Based on staff interviews and record review the facility failed to put safety measures in place to prevent an accident during van transport for one (1) of three (3) residents reviewed. Resident #1. Findings Include: Record review of Instructions for loading and unloading a resident with a wheelchair lift on a transport vehicle, provided by the Administrator, revealed Securing the resident in the vehicle. Secure vehicle supplied safety seat belt around the resident. Interview with the Staff Development Nurse on 5/21/25 at 12:15 PM, she verified that the facility did not have a policy on accident prevention or van transport. Record review of the facility investigation revealed on 5/2/25, during transportation to a physician's appointment Resident #1 fell from the wheelchair on to the van floor. Emergency Medical Services (EMS) was contacted, and the resident was transferred to the local emergency room. Resident #1 had no injuries and was transported back to the facility. Record review of Resident #1's hospital records dated 5/2/25 revealed that she sustained no injuries and no treatment was required. An interview with Certified Nursing Assistant (CNA) #1 on 5/21/25 at 12:05 PM, she stated that on 5/2/25 she was transporting Resident #1 from the nursing home to a physician's office approximately two (2) hours away from the facility. She stated when she stopped at a red light down the street from the doctor's office, she checked her rearview mirror and did not see the resident. She stated she drove to where she could pull over to check on the resident and noticed that she was lying on her side on the floor. CNA #1 stated that she was unsure how long the resident had been on the floor of the van. She stated the resident responded to her and she was instructed by the Director of Nursing to call EMS. She stated that EMS arrived and transported the resident to the local emergency room. CNA #1 stated that the resident must have slid out of the wheelchair and admitted that the seat belt was not buckled. She stated that she secured the wheelchair to the van but confirmed that she did not put the safety seat belt around the resident. An interview with the Administrator and Director of Nursing (DON) on 5/21/25 at 12:10 PM, they verified that CNA #1 did not put the safety seat belt around the resident, and it was their expectation that she would have. They agreed that failure to apply the seat belt could result in injuries. Record review of the admission Record revealed that the facility admitted Resident #1 on 4/18/25 with diagnoses including Acquired Absence of Left Leg Below Knee.

Based on record review, staff interview and facility policy review the facility failed to ensure residents were free from significant medication errors for seven (7) of 30 residents reviewed. Resident #1, #2, #3, #4, #5, #6, and #7. Findings Include: Record review of the facility policy, titled Administering Medications with a revision date of 04/2019 revealed Policy Statement, Medications are administered in a safe and timely manner and as prescribed . Record review of a facility investigation revealed that on 2/20/25 Registered Nurse (RN) #1 notified the Director of Nursing (DON) that she had not given medication to seven (7) of the residents she was assigned to for the 7:00 AM to 3:00 PM shift. The DON conducted an audit and verified that seven (7) out of 30 residents RN #1 was assigned to for the 7:00 AM to 3:00 PM shift had not received their scheduled medications. Record review of Resident #1 and Resident #7's written statement dated 2/21/25 confirmed the resident did not receive their scheduled medicines on time on 2/20/25. Record review of the Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/25 for all residents in the facility revealed that Residents #1, #2, #3, #4, #5, #6 and #7 had no documentation of administration of medications scheduled between 7:00 AM and 3:00 PM on 2/20/25. Resident #1 Record review of the Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #1 had active orders that included Metoprolol Succinate ER Oral Tablet Extended Release 24-hour 25 milligram (mg) give one (1) tablet by mouth one time a day with missed dose at 9:00 AM, Eliquis Oral Tablet 5 mg give 1 tablet by mouth two (2) times a day with missed dose at 9:00 AM, Cozaar Oral Tablet 50 mg give one (1) tablet by mouth one time a day with missed dose at 9:00 AM, and Dilantin Oral Capsule 100 mg 2 capsules three (3) times a day, with a missed dose at 9:00 AM and 1:00 PM. Record review of the admission Record revealed that the facility admitted Resident #1 on 2/13/25 with diagnoses that included Cerebral Infarction, Hyperlipidemia, Occlusion and Stenosis of Bilateral Carotid Arteries, and Hypertension. Resident #2 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #2 had active orders that included Rivaroxaban Tablet 20 mg give 1 tablet by mouth one time a day, with a missed dose at 9:00 AM. Record review of the admission Record revealed that the facility admitted Resident #2 on 10/29/21 with diagnoses that included Acute Kidney Failure, Protein-Calorie Malnutrition, Peripheral Vascular Disease and Hypertension. Resident #3 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #3 had active orders that included Hydralazine Hydrochloride (HCL) Tablet 100 mg give 1 tablet by mouth 3 times a day, with a missed dose at 9:00 AM and 1:00 PM. Keppra Tablet 500 mg give 1 tablet by mouth 2 times a day, with a missed dose at 9:00 AM. Amlodipine Besylate Tablet 10 mg give 1 tablet by mouth one time a day, with a missed dose at 9:00 AM. Carvedilol Tablet 12.5 mg give 1 tablet by mouth 2 times a day, with a missed dose at 9:00 AM. Spironolactone Oral Tablet 25 mg give 12.5 mg by mouth one time a day, with a missed dose at 9:00 AM. Record review of the admission Record revealed that the facility admitted Resident #3 on 12/8/18 with diagnoses that included Cerebral Infarction, Hypertension, Congestive Heart Failure, Other Seizures, and Cardiomyopathy. Resident #4 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #4 had active orders that included Hydralazine Hydrochloride (HCL) Tablet 25 mg give 1 tablet by mouth 1 time a day, with a missed dose at 9:00 AM. Keppra Tablet 500 mg give 1 tablet by mouth 2 times a day, with a missed dose at 9:00 AM. Coreg Tablet 3.125 mg give 1 tablet by mouth 2 times a day, with a missed dose at 9:00 AM. Record review of the admission Record revealed that the facility admitted Resident #4 on 2/1/25 with diagnoses that included Diabetes Mellitus, Hypertension, Chronic Venous Hypertension, Gastro-Esophagel Reflux Disease, and Atherosclerotic Heard Disease. Resident #5 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #5 had active orders that included Metformin HCL Oral Tablet 500 mg give 1 tablet by mouth 2 times a day with a missed dose at 9:00 AM. Lisinopril Oral T ablet 2.5 mg give 1 tablet by mouth 1 time a day, with a missed dose at 9:00 AM. Record review of the admission Record revealed that the facility admitted Resident #5 on 1/30/25 with diagnoses that included Diabetes Mellitus, Hypertension, and Dementia. Resident #6 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #6 had active orders that included Amlodipine Besylate Oral Tablet 5 mg give 1 tablet by mouth 1 time a day with a missed dose at 9:00 AM. Lacosamide Oral Tablet 200 mg give 1 tablet 1 time a day with a missed dose at 9:00 AM. Levetiracetam Oral Tablet 750 mg give 1 tablet in the morning with a missed dose at 9:00 AM. Cephalexin Oral Tablet 500 mg give 500 mg by mouth 2 times a day with a missed dose at 9:00 AM. Hydralazine HCL Oral Tablet 50 mg give 1 tablet by mouth 2 times a day with a missed dose at 9:00 AM. Lasix Oral Tablet 40 mg give 1 tablet by mouth 2 times a day with a missed dose at 9:00 AM. Sinemet Oral Tablet 25-100 mg give 1 tablet by mouth 3 times a day with missed doses at 10:00 AM and 2:00 PM. Record review of the admission Record revealed that the facility admitted Resident #6 on 2/28/24 with diagnoses that included Parkinsonism, Angina Pectoris, Congestive Heart Failure, Myoclonus, Visual Hallucinations, Tremor, and Unspecified Convulsions. Resident # 7 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #7 had active orders that included Enalapril Maleate Oral Tablet 10 mg give 1 tablet 1 time a day with a missed dose at 9:00 AM. Record review of the admission Record revealed that the facility admitted Resident #7 on 2/21/24 with diagnoses that included Protein-Calorie Malnutrition and Hypertension. An interview with the Staff Development Nurse (SDN) on 2/26/25 at 10:00 AM, she confirmed that on 2/20/25 RN #1 was assigned to the medication cart for 7:00 AM to 7:00 PM due to a call in. She stated that if there is a call in then an on-call nurse or supervisor is pulled to the cart to cover. She stated that she offered to assist RN #1 but was told she did not need any help. She stated that she offered to assist RN #1 again by checking blood sugars and vital signs around lunch but was told that she did not need help. She stated later in the afternoon she overheard RN #1 complaining to other staff and she called her into the DON ' s office to talk with her. She stated at that time RN #1 became agitated and turned in her resignation. She stated at that time RN #1 informed the DON of a list of residents that she had not yet administered medications to. SDN stated she assisted the DON with the care of the residents in that section. An interview with RN #2 on 2/26/25 at 10:30 AM, she stated that the Supervisor may get pulled to work the med cart once about every two (2) weeks. She stated that all staff is trained to administer medications and if they are not comfortable then they can notify the Supervisors or DON in order to get more training. She stated that she tries to watch staff to see if they need help and help them. An interview with Licensed Practical Nurse (LPN) #1 on 2/26/25 at 10:45 AM, she stated that she worked on 2/20/25 and was assigned the opposite hall from RN #1. She revealed that she did hear the SDN offer to assist RN #1 with med pass. LPN #1 revealed she did not have any trouble getting assistance if needed and that administrative staff was very helpful. A telephone interview with RN #1 on 2/26/25 at 11:16 AM, she revealed that she had worked at the facility for about a month and 2/20/25 was the first time she had worked independently on medication administration and no one offered her any assistance. She then admitted that she had previously followed a nurse on medication administration. She revealed that around 3:00 PM the SDN called her into the DON's office about her attitude and at that time she gave report, counted narcotics and gave the DON a list of residents that she had not given medications to yet. She stated she had just not gotten to those residents yet. A follow up interview with the SDN on 2/26/25 at 11:30 AM, she stated that RN #1 had never complained about working on the medication cart before and that she had previously worked on the med cart on 2/10/25, 2/14/25 and 2/19/25 with no issues noted. An interview with the Administrator on 2/26/25 at 2:05 PM he verified that he was present and heard the SDN offer RN #1 assistance, but she declined it. He verified that it was his expectation that RN #1 would have administered the residents' medications timely as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to ensure a resident's privacy during a bed bath for one (1) of 17 residents sampled. Resident #33 Findings Include: Review of the facility policy titled, Privacy with an effective date of 11/30/14 and no revision date revealed, Policy .It is the policy of The Company to give all residents the opportunity for privacy .Procedure: #2 Residents privacy will always be respected. An observation on 06/03/24 at 10:25 AM, revealed Resident #33 lying in bed uncovered with only a brief on and the privacy curtain was not pulled between her and Unsampled Resident #40 (roommate). Certified Nurse Assistant (CNA) #2 was at the resident's bedside and did not announce patient care when the State Agent (SA) knocked on the resident's room door for entry. This observation revealed the resident was receiving a bed bath. Resident #33 was yelling randomly, difficult to understand and unable to answer questions. Record review of Resident #33's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Moderate Intellectual Disabilities and Pseudobulbar Affect. An interview on 06/03/24 at 2:20 PM, with CNA #2 confirmed she did not have the privacy curtain pulled between Resident #33 and her roommate while she gave her a bed bath this morning. She admitted the curtain should have been pulled for the resident's dignity and privacy. An interview on 6/4/24 at 9:29 AM, with CNA #3 confirmed that the privacy curtain should be pulled when you are giving a resident a bed bath just in case someone walks in the room or to give privacy between roommates. She stated it provides the resident with the dignity of privacy from people seeing their private areas. An interview on 06/04/24 at 09:39 AM, with the Director of Nurses (DON) confirmed that a privacy curtain should be pulled for any type of care provided to a resident not just bed baths. She stated it was important to provide the residents with dignity and privacy and that was a big pet peeve of mine and nursing 101. Record review of Resident #33's Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 5/10/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 03, which indicates the resident is severely cognitively impaired.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to provide a resident with a wheelchair in good repair as evidenced by torn and tattered arm rest and a broken wheelchair brake for one (1) of 17 sampled residents. Resident #16 Findings Include: Review of the facility policy titled Maintenance with an effective date of 11/30/2014 revealed, Policy: The facility's physical plant and equipment will be maintained through a program of preventative maintenance and prompt action to identify areas/items in need of repair .Procedure: All employees will report physical plant areas or equipment in need of repair or service to their supervisor . An observation and interview with Resident #16 on 6/3/2024 at 10:39 AM, revealed him sitting in a wheelchair in his room. The resident explained that his wheelchair brake was broken and had been broken for some time. The right brake was hanging down loosely and would not fasten to secure the wheel in place. The right arm rest was tattered and torn on the edges, with black foam exposed. An observation and interview on 6/4/2024 at 9:40 AM, with the Maintenance Director revealed he was not aware that Resident #16's wheelchair was in disrepair. He explained that he was responsible for making rounds and ensuring that resident equipment was in good working order. He confirmed that the resident needed a new armrest and voiced the brake could be repaired. An interview with the Director of Nursing (DON) on 6/4/2024 at 9:43 AM, revealed the aides wash and clean the wheelchairs at night and were responsible for notifying the Maintenance Director either verbally or by leaving a note of resident equipment in disrepair. She confirmed resident equipment should be in good working condition. Record review of the admission Record revealed the facility admitted Resident #16 on 10/19/2023 with a medical diagnosis of Hemiplegia and Hemiparesis following Cerebrovascular Disease affecting the right dominant side.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to honor a resident's choice for salt with meals for one (1) of twenty-four residents included in the initial pool. Resident #45 Findings Include: Review of the facility policy titled Resident Rights with an effective date of 11/30/2014 revealed, Policy: The facility will ensure that the resident is not deprived of his/her rights An observation and interview with Resident #45 on 6/3/2024 at 10:46 AM, revealed him lying in bed. The resident voiced that he had asked staff several times for salt with his meals, but they would not allow it because he had high blood pressure. He revealed he could not eat the food without some salt for flavor. Record review of Resident #45's Order Summary revealed an order, NAS (No Added Salt) diet . An interview with the Dietary Supervisor #1 on 6/4/2024 at 1:14 PM, confirmed Resident #45 had a physician's order for a No Added Salt (NAS) diet; therefore, he would not be given salt on his tray or if he requested it to add to his food. She revealed that she had spoken to the resident a couple of times because he was requesting salt. She explained that she educated him that he could not have it due to his diagnosis of high blood pressure and potential outcomes such as swelling. An interview with the Director of Nursing (DON) on 6/4/2024 at 3:16 PM, revealed Resident #45 had the right to request and be given salt with his meals. She stated she was not aware that the resident requested salt, and acknowledged he could have signed a waiver. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/2024 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 14, which indicates Resident #45 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #45 on 12/30/22 with a medical diagnosis of Peripheral Vascular Disease and Essential (Primary) Hypertension.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to ensure Advanced Directive for code status preference was discussed and completed by the resident's representative for one (1) of 24 residents in initial pool. Resident #22 Findings include: Record review of the facility policy titled, Advanced Directives, with revision date of 11/14/18, revealed, The center will abide by state and federal laws regarding advance directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative. Process: 1. Upon admission, Social Service Director or Business Development Coordinator/designee will: a) Communicate to resident and/or representative his or her right to make choices concerning health care and treatments, including life sustaining treatments. 5. Advanced Directives will be reviewed: Quarterly . Record review of Resident #22's electronic Order Summary Report revealed a physician order dated 2/1/18 for a full code status. Record review of Resident #22's electronic and paper record revealed there was no signed document to indicate the desired end of life care for this resident. The record review revealed the facility's Notification and Consent Form which contained advance directives options was not completed by the resident or the resident's representative. During an interview on 6/4/24 at 10:05 AM, the Director of Nursing revealed Resident #22 had an electronic order for a full code but did not have the advance directive document used by the facility that indicated the resident's or the resident representative's desire for end-of-life care. She revealed the social service director was responsible for completing this on admission as well as quarterly to ensure the facility maintains accurate documentation for end-of-life care. She confirmed that end-of-life care choice should be honored and the facility failed to discuss with the resident and/or representative the options for end-of-life care and failed to obtain a consent for the desired care for the resident. Record review of admission Record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included Dementia with behavioral disturbance, Congestive Heart Failure, and Type 2 Diabetes Mellitus. Record review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/6/24 revealed Resident #22 had a Brief Interview for Mental Status (BIMS) of 5 which indicated the resident had severe cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan regarding turning and repositioning for a resident that was dependent on staff for one (1) of seventeen care plans reviewed. Resident #18 Findings Include Cross Reference F684 Record review of the facility policy titled, Plans of Care with a revision date of 09/25/17 revealed, Procedure .Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs . Record review of Resident #18's care plans revealed the resident had a care plan for ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Confusion, Limited Mobility and interventions that included that the resident required extensive assistance x 2-person physical assist to reposition and turn in bed. An observation on 06/04/24 at 08:15 AM, revealed Resident #18 was lying in bed with the head of bed (HOB) at 90 degrees while a staff member was feeding the resident breakfast. An observation on 6/4/24 at 9:00 AM, 10:30 AM, 11:15 AM and 12:30 PM revealed Resident #18 in the same position, lying in bed with the HOB at 90 degrees. An interview on 6/4/24 at 1:30 PM, with Licensed Practical Nurse (LPN)/ Minimum Data Set (MDS) nurse confirmed that Resident #18 would need to be turned every two (2) hours because she cannot do that on her own. She revealed that the resident has a care plan regarding the need for ADL assistance, but nothing is in there about turning. She stated that should just be common sense. She stated she is responsible for putting in the resident's care plans, and they do not always put turning and repositioning in a resident's care plan. An interview on 6/4/24 at 1:45 PM, with CNA #4 confirmed that residents need to be turned every 2 hours and most of them have that in their POC (Plan of Care) where the CNA's document. She revealed a resident's care plan tells them what care the resident needs. An interview and record review on 6/4/24 at 1:50 PM, with LPN #2 revealed Resident #18 did not have reposition/turn on her POC but did have that the resident needed assistance. She revealed that the purpose of the care plan was to provide information regarding the care a resident needed. She confirmed that turning and repositioning was to prevent skin breakdown and pressure ulcers. An interview on 6/5/24 at 8:00 AM with the DON confirmed that Resident #18 did not have turning/repositioning on her POC which comes from the care plans that are put in by Minimum Data Set (MDS) and that could use some improvement. She stated that Resident #18 should have had turning and repositioning on her care plan to prevent skin breakdown. Record review of Resident #18's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Other Lack of Coordination, Unspecified Dementia and Cognitive Communication Deficit. Record review of Resident #18's MDS with an Assessment Reference Date (ADR) of 4/16/24 revealed in Section C no Brief Interview for Mental Status (BIMS) score of, which indicated the resident was severely cognitively impaired and in Section GG that the resident needs substantial/maximal assistance with rolling left to right.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to ensure a resident was clean and dry for one (1) of seventeen sampled residents. Resident #45 Findings Include: Review of the facility policy titled Activities of Daily Living revealed under, Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, cuing and assistance as necessary. ADLs include bathing, dressing, grooming, hygiene, toileting and eating. An observation on 6/4/2024 at 12:31 PM, revealed Certified Nurse Aide (CNA) #5 entered Resident #45's room and delivered a lunch tray, then exited the room. An observation and interview with Resident #45 on 6/4/2024 at 12:32 PM, revealed him lying in bed with his lunch tray sitting on top of the overbed table covered. The resident instructed the Survey Agent not to touch the side of the bed because it was wet. Resident #45 explained that he was wet, but he could not recall if he had told any of the staff he needed changing. The resident had a disposable pad over the top of a cloth pad that was fully saturated in yellow urine, which covered the entire pad on the left side of the resident. CNA #5 entered the room holding a flat sheet of which she applied over the residents' legs. The Survey Agent inquired was she going to change the resident and CNA #5 replied, We don't change during mealtimes; I was just bringing a sheet for his legs because he did not have one and left the room. The resident further explained that staff has told him in the past they cannot change him during meals. He revealed he was told it was a facility rule that he must wait until after mealtime and trays were picked up to get changed. An interview with the Director of Nursing (DON) on 6/4/2024 at 12:42 PM, revealed the aides and nurses were responsible for changing and toileting the residents during mealtimes. She revealed if a resident required changing, the aides were to stop passing the trays and take care of the resident at that point. She stated leaving a resident wet during mealtimes was unacceptable and confirmed this could cause skin concerns. An interview with CNA #5 on 6/4/2024 4 at 2:18 PM, revealed that she was a shower aide and was helping pass out lunch trays today. She revealed that when she entered Resident #45's room, he did not tell her that he was wet. She stated that she went to go get him a sheet because he did not have one to cover his legs. CNA #5 revealed to her knowledge she was not supposed to change a resident that was soiled during mealtime because if someone else was eating on the other side of the room it would cause infection concerns. She acknowledged that leaving a resident wet during mealtimes could cause skin concerns. Record review of the admission Record revealed the facility admitted Resident #45 on 12/30/22 with diagnoses including Sarcopenia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to turn or reposition a resident that was dependent on staff for one (1) of eight (8) residents reviewed that were dependent on staff. Resident #18 Findings Include: Cross Reference to F726 and F656 Record review of the facility policy titled, Contractures, Prevention with a revision date of 8/22/17 revealed Positioning .Residents who are unable to move themselves should be repositioned frequently, at least every two hours, when in bed or when sitting in the chair. On 06/04/24 at 08:15 AM, observation revealed Resident #18 was lying in bed with the head of bed (HOB) at 90 degrees while a staff member was feeding the resident breakfast. On 6/4/24 at 9:00 AM, 10:30 AM, 11:15 AM and 12:30 PM, observations revealed Resident #18 in the same position, lying in bed with the HOB at 90 degrees. On 6/4/24 at 12:35 PM, an interview with Certified Nurse Assistant (CNA) #1 confirmed that she had not turned Resident #18. She stated that she had only been at the facility for two (2) weeks and this was the first time she had this resident. She stated they did not train her, they just put her to work. She admitted that she had been a CNA for a while and had worked at another facility. She confirmed that the resident could not turn herself or get out of bed on her own and could not answer questions and she should have known to turn her. She stated that she changed the resident around 10:30 AM and thought she had let the HOB down. An interview on 6/4/24 at 12:45 PM with Licensed Practical Nurse (LPN) #2 revealed she is the supervisor for the CNA's . She confirmed that Resident #18 should be turned every two hours to prevent skin breakdown and pressure ulcers. She stated that the CNA's should use common sense regarding turning residents and if they are not sure then they should ask someone. She stated that they have a meeting with the CNA's each morning, to give them their assignments and let them know anything new about the residents they are assigned to, but Resident #18 has been here a long time. An interview on 6/4/24 at 1:10 PM, with CNA #1 revealed that she asked a couple of the other CNA's and they told her she could turn the Resident #18. An interview on 6/4/24 at 1:15 PM, with the Director of Nurses (DON) confirmed that her expectation was that residents would get turned every two hours. She confirmed that staff have access to the Plan of Care for the residents and that if they are not sure they should ask staff. She stated it is common sense that a resident is in the nursing home for a reason, they need help taking care of themselves and if they are not cognitive enough to answer questions then that should be a given that they need to be repositioned to prevent skin breakdown and discomfort from being in the same position for so long. On 6/4/24 at 1:45 PM, an interview with CNA #4 confirmed that residents need to be turned every 2 hours and most of them have that in their POC (Plan of Care) where the CNA's document, but even if they do not, we know they need to be turned to prevent skin breakdown. An interview on 6/4/24 at 1:50 PM, with LPN #2 revealed Resident #18 needed assistance with bed mobility. She stated that staff should be familiar with their residents and the care they need and if they are not sure then they should ask. An interview and observation on 6/4/24 at 2:15 PM, with LPN/Wound Nurse revealed she completed a full body audit on Resident #18 with no issues of skin breakdown or pressure wounds. An interview on 6/4/24 at 2:30 PM, with the Director of Therapy confirmed that Resident #18 was totally dependent on staff for everything, even feeding. An interview on 6/5/24 at 8:00 AM, with the DON confirmed that CNA #1 had been a CNA for a while and they teach the importance of turning and repositioning in CNA classes, so she should have known to do that. Record review of Resident #18's Minimum Data Set (MDS) with an Assessment Reference Date (ADR)of 4/16/24 revealed in Section C no Brief Interview for Mental Status (BIMS) score, which indicated the resident was severely cognitively impaired and in Section GG that the resident needs substantial/maximal assistance with rolling left to right. Record review of Resident #18's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Other Lack of Coordination, Unspecified Dementia and Cognitive Communication Deficit.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure staff completed an orientation competency check off prior to caring for residents for one (1) of six (6) staff personnel files reviewed. CNA #1 Findings Include: Cross Reference F684 Record review of the facilities policy titled, New Hire Orientation with a revision date of 8/17/21 revealed under Policy .It is the policy of the Company to orient each new employee upon hire by providing the employee with general and job specific information regarding the mission and values of the Company, policies and procedures, job duties, benefits and safety regulations. Review of Certified Nursing Assistant (CNA) #1's personnel record revealed there was no skills competency check off completed. An interview on 6/4/24 at 12:35 PM with Certified Nurse Assistant (CNA) #1 stated that she had only been at the facility for two (2) weeks. She stated they did not train her, they just put her to work. An interview on 6/4/24 at 4:24 PM, with Licensed Practical Nurse (LPN) #1 confirmed that CNA #1 worked without completing her competency skills check offs. She revealed it is her responsibility to make sure those check offs are complete before they start working. She stated that the CNA was hired and had days off requested so for some reason it was missed. She stated that the purpose of staff members completing the competency skills check off was to make sure the staff were competent. Record review of CNA #1's timesheet revealed she has worked 5/15/24, 5/16/24, 5/20/24, 5/28/24, 5/29/24, 5/30/24, 5/31/24, 6/1/24, 6/3/24 and 6/4/24. An interview on 6/5/24 at 9:36 AM with the Director of Nurses (DON) confirmed that CNA #1 should have completed her orientation skills check off prior to caring for the residents. She stated that previously it was the CNA that trained the CNA that was responsible for checking off the orientation competency skills check off. She revealed that from now on LPN #1 will be ultimately responsible for making sure the orientation check offs are completed then she is going to get that sheet to me for review before we put them on the schedule.

Based on staff interview, record review, and facility policy review, the facility failed to ensure that the Infection Preventionist (IP) had completed the required training for the Infection Preventionist role for three (3) of three (3) survey days observed. Findings include: Record review of the facility policy Infection Prevention and Control Program with a revision date of October 2018 revealed under, Policy Interpretation and Implementation: .5. Coordination and Oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). An interview on 6/04/2024 at 3:05 PM, Licensed Practical Nurse (LPN) #1 revealed she was the facility Infection Control nurse. She explained that when she started working in January of this year, she was not aware that she had to have formal training or a certification for the Infection Preventionist role. She revealed she had started the training with the World Health Organization (WHO) to be certified as an Infection Preventionist but had not completed her training. An interview on 6/04/2024 at 3:41 PM, the Director of Nurses (DON) revealed we have three (3) nurses involved in the Infection Preventionist training including myself, however, at this time we have no one who has completed the course. She revealed that we are just doing our best to care for the residents at this time. An interview on 6/05/2024 at 9:46 AM, the Administrator (ADM) revealed, he was made aware when he became Administrator back in April that the facility did not have an Infection Preventionist that was certified. He revealed he was made aware that the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 were signing up for the course at that time but was unaware that it had not been completed.

