**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that were accurately documented for one (1) of eight (8) sampled residents. Resident #1.Findings include:Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, schizoaffective disorder-bipolar type with onset date 11/02/22 (upon admission). There was no diagnosis of dementia included. Record review of the Social Service Progress Review for Resident #1 dated 7/07/2023 revealed that the resident had impaired daily decision making with described impairment listed as resident has dementia. Record review of the Social Service Progress Review for Resident #1 dated 2/02/2024 revealed the that the resident had impaired daily decision making with described impairment listed as resident has dementia.Record review of the Social Service Progress Review for Resident #1 dated 6/11/2024 revealed the assessment indicated that the resident had impaired daily decision making with described impairment listed as resident has dementia and is manic depressive.On 8/25/25 at 8:15 AM, an interview with the Complainant revealed she had concerns related to Resident #1 had not received appropriate assessment, diagnostic tests or diagnosis while a resident at the facility, therefore rendering her care not appropriate for her actual condition, which she alleged was not discovered until she had discharged from the facility, spent a month at a different facility where she suffered a severe fall and head trauma and then spent a number of days at a third facility where she suffered a second severe fall with additional head trauma. She stated that she was in no way alleging that Resident #1 had not suffered from psychiatric illness of schizoaffective disorder-bipolar type but instead said that it was her belief that she also suffered from frontotemporal dementia. She stated that she was confused because after Resident #1 discharged from the facility she obtained a copy of her entire medical record and noted three (3) documents, specifically social services review notes, which clearly stated that the resident had dementia.On 8/26/25 at 5:17 PM, during a telephone interview with the former Social [NAME] Director (SSD), she stated that she was aware but concerned that Resident #1 showed signs of dementia and discussed this with the interdisciplinary team (IDT). She confirmed that she was aware that the resident had multiple head CT scans during her residence at the facility. She confirmed that she had documented that the resident had dementia in her notes throughout Resident #1's residence at the facility. She stated that the documentation was in error and said she thought she had inaccurately documented the resident's diagnosis of dementia and manic depression because, maybe I thought I heard someone say that. She confirmed that she had not reviewed Resident #1's diagnosis list or medical record to ascertain her actual diagnoses. On 8/27/25 at 3:30 PM, during a telephone interview the primary healthcare provider (physician) confirmed that Resident #1 was admitted by the facility with diagnosis of schizoaffective disorder-bipolar type. He said the during Resident #1's stay at the facility he received regular reports from his Nurse Practitioner (NP) and that the resident's behaviors were in line with the signs and symptoms of her diagnosis. He confirmed that the signs and symptoms exhibited by Resident #1 were also associated with frontotemporal dementia and that usually radiographic study may reveal the differential diagnosis. He confirmed that the resident had multiple head CT scans during her residence at the facility, read by a radiologist with no noted change or addition to the diagnosis she had at the time of admission by the facility. He stated that if he had been made aware of a new diagnosis the treatment would not have changed, because the treatments are basically the same in as much as the symptoms/behaviors were targeted and treated the same. He stated that he did not believe that the resident was inappropriately placed and said that her preexisting diagnosis would have limited her appropriateness for dementia or memory care units. He stated that since the resident had been diagnosed with impaired cognition of unknown etiology, the facility care planned and provided care in the same manner to a resident who had an official dementia diagnosis. On 8/27/25 at 4:30 PM, during an interview the Director of Nursing (DON) confirmed that Resident #1 did not have a diagnosis of dementia during her residence at the facility but did have a care planned diagnosis of impaired cognition. She confirmed that any documentation of dementia was inaccurate. She stated that resident diagnoses were listed in their entirety on each resident's admission record. She confirmed that it was important for documentation to be accurate for each resident in order for staff to provide appropriate patient centered care and that inaccurate documentation could result in care for the resident that was not directed towards the needs of the resident. On 8/27/25 at 5:00 PM, during an interview the Executive Director (ED) stated that Resident #1 did not have a diagnosis of dementia during her residence at the facility but did have a care planned diagnosis of impaired cognition. She confirmed that any documentation of dementia was inaccurate. She confirmed that resident diagnoses were listed in their entirety on each resