39 some time ago about Resident #36 entering her room, and that she did not want an uninvited man coming in her room, and that Resident #39 wanted the Administrator to tell her she would stop Resident #36 from coming in her room. She noted that she had informed Resident #39 that she would do all that she could to keep Resident #36 out of her room but could not promise that he would not enter her room again. She also noted she did not document the conversation she had with Resident #39 and that a formal grievance had not been initiated and resolved for Resident #39's complaint. She confirmed that a formal grievance should have been filed, initiated, and resolved for Resident #39's grievance. The Administrator did confirm that Resident #36 had been confirmed to wander in and out of other residents' rooms. An interview on 4/19/23 at 1:45 PM with Social Services confirmed there was no formal grievance filed for Resident #39's complaint that Resident #36 unwantedly entered her room. Social Services also confirmed that Resident #36 did wander in and out of other resident's rooms. She noted that Resident #39 did not present the complaint to her in the manner of being bothered by Resident #36 entering her room, so she did not think Resident #39's complaint should have been written up as a grievance. She also noted Resident #39's complaint was not a major occurrence with Resident #36 going into her room. Social Services shared that she informed Resident #39 that Resident #36's mind did not function like hers anymore, and he was not aware of what he was doing. Record review of the Grievance Log revealed there was no grievance form initiated or resolved for Resident #39's complaint of the resident wandering into her room. Record review of the Face Sheet for Resident #39 revealed an admission date of 12/03/21 and a diagnosis of adjustment disorder with Mixed Anxiety and Depressed Mood. Record review of the Quarterly Minimum Data Set (MDS) Assessment, with and Assessment Reference Date (ARD) of 2/14/23, for Resident #39, revealed an interview dated 2/13/23 with a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #39 is cognitively intact.

Based on observation, resident interview, staff interview, record review and facility policy review the facility failed to ensure a resident was free of the use of a restraint as evidenced by use of a body alarm that restricted the movements of a resident who could turn and position themselves and they could not easily remove the device for one (1) of 54 residents reviewed. Resident #43 Findings include: A review of the facility's policy titled SUBJECT: RESTRAINT POLICY, revealed, POLICY: As per OBRA (Omnibus Budget Reconciliation Act) requirements all residents have the right to be unrestrained. Restraints should be used only as a last alternative and only when other less restrictive measures have been tried and rejected. DEFINITION: Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body .PROCEDURE: 2.) All residents using a restraint are to be evaluated and re-evaluated approximately every quarter . A review of the facility's policy titled SUBJECT: PHYSICIAN'S ORDER FOR A PHYSICAL RESTRAINT DEVICE, revealed, POLICY: All residents requiring a physical restraint must have a Physician's Order . An interview with CNA #4 on 4/17/23 at 11:00 AM, revealed she provides care to Resident #43 at times and confirmed she would fuss when we had to put the alarms on, but we didn't want her to fall. An observation and interview on 4/17/23 at 1:43 PM, Resident #43 was asked why she had a body alarm clipped to the back of her blouse, she revealed the staff put it on her because she has had a couple of falls when she came in, but she is in therapy and stronger now. She stated, I hate the alarm and I feel insulted having to wear it, I can't even bend down to pick something up if I need to without it going off and when I'm in bed I hate to even turn over because the alarm scares me and wakes up the whole hall. She also revealed the staff had showed her how to put the alarm back together so it would stop alarming when she moves to much in the bed and stated, That's kind of hard to do when its dark or you can't reach it on the back of the chair, and confirmed she had told the staff over and over she wanted it off. Record review of the April 2023 Physician Orders revealed no order for a body alarm. An interview on 04/18/23 at 10:00 AM, with Certified Nurse Aide (CNA) #1, revealed Resident #43 was to wear the chair alarm all the time while up in the wheelchair to deter her from wanting to stand up and risk falling. She noted that each time she had been assigned Resident #43, she had placed the alarm on Resident #43 when she helped her get in the wheelchair. CNA #1 shared that she was told by the nurses the chair alarm had to be clamped onto Resident #43, because she had fallen not long after being admitted to the nursing facility. She stated that Resident #43 was out of her head when she admitted and was not safe to stand up but has not fallen again in a long time. She also confirmed that there was an alarm the CNAs were to place on Resident #43 when she was in the bed to deter her from getting up and risk falling at night. She admitted she had not asked Resident #43 if she agreed with wearing the chair alarm or if