Based on record review and staff interviews, and facility policy review, the facility failed to develop a Baseline Care Plan for a resident admitted to the nursing facility with a Stage II Sacrum/Coccyx Wound and failed to update the Baseline Care Plan for a resident with a new order for positioning related to the care of a Left Lower Leg Wound. Resident #156 and Resident #157. Findings include: Review of the facility policy titled, Policies and Procedures, with a revision date of 09/25/2017, revealed Subject: Plan of Care . Procedure: . Develop and implement an individualized Person-Centered baseline plan of care . to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. Resident #156 Record review of the Baseline Care Plan for Resident #156 did not reveal a care plan for his Stage II Sacrum/Coccyx Wound. There was no entry observed on the Baseline Care Plan for Impaired Skin integrity: Location. Record review of the Order Summary Report revealed the physician's order Cleanse stage II to sacrum/coccyx with wound cleanser, pat dry, apply calcium alginate and dry dressing daily and as needed, dated 12/30/22. An interview and record review of the Order Summary Report and the Baseline Care Plan, on 1/10/22 at 10:20 AM. with the Director of Nursing (DON)/Treatment Nurse, confirmed Resident #156 was admitted to the nursing facility with a physician's order for care to a Stage II Sacrum/Coccyx Wound and confirmed the Baseline Care plan did not have a care plan developed for the Stage II Sacrum/Coccyx Wound. The DON/Treatment Nurse confirmed that the Baseline Care Plan only noted At risk for impaired skin. The DON/Treatment Nurse confirmed a care plan, for Resident #156's Stage II Sacrum/Coccyx Wound, should have been developed. An interview and record review of the resident's Baseline Care Plan on 1/10/22 at 10:25 AM with Minimum Data Set (MDS)/Care Plan Nurse, confirmed that Resident #156 did not have a care plan developed for the Stage II Sacrum/Coccyx Wound that was present upon admission to the nursing facility on 12/30/22. The MDS/Care Plan Nurse revealed she must have missed the order when she initiated Resident #156's Baseline Care Plan. She confirmed she was responsible for developing the Baseline Care Plan, for the Stage II Sacrum/Coccyx Wound. An interview on 1/10/23 at 10:33 AM, with the Administrator confirmed that Resident #156 should have had a Baseline Care Plan developed for the Stage II Sacrum/Coccyx Wound. Record review of the admission Record, for Resident #156 revealed an admission date of 12/30/22. Record review of the Diagnosis Report for Resident #156 revealed diagnoses that included Unspecified Protein-Calorie Malnutrition. Resident #157 Record review of the Order Summary Report for Resident #157's physician orders revealed Elevate legs in bed at all times. Every Shift. Record review of the Baseline Care Plan for Resident #157 did not reveal a care plan developed for the physician's order Elevate legs in bed at all times. Every Shift. An interview and record review of the Order Summary Report and the Baseline Care Plan, for Resident #157, on 1/11/23 at 03:00 PM, with the DON, confirmed the order Elevate legs in bed at all times. Every Shift, dated 1/3/23, and confirmed there was not a care plan developed on the Baseline Care Plan for this order. She revealed that the care plan not being developed could have possibly contributed to the ordered care not being carried out for Resident #157. She noted that the MDS/Care Plan nurse was responsible to update the Baseline Care Plan. She confirmed that a Baseline Care Plan for the physician's order Elevate legs in bed at all times. Every Shift, dated 1/3/23, should have been developed. An interview and record review of the resident's Baseline Care Plan on 1/11/23 at 03:15 PM, with the MDS/Care Plan Nurse, confirmed that Resident #157 did not have a Baseline Care Plan developed for the physician's order Elevate legs in bed at all times every shift, dated 1/3/23. She revealed that it was her responsibility to review Resident #157's chart weekly for new orders to update his Baseline Care Plan. The MDS/Care Plan Nurse revealed she must have just missed that physician's order. She confirmed Resident #157 should have had a Baseline Care Plan developed for the physician's order Elevate legs in bed at all times. Every Shift, dated 1/3/22, to be implemented to assist with the care of the Left Lower Leg Wound. An interview on 1/11/23 at 03:35 PM, with the Administrator confirmed that a Baseline Care Plan should have been developed, for Resident #157, from the physician's order Elevate legs in bed at all times. Every Shift, dated 1/3/23. Record review of the admission Record for Resident #157 revealed an admission date of 12/30/22, and diagnoses of Multiple Fractures of Ribs, Left Side, Sequela, Sarcopenia, History of Falling, and Localized Edema.

Based on observations, staff and resident interviews and record review, the facility failed to position a resident as ordered by the physician for one (1) of four (4) residents with positioning devices. Resident #157 Findings include: Review for the nursing facility policy related to Positioning revealed the nursing facility did not have a policy for Positioning. The Administrator provided a signed letter on the nursing facility's letterhead, that revealed, This statement is being made in response to a request made by surveyors on 01/11/2023, for our facility to provide a specific policy for positioning to them during the Annual Survey process that started here on 01/08/2023. We are currently unable to provide the above requested information/documentation, due to being unable to locate said information/documentation. An observation on 01/09/23 at 09:10 AM, revealed Resident #157 had a wound dressing on his left lower leg and his feet rested on top of a folded flat sheet. An observation and interview on 1/9/23 at 04:10 PM, revealed the folded flat sheet had been removed. Resident #157 revealed the staff use to put his legs up on pillows but could not remember the last day his legs were elevated. An observation and interview on 1/10/23 at 09:45 AM, with the Director of Nursing (DON) and the Administrator, confirmed resident's legs were not elevated while in bed. The DON revealed due to Resident #157 having left lower leg wounds, he did need to have his legs elevated in the bed to avoid the likelihood of further decline and increased injury to wounds. The DON confirmed the staff should have been following the physician orders to elevate Resident #157's legs in the bed to ensure his care needs were being met. The Administrator confirmed Resident #157 was not receiving all care needed from the nursing facility and he should have had this care done daily according to the physician's orders for care. An observation and interview on 1/10/23 at 04:20 PM, with Certified Nurse Aide (CNA) #4, confirmed Resident #157's legs were not elevated while he was in bed and that she was not aware his legs had to be elevated while in bed. Record review of the Order Summary Report for Resident #157 revealed, Elevate legs in bed at all times. Every Shift. Record review of the admission Record for Resident #157 revealed an admission date of 12/30/22, and diagnoses that included Multiple Fractures of Ribs, Left Side, Sequela, Sarcopenia, History of Falling, and Localized Edema. Record review of the Admission/5-Day Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 1/6/23, for Resident #157 revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating that Resident #157 has moderately impaired cognition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record reviews and facility policy review the facility failed to prevent a resident from obtaining a urinary catheter without a physician's order for one (1) of three (3) residents reviewed. Resident # 35 Findings include: Record review of the policy titled, Physician Orders , revised 3/3/21, revealed : The facility will ensure that Physician orders are appropriately timely documented in the medical record. An observation and interview on 1/08/23 at 10:16 AM, revealed a catheter hanging beside Resident #35's bed. Resident #35 revealed she does not know why she has a tube in her bladder. An observation on 1/10/23 at 7:49 AM, revealed a catheter bag hanging beside the bed in a privacy bag. An observation and interview with the Director of Nursing (DON) on 1/10/23 at 10:01 AM , confirmed Resident #35 does have an indwelling catheter and verified she cannot find an order for the catheter. An interview with Licensed Practical Nurse (LPN) # 4 on 1/10/23 at 12:45 PM, verified she believed resident had catheter about a week but not sure of reason. An interview with the Administrator (ADM) on 01/10/23 at 12:56 PM, confirmed that a possible complication of having an indwelling catheter is an infection. An interview with the Director of Nursing on 1/10/23 at 1:00 PM, revealed a possible complication of having an indwelling catheter is an infection and confirmed Resident #35 was having no symptoms and did not have an order for a urinary catheter .The DON confirmed she received an order to remove the indwelling catheter and monitor for signs and symptoms of retention and urinary tract infection. An interview with LPN #4 on 1/11/23 at 08:28 AM, confirmed the catheter was removed and Resident #35 is being monitored for any concerns. A record review of the Physician's Orders revealed no order for an indwelling foley catheter. A record review of the progress notes for the last month revealed no documentation of the indwelling catheter. A record review of Resident # 35's admission Record revealed she was admitted [DATE] with diagnoses which include, Cerebral Infarction due to embolism of left posterior cerebral artery. Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of the Quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 12/27/2022 revealed Resident # 35 had a Brief Interview for Mental Status (BIMS) of 14 indicating, Resident #35 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #37 During an interview with Resident #37 on 1/8/23 at 3:15 PM, revealed she had not had a bath the previous week and has complained to her nurse about not getting a bath but does not recall which nurse it was. A record review of the Documentation Survey Report v2 revealed Resident #37 has received no showers or bed baths from 1/1/2023 through 1/10/2023. During an interview with Licensed Practical Nurse #1 (LPN) on 1/10/23 at 6:10 AM, she revealed the CNAs do not have enough time to give showers. A record review of Resident's #37's admission Record revealed she was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. A record review of Resident's #37's MDS with an ARD of 10/20/2022 revealed in Section C a BIMS score of 7 indicating severe cognitive impairment and total dependence for bathing in Section G, Functional Status. During an interview on 01/10/23 at 1:00 PM, the Director of Nursing (DON) and the Corporate Nurse revealed that staffing shortages were the main reason residents may not be getting nail care and showers. They both revealed that resident's not getting showers and nail care can lead to medical issues and concerns. Resident #32 An observation on 1/08/23 at 4:00 PM, revealed Resident #32 with a long white beard that was unkept, with a dried orange substance in his beard, nails long with a brown substance under them and wearing a white shirt with stains around the neckline. An observation on 1/09/23 at 09:39 AM, revealed Resident # 32's beard remains with dried orange substance in his beard and nails remain long with a brown substance underneath the nails and still wearing a white shirt with stains. An observation on 1/10/23 at 7:00 AM, revealed Resident # 32 wearing a white shirt with stains around the neck and nails remain long with brown substance under nail beds. An observation and interview on 1/10/23 at 7:37 AM, of Resident # 32 with the Director of Nursing (DON) confirmed Resident #32's fingernails were long with a brown substance under the nails and the resident was wearing a dirty stained white shirt and his beard was long and unkept. Record review of Resident # 32's Documentation Survey Report V2 revealed no documentation of baths given for the month of January 2023 and 15 shifts from January 1 through January 10th with missing documentation for personal hygiene. A record review of Resident #32's admission Record revealed he was admitted [DATE] with diagnoses which include, Hemiplegia and Hemiparesis following a Cerebral Infarction on the right dominant side. A record review of Resident # 32's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/24/2022 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired for decision making. Resident #156 An observation and interview on 1/9/23 at 11:28 AM, with Resident #156 revealed his hair was oily, disheveled, approximately six (6) inches long, extending halfway over his ears and a full beard that was approximately one (1) and a half (1/2) inches long. Resident #156's toenails were approximately 1/2 inch long and were curving over the ends of his toes on both feet. Resident #156's fingernails were approximately 1 third (1/3) of an inch long, extending above the tips of his fingers on both hands, and had a build-up of a black substance under each fingernail on both hands. Resident #156 revealed he wanted his hair washed and cut, he wanted his toenails cut, his fingernails cleaned and cut, and the hair shaved from his face. Resident #156 revealed he did not like looking like this, he liked being well groomed and that no staff had offered to help him with this personal care. He revealed he had not had a full bath or shower since admission to the nursing center. An observation and interview on 1/9/23 at 4:25 PM, with Resident #156 revealed his appearance was the same as the observation at 11:28 AM. Resident #156 revealed he did not normally look this way and he was not satisfied with the level of help he was getting from the nursing staff with his personal care needs. He revealed a CNA had been in his room but did not offer to give him a full bed bath or shower. An observation and interview in Resident #156's room on 1/10/23 at 9:35 AM, with the Director of Nursing (DON) and the Administrator (ADM) confirmed Resident #156's hair was oily, disheveled and long over his ears. They confirmed he had a full beard, approximately 1/2 inches long, his toenails were approximately 1/2 an inch long and curved over the ends of his toes on both feet. They confirmed his fingernails were approximately 1/3 an inch long, extending above the fingertips on both hands, with a build-up of a black substance under each fingernail on both hands. Resident #156 informed the DON and ADM that he did not want long, oily hair, a beard, long, dirty fingernails and long toenails. Resident #156 informed the DON and ADM that no nursing staff member offered to wash or cut his hair, to shave him, to cut or clean his fingernails or toenails, or to give him a full bed bath or shower since he was admitted to the nursing facility and that he wanted to be groomed. The DON confirmed that Resident #156 was not being provided adequate activities of daily living (ADL) care by the nursing facility and he should have received personal care from the nursing staff on the day of admission and the facility was not providing adequate ADL care to the resident according to the resident person-centered needs and requests for service. An observation and interview on 1/10/23 at 4:00 PM, with Certified Nursing Aide (CNA) #4, that worked 7-3 shift. CNA #4 confirmed Resident #156's hair was oily disheveled, long, over his ears a full beard, his toes were long and curved over the ends of his toes on both feet, and his fingernails were long on both hands with a dark substance built up under each fingernail. State Agency (SA) observed as CNA #4 ask Resident #156 if he remembered when she asked if he wanted to be shaved on 12/31/22 and he informed her that no staff had asked him if he wanted his hair washed or cut, shaved clean or cut his fingernails or toenails. CNA #4 revealed she did not remember if she had bathed or showered Resident #156 and confirmed he needed assistance grooming his hair, beard, fingernails and toenails and needed a bath. An observation and interview on 1/10/23 at 4:05 PM, with CNA #5 revealed she partners with CNA #4 with Resident #156's care and confirmed he needed personal care and grooming. Record review of the Documentation Survey Report, for Resident #156, revealed he did not have a bath or shower documented as being completed on the days of January 1, 4, 5, 6, 7, 2023. Record review of the admission Record for Resident #156 revealed an admission date of 12/30/22. Record review of the Diagnosis Information for Resident #156 revealed diagnoses that included Unspecified Protein-Calorie Malnutrition. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/6/23, for Resident #156 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident is cognitively intact. Resident #157 An observation on 1/9/23 at 2:41 PM, with Resident #157 revealed his hair to be 12 inches long, tangled, matted to the back of his head, disheveled, and greasy, his beard was approximately nine (9) inches long, extending down to his chest. Resident #157's fingernails were approximately one fourth (1/4) inches long, with a build-up of a black substance underneath each fingernail on both hands. His toenails were approximately 1/2 inches long, extending above the end of each toe on both feet. Resident #157 noted he wanted his hair washed and combed out, if possible, he did not usually wear his beard this long and really wanted it to be cut and shaped. Resident revealed he would like the nursing facility staff to clean and cut his fingernails and toenails but will not go out to an appointment because it hurts his broken ribs to travel. He revealed he wanted to get groomed and no nursing staff member had offered to wash or comb his hair, offered to cut his beard, offered to cut or clean his fingernails, or offered to cut his toenails. An observation and interview on 1/9/23 at 4:29 PM, with Resident #157 revealed his physical appearance had not changed since the observation at 2:41 PM. Resident #157 revealed a CNA had been in his room but did not offer to assist with washing or combing his hair, cut his beard, cut or clean his fingernails or toenails. An observation and interview on 1/10/23 at 9:40 AM, with the DON and the ADM confirmed that Resident #157's hair was long, tangled, and matted on the back of his head, disheveled, and greasy. They confirmed his beard was long and extended down to his chest, his fingernails were long, with a black residue underneath every fingernail, and his toenails were long, extended above the end of each toe on both feet. The SA observed Resident #157 as he informed the DON and ADM that he believed his hair will have to be cut off because it was matted to his head and too tangled to comb out and informed them that he did not like for his beard, fingernails and toenails to be long. The DON noted that Resident #157 was not a diabetic and should have received assistance from nursing staff to have his fingernails and toenails cut. The DON noted Resident #157 should have been receiving personal grooming beginning at the time of his admission to the nursing facility and confirmed that the facility was not providing adequate, person-centered ADL Care. The ADM confirmed that the resident was not being provided adequate care by the nursing facility. An observation and interview on 1/10/23 at 4:05 PM, with CNA #4 confirmed that Resident #157's hair was approximately 12 inches long, tangled, matted, disheveled and greasy, his beard was long, extended down to his chest, his fingernails appeared to be approximately 1/4 inches long, with black residue underneath every fingernail, and his toenails were approximately 1/2 inches long, extending above the end of each toe on both feet. The SA observed Resident #157 as he informed CNA #4 he did not remember any staff offering to cut his beard. CNA #4 revealed she could not recall an offer to cut or clean the resident's fingernails or toenails and did not recall an offer to give him a bed bath or shower. CNA #4 did confirm Resident #157 needed care to his hair, beard, fingernails, toenails and needed a bath. An observation and interview on 1/10/23 at 4:05 PM, with CNA #5 revealed she partners with CNA #4 to provide care for Resident #157 and confirmed the resident's hair was long, tangled, matted, disheveled, and greasy, his beard was long and extended down to his chest, his fingernails were long with black residue underneath every fingernail on both hands and his toenails were long and extended above the end of each toe on both feet. CNA #5 confirmed she did not offer to wash or comb Resident #157's hair, cut or clean his fingernails or toenails, and provide him with a bed bath or shower. Record review of the admission Record for Resident #157 revealed an admission date of 12/30/22, and had diagnoses that included Multiple Fractures of Ribs left Side, Sequela, Sarcopenia, History of Falling and Localized Edema. Record review of the Documentation Survey Report, for Resident #157 revealed that no bed bath or shower was documented as being completed on the days of January 1, 4, 5, 6, and 7, 2023. No documentation was provided by the nursing facility for December 30-31, 2022. Record review of the Admission/five day MDS with an ARD of 1/6/23 revealed a BIMS score of 10 that indicates the resident has moderately impaired cognition. Based on observations, staff and resident interviews, record reviews and facility policy review the facility failed to provide showers, shaving and nail care for six (6) of 54 residents reviewed for activities of daily living. Resident # 7, Resident # 13, Resident #32, Resident # 37, Resident # 156, Resident # 157 Findings include: A review of the facility policy titled Bathing/Showering with a revision date of 4/20/2022 revealed Policy The resident preferences on bathing/showering will be reviewed and identified upon admission, including frequency, and other preferences . A review of the facility policy titled Shaving Residents with a revision date of 9/5/2017 revealed the policy did not address the frequency of shaving. A review of the facility policy titled Care of Nails with a revision date of 9/1/2017 revealed the policy did not address the frequency of nail care. Resident #7 An observation on 01/08/23 at 3:30 PM, revealed Resident #7 sitting up in his wheelchair in his room with long jagged nails on his right hand. An observation on 01/09/23 at 9:22 AM, revealed Resident #7 sitting up in his wheelchair in his room with long jagged nails on his right hand. An observation on 01/09/23 at 4:25 PM, revealed Resident #7 sitting up in his wheelchair in his room with long jagged nails on his right hand. An observation and interview on 01/10/23 at 6:10 AM, with Licensed Practical Nurse (LPN) #2 confirmed that Resident #7 had long jagged fingernails and they needed to be trimmed. She revealed the purpose for trimming the resident's nails was to prevent infection and injury from scratches and she was not sure why they had not been trimmed. An interview and observation on 01/10/23 at 11:40 AM, revealed Certified Nurse Assistant (CNA) #2 trimming Resident #7's nails. She confirmed that the resident's nails were too long. An interview on 01/11/23 at 7:30 AM, with LPN #3 revealed that nails need to be trimmed to prevent skin issues and infection control issues. She revealed if the resident is not a diabetic then the CNAs are responsible for trimming the resident's nails as needed. She confirmed that Resident #7 is not a diabetic and the plan of care is in the resident's paper record which the CNA's have access to. An interview on 01/11/23 at 7:45 AM, with LPN #4 revealed that nails need to be trimmed to prevent infections and the plan of care is on the record for any staff to see. She revealed the CNA's can look at the resident's record to see if they are a diabetic. An interview on 01/11/23 at 8:00 AM, with CNA #1 revealed he is responsible for doing Resident #7's nails. He revealed it was his fault that the resident's nails were long and needed trimming, because he thought the resident was a diabetic and the treatment nurse was going to do it. He revealed he should have looked at the resident's record to verify he was a diabetic. He revealed that Resident #7 has had a stroke that affected his right side, so he cannot trim his own nails. An interview on 01/11/23 at 11:00 AM, with the Director of Nurses (DON) confirmed that Resident #7 could not trim his own nails. Record review of Resident #7's admission Record indicated the resident was admitted to the facility on [DATE] with medical diagnoses that included Contracture of the right hand and Cognitive communication deficit. Record review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 12/31/22 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 06 which indicates the resident has severe cognitive impairment. Resident #13 An interview with Resident #13's daughter on 01/09/23 at 10:10 AM, revealed that her mother goes multiple days without showers. She stated that her mother wore the same gown last week on Friday and Saturday and then on Sunday staff came in and changed her gown but did not bathe her. She states they do not have enough staff to take care of the residents. She stated the resident's legs were discolored and when she wiped her leg it was brown like dirt. Resident #13's daughter stated she verbalized her concerns to the Minimum Data Set (MDS) Nurse. A review of the Documentation Survey Report v2 revealed Resident #13 had not had a shower or bath from 1/1/23 through 1/10/23. An interview on 01/10/23 at 7:25 AM, with CNA #1 revealed that many times there are only two (2) CNAs on duty so residents may not get a shower, but he tries to give them a good bed bath. An interview on 1/10/23 at 7:30 AM, the MDS nurse stated that she did receive a concern from Resident #13's daughter regarding not receiving showers. The MDS nurse stated that she addressed the concerns with the Certified Nursing Assistants (CNAs). A record review of Resident #13's admission Record revealed she was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia unspecified, affecting right dominant side. A record review of Resident #13's MDS with an Assessment Reference Date (ARD) of 12/15/2022 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 3 , indicating severe cognitive impairment and extensive assistance for bathing in Section G, Functional Status.