it bothered her to do so. An interview with the Director of Nurse (DON) and the Registered Nurse (RN) Supervisor on 4/18/23 at 1:15 PM, both nurses confirmed that Resident #43 had a body alarm on at all times because the resident's granddaughter insisted she have one after a fall on 3/31/23 and related to confusion on admission, not always using the call light, and she would get up unassisted at night but both nurses confirmed that she is much better now. The DON and RN Supervisor stated that the body alarm would be considered a restraint because it does restrict Resident # 43's movement in the chair and the bed. The RN supervisor confirmed Resident # 43 can turn and reposition herself in the bed and chair and confirmed that there was no physician's order for the body alarm, nor had there been a restraint assessment or consent completed. The DON confirmed that the use of a device restricting movement could cause withdrawal from activities or socialization and cause a decrease in the resident assisting herself. An interview with the Social Services on 4/18/23 at 2:18 PM, revealed that a restraint restricting a resident's movement could cause anxiety, decrease the desire to do things for themselves and they may isolate themselves to their room. An interview with the DON on 4/19/23 at 1:59 PM, she revealed Resident # 43 sometimes transfers with handheld assistance and other times may need extensive assistance for transfers. An interview with the Physical Therapist (PT) on 4/19/23 at 2:47 PM, revealed Resident # 43 can walk 150 feet with a rolling walker and that she required a lot of cueing related to left side impairment. PT stated she is riding the new step bike to strengthen her motor control and is extensive assist of one for transfers. An interview with the Speech Therapist (ST) on 4/19/23 at 2:49 PM, revealed Resident # 43 is alert and oriented at this time, and confirmed she was alert and oriented at the time of admission. Record review of the Face Sheet revealed that the facility admitted Resident # 43 to the facility on 2/07/23 with diagnoses of Hemiplegia following cerebral infarction affecting left side, Pulmonary Embolism without acute core pulmonale, Dizziness and giddiness, and Unspecified abnormality of gait. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on 2/11/23, revealed that Resident # 43 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated that she was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #43 During an interview and observation with Resident #43 on 4/17/23 at 1:43 PM, the State Agency (SA) asked the resident why she had a body alarm clipped to the back of her blouse. She revealed the staff put it on her because she had a couple of falls when she came into the facility. An interview on 4/18/23 at 10:00 AM, with Certified Nurse Aide (CNA)#1, revealed Resident # 43 was to wear the chair alarm all the time while up in the wheelchair to detour her from wanting to stand up and risk falling. An interview with the Director of Nurse (DON) and the Registered Nurse (RN) Supervisor on 4/18/23 at 1:15 PM, both nurses confirmed that Resident #43 has a body alarm on. An interview with the DON on 4/19/23 at 1:59 PM, revealed the purpose of the care plan is to guide care for each resident and revealed the alarm device should have been on the fall care plan and confirmed that a care plan had not been developed for the chair alarm device. A review of Resident #43's care plan titled, I HAD A FALL ON 02/23/23, 03/31/23 with a start date of 2/23/23, revealed no documentation of a body alarm, and further review of all care plans also revealed no use of a body alarm. Record review of the Face Sheet revealed that the facility admitted Resident # 43 to the facility on 2/07/23 with diagnoses that included Hemiplegia following cerebral infarction affecting left side and Dizziness and giddiness unspecified abnormality of gait. Record review of the Minimum Data Set (MDS) Section C with an ARD on 2/11/23, revealed that Resident # 43 had a BIMS score of 14 which indicated that she was cognitively intact. Based on staff interviews, record review, and facility policy review the facility failed to develop a care plan for a resident who wanders, failed to develop a care plan for a resident with the use of a body alarm, and failed to implement a positioning care plan for a resident for three (3) of 24 residents reviewed for care plans. Resident #2, Resident #36, and Resident #43. Findings Include: A record review of the facility's policy titled, Care Plans updated 2/03/23, revealed Policy: Each resident will have a person-centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care .Definitions: Care plan- contains resident problems/needs/strengths, Resident goals and interdisciplinary approaches .Resident Care Summary- part of the Comprehensive Care plan and used as the tool to make staff aware of the resident's care needs as ADL (Activity of Daily Living) care plan . Record review of the facility care plan, titled, TURNING AND POSITIONING POLICY, with no date revealed, All residents will be .positioned as per the plan of care . Resident #2 Observation on 4/17/23 at 2:46 PM, revealed Resident # 2 lying in bed, propped on her left side. Her heels were not elevated and there were no heel booties in place. In an