Based on observations, staff and resident interviews and facility policy review the facility failed to follow the approved resident menu for one (1) of nine (9) meals observed. Findings include: Record review of the facility policy titled, Menus with no revision date revealed under Policy .Menus are planned by a registered dietitian to meet the nutritional needs of the residents. Menu items are adjusted as needed to meet the regional and cultural preferences of the resident population. Record review of the facility policy titled, Meal Substitutions with no revision date revealed under the Policy .All Menu substitutions will be of equal nutritional value and be documented. Initial tour of the kitchen on 01/08/23 at 3:15 PM, revealed Dietary Staff #1 was preparing ham and cheese sandwiches for the resident's dinner. An observation on 01/08/23 at 4:50 PM, revealed that residents' dinner meal consisted of a ham and cheese sandwich with some chips. An interview on 01/09/23 at 1:15 PM, with Dietary Staff #1 and #2 confirmed that the menu for the dinner meal on 01/08/23 should have included chicken noodle soup, ham and cheese sandwich, lettuce/tomato/onion, potato salad and fresh fruit. Dietary Staff #1 confirmed that she did not follow the menu, because she was tired from being there all day. Dietary Staff #1 confirmed that the residents only got a ham and cheese sandwich and some chips for dinner on Sunday night 01/08/23. Dietary Staff #1 revealed that it was her responsibility to follow the menu. Dietary Staff #2 revealed they are out of potato salad, and they are allowed to make substitutions and she could have substituted canned fruit for the fresh fruit. Dietary Staff #1 and #2 confirmed that soup and fruit should have been served with the resident's dinner last night and that the menus are developed by dieticians in order to make sure the residents are getting the correct nutrition and if they do not follow the menu then the residents are not getting the nutrition they need. An interview with Resident #3 on 01/09/23 at 2:08 PM, revealed that sometimes they do not get served the food that is on the menu, and it usually happens on the weekends, but it has not happened very often. An interview on 01/10/23 at 4:20 PM, with the Director of Nurses (DON) confirmed the dietary staff need to follow the Registered Dietician approved menus for the residents in order to provide the correct nutrition. An interview on 01/11/23 at 9:49 AM with the Registered Dietician (RD) revealed she comes to the facility once per month or more if needed. She revealed that she has had an issue with the dietary staff not serving what was on the menu one time before and she addressed it with the Dietary Manager (DM) that was at the facility at that time. She revealed that the DM is not at the facility anymore. Record review of the menu for 01/08/23 dinner meal revealed that the meal should have consisted of chicken noodle soup, ham and cheese sandwich, lettuce/ tomato/ onion, potato salad and fresh fruit.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that there were sufficient nursing staff in the facility to provide adequate care and assistance for residents for three (3) of four (4) days of survey. Findings include: Cross reference F677. Review of the PBJ Staffing Data Report revealed for Fiscal Year Quarter 4 2022 (July 1-September 30) revealed the facility triggered for one star staffing Rating and for Excessively Low Weekend Staffing. Record review of a typed document on facility letterhead, undated, and signed by the facility Administrator revealed, .We are currently unable to provide the above requested information/documentation, due to not having said policy. An entrance interview with the Director of Nursing (DON) and the Administrator (ADM) on 1/08/23 at 3:30 PM, revealed the DON is also working as the Infection Control Nurse, Staffing Nurse and Floor Nurse if needed. The ADM confirmed they are actively trying to hire staff and that she had only been employed at the facility for one week. During an interview with Licensed Practical Nurse (LPN) #1 on 1/9/23 at 3:35 PM, she stated that she usually works the 11 PM to 7 AM shift, but since they have been so short staffed she has been coming in at 3:00 PM and usually works three (3) extra shifts from 3 PM to 11 PM every week. An interview on 01/10/23 at 5:30 AM, with CNA #3, revealed there were 3 CNA's on duty for 11PM to 7 AM shift last night, and there are only two (2) CNAs that are direct hires of the facility for 11 PM-7 AM shift and they fill in with agency staff. CNA #3 revealed there have been times where there were only one (1) CNA on duty for 11 PM-7 AM and times where there were only 2 CNAs for that shift. She revealed that when they have just 2 CNAs on duty they do not give showers, because they don't have time to do that and their rounds. CNA #3 revealed they always make sure the residents are turned and changed as close to every 2 hours, no matter how many CNAs are on duty. She revealed she pulls a double shift about 3 days per week because they are short staffed. An interview on 01/10/23 at 6:02 AM, with LPN #5, revealed there were 2 LPNs and 3 CNAs on duty for this 11 PM-7 AM shift. She revealed the least amount of CNAs she has had on this shift is 2 since she has been here the last 3-4 weeks. She revealed she does not feel like they have enough staff on duty when there are only 2. An interview on 01/10/23 at 7:25 AM, with CNA #1, revealed that they are supposed to have four (4) CNAs on the day shift , but that sometimes it is just 2. CNA #1 revealed the residents may not get a shower, but he tries to give them a good bed bath. He revealed we do need more staff and I hope they get us some, because we are doing the best we can. During an interview on 01/10/23 at 7:40 AM, with the Director of Nursing (DON) revealed she is responsible for wound treatments, but does have an agency Registered Nurse (RN) that comes in at night some and a PRN (As Needed) RN that works a few days a month and both of those RN's help with wound treatments. She confirmed that there are 25 wound treatments due today. An interview with the ADM on 01/10/23 at 8:40 AM, revealed she has contacted the corporate office about halting admissions due to low staffing, and confirmed when the facility is low on staff there is no possible way they can provide all the care they are supposed to with the current census. An interview on 01/10/23 at 11:06 AM, with the DON, the Minimum Data Set (MDS)/Careplan Nurse, Corporate Nurse and ADM all confirmed they need more staff. They confirmed that they felt like they did not have enough staff to take care of the number of residents they currently have. The ADM revealed they had two new admissions coming today. All four (4) revealed they have no control over halting admissions, that would be a corporate decision. An interview on 01/10/23 at 1:00 PM, with the DON and Corporate Nurse revealed that staffing shortages were the main reason residents may not be getting nail care and showers. They revealed that resident's are not getting showers and nail care. An interview on 01/11/23 at 9:34 AM, with the DON, ADM and the Corporate Nurse confirmed that according to the past 14 days on the staffing grid, the facility had been short a lot.

Based on record review, staff interview and facility policy review, the facility failed to complete a Discharge Minimum Data Set (MDS) Assessment for one (1) of 18 MDS assessments reviewed, Resident #2. Findings include: Review of a facility statement, dated 10/2/19, signed by the Administrator, revealed, All Minimum Data Set MDS assessments are completed as required by the Resident Assessment Instrument (RAI) Manual. Review of the RAI OBRA - required Assessment Summary (cont.), page 2-17, October 2018, revealed, Discharge Assessment - return not anticipated (Non-comprehensive) MDS Completion Date (Item Z0500B) No Later Than discharge date + 14 calendar days, Transmission Date No Later Than MDS Completion Date + 14 calendar days . Review of the MDS Tracking/Discharge Roster revealed Resident #2's Discharge Assessment Reference Date (ARD) was 5/30/19, and the assessment had not been submitted; the assessment was 111 days overdue. Review of the Physician's Order Sheet revealed an order, dated 5/24/19, to discharge the resident to a Personal Care home on 5/28/19 - 5/29/19. During an interview, on 10/02/19 at 10:00 AM, Licensed Practical Nurse #1(LPN)/ MDS Coordinator, stated, She's on my case mix roster. It wasn't done, I don't know what happened in May, I have been in MDS for two (2) years. She stated she usually had assessments done by day three (3) of the ARD. LPN #1 confirmed Resident #2's discharge assessment should have been done, signed, and completed by 6/2/19. In an interview on 10/2/19 at 11:00 AM, the Administrator stated it was the policy of the facility to follow the RAI Manual for submission of the MDS.

Based on record review, staff interview, and facility policy review, the facility failed to ensure that a Discharge Minimum Data Set (MDS) Assessment was completed accurately for one (1) of 18 MDS reviewed, Resident #52, as evidenced by the MDS was coded for discharge to the hospital and the resident was discharged home. Findings include: Review of the Resident Assessment Instrument (RAI) for MDS coding, used by the facility for their policy, revealed to review the medical record, including the discharge plan and discharge orders, for documentation of the discharge location. Review of the discharge Minimum Data Set (MDS) for Resident #52, with an Assessment Reference Date (ARD) of 7/2/19, revealed in section A2100 the discharge status was to an Acute Hospital. Review of the physician's orders, dated 7/2/19, revealed Resident #52 was to be discharged home with Home Health for follow-up care. On 10/1/19 at 4:54 PM, an interview with the Director of Nursing (DON) confirmed Resident #52's discharge MDS with the Assessment Reference Date (ARD) of 7/2/19, was coded for discharge to an acute hospital and the resident was discharged home. The DON stated she remembered the resident went home with Home Health. On 10/2/19 at 3:28 PM, an interview with Licensed Practical Nurse (LPN) #1/MDS Coordinator, confirmed the discharge MDS for Resident #52, on 7/2/19, was coded as being discharged to the acute hospital and he was discharged home with Home Health. LPN #1 revealed she does not know how it got coded wrong.