observation and interview on 4/17/23 at 5:30 PM, with Licensed Practical Nurse (LPN) # 1 she verified that Resident #2 should have had her heels floated and heel booties on and that not having them on could result in pressure ulcers. Record review of Resident #2's Care Plan, with a start date of 7/1/2019, revealed Care Plan Description, PRESSURE: I AM AT RISK FOR PRESSURE ULCER DUE TO INCONTINENCE, DECLINE IN ADL (Activities of Daily Living) FUNCTION, DEMENTIA & ALZHEIMER'S, Care Plan Goal: Skin will remain intact thru the next review date . Intervention .FLOAT HEELS WHILE IN BED, ENSURE HEEL BOOTIES ARE IN PLACE WHILE IN BED . An interview with the DON on 4/19/23 at 1:59 PM, revealed the purpose of the care plan is to guide care for each resident. Record review of Resident #2's Face Sheet revealed, she was admitted to the facility on [DATE] with diagnosis included Alzheimer's disease, unspecified, Ankylosing spondylitis of unspecified sites in spine. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/2023, the Brief Interview for Mental Status (BIMS) score is 9, indicating impaired cognition and Functional Status for bed mobility is extensive assistance of two staff members. Resident #36 An observation on 04/18/23 at 9:15 AM, revealed Resident #36 was sitting in his wheelchair at the exit door to the lobby of the nursing facility informing staff that he needed to go outside to find his car. Staff were observed to redirect Resident #36 away from the main door to the lobby to allow visitors to enter the hallway to the nursing facility. An observation on 4/18/23 at 9:30 AM, revealed Resident #36 was in his wheelchair wandering aimlessly throughout the building and was observed to make two (2) trips, back-to-back, from the nurse's desk, and back up the hall to one of the side exit doors to sit and look outside. An interview on 4/19/23 at 1:45 PM, with Social Services revealed she did not do a care plan for the resident being a wanderer. She confirmed that she did not think he should have been care planned as a wanderer because he did not exhibit exit seeking behaviors while wandering. An interview on 4/19/23 at 3:01 PM, with the Registered Nurse (RN) Supervisor revealed , that she did not think that a care plan had been developed for his wandering behavior. Record review of the care plan for Resident #36 revealed there was not a care plan for wandering behaviors. An interview on 4/19/23 at 4:40 PM, with the Director of Nursing (DON), revealed Resident #36 did wander aimlessly daily. She also revealed that he should have a had a wandering care plan done to ensure all staff were aware of his behaviors and need for staff to monitor him for his safety. Record review of the Face Sheet for Resident #36 revealed an admission date of 12/19/17 and diagnoses of Unspecified Dementia, Unspecified Severity, with Behavioral Disturbance, Anxiety Disorder, Unspecified, Restlessness and Agitation. Record review of the Minimum Date Set (MDS) with an ARD of 2/22/23 revealed a BIMS score of 10 indicating Resident #36 had moderate cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to apply heel booties and float heels while in bed for one (1) of 24 residents reviewed. Resident #2 Findings include: Record review of the facility policy, TURNING AND POSITIONING POLICY, with no date, revealed All residents will be .positioned as per the plan of care .Procedure: .2. Charge Nurse is responsible for visually observing .positioning as needed . An observation on 4/17/23 at 2:46 PM, revealed Resident # 2 lying in bed, propped on her left side. Her heels were not elevated and there were no heel booties in place. In an observation and interview with Certified Nursing Assistant (CNA) # 2 on 4/17/23 at 5:26 PM, she verified that Resident #2 did not have her heels floating or have heel booties in place. CNA #2 verified that Resident # 2 should have had heels floating and have heel booties in place. She stated that Resident #2's right heel bothered her and if Resident #2 did not have the heel booties in place she could get a sore. CNA # 2 stated that she used the kiosk to know what interventions the residents need. In an observation and interview on 4/17/23 at 5:30 PM, with Licensed Practical Nurse (LPN) # 1 she verified that Resident #2 should have had her heels floated and heel booties on and that not having them on could result in pressure ulcers. She stated that the CNAs were responsible for ensuring these interventions were in place. LPN # 1 stated that the interventions trigger on the electronic Treatment Administration Record (eTAR) for the nurse to check to be sure that they are in place. She stated that the treatment nurse checks on day shift, and the floor nurses check during the evening and night. In an interview with the Director of Nursing (DON) on 4/17/23 at 5:35 PM, she stated that the CNA who put the resident back to bed should have made sure the heel booties were in place. An interview with Treatment Nurse on 4/19/22 at 8:15 AM, verified that she checks the residents when she comes in in the morning to make sure that heels are floated, and heel booties are in use. She stated that she signs off the eTAR for the day shift and the floor nurses check them and signs off the eTAR for the evening and night shift. She stated that floating heels and use of heel booties were used to prevent pressure ulcers. An interview with the DON on 4/19/23 at 2:45 PM, she verified that failure to provide these interventions could result in a pressure ulcer. Record review of the April 2023 Physician Orders revealed an order dated 9/2/22 Float heels in bed. Record review of Resident #2's eTAR revealed FLOAT HEELS IN BED, with an onset date of 9/2/22, and ENSURE HEEL BOOTIES ARE IN PLACE WHILE IN BED, with an onset date of 11/13/22. The AM shift was initialed indicating the heel booties were in place and heels were floated. Record review of Resident #2's Face Sheet revealed, she was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified, Ankylosing spondylitis of unspecified sites in spine. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/2023 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of nine (9), indicating impaired cognition and review of Section G indicated functional status for bed mobility is extensive assistance of two staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interviews, and facility policy review, the facility failed to promptly deliver postal mail to residents on Saturdays for 54 of 54 residents in the nursing facility that would possibly receive postal mail. Resident #25 Findings include: Review of a document on facility letterhead from the Administrator dated 4/20/23, revealed, The Policy of (Proper Name of the facility) is to pass mail daily. Activities passes on the weekdays and the Registered Nurse (RN) supervisor or charge nurse is responsible for mail collection on the weekends. Review of the Resident's Rights with a copyright date of 2018, revealed, .7. Information and communication . i. The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through means other than a postal service. An interview on 4/18/23 at 3:45 PM with Resident #25, the Resident Council President, revealed there is no mail delivered to the residents on Saturday. He revealed he saw the staff member that works at the main entrance door bring in mail from the mailbox on a Saturday, could not recall which Saturday, but she refused to go through it to see if he had any mail delivered from the post office. He revealed the nursing staff will bring him his packages and the newspaper, if he tells them to look out for it on the weekend, but the young lady will not give him his Saturday mail. An interview on 4/19/23 at 2:35 PM, with the COVID Check Point Staff, revealed she had gotten the mail out of the mailbox one Saturday and took the mail to the nurse's desk to be placed in the main office to be passed out to the residents on the following Monday. She revealed it was taken to the nurse's desk because she did not have access to a key for the main office. An interview on 4/19/23 at 2:40 PM, with Licensed Practical Nurse (LPN) #2, revealed she has worked on Saturday and reported the mail was brought to the nurse's desk on Saturdays and to be passed out by the Activities Department, if they are working on Saturday. She stated there was not an Activities person at work every Saturday and the mail would then be placed in the main office to be passed on to the residents on the following Monday. An interview on 4/19/23 at 2:43 PM, with LPN # 3, revealed mail had been brought to the nurse's desk when she worked on a Saturday and would be placed in the main office to be passed out to residents on the following Monday if no one was working on Saturday from the activities department. An interview on 4/19/23 at 2:50 PM, with the Activities Coordinator revealed she had passed out mail before on a Saturday. But she was not at work this past Saturday, 4/15/23, and was not sure about what happened with the mail. She noted if she is at work, the nurses give the mail to her to pass it out to the residents. An interview on 4/19/23 at 2:55 PM, with the Administrator revealed the weekend RN Supervisors are responsible for getting the Saturday mail from the mailbox and distributing it to the residents. She revealed it was not the responsibility of the Activities department to distribute Saturday mail and was not aware that no staff was delivering Saturday mail to the residents every Saturday. She confirmed all residents should receive their mail the day it is delivered, and Resident #25 had the right to receive his postal mail, if there was some delivered for him, on Saturday. An interview 4/19/23 at 3:01 PM, with Registered Nurse (RN) Supervisor #1, revealed she would look for a newspaper or a package that was delivered on Saturday when Resident #25 would tell her he wanted the newspaper and if had a package coming. She revealed that she would be involved providing resident care and was not aware she was responsible to go to the mailbox to get resident mail and distribute it on a Saturday. She confirmed that she had not gotten mail out of the mailbox on any Saturday she had worked. Record review of the Face Sheet revealed that the facility admitted Resident # 25 to the facility on [DATE] with diagnoses of Vascular dementia with Sepsis, Unspecified dementia without behaviors, and Benign prostatic hyperplasia. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 3/28/23, revealed that Resident # 25 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated that she was cognitively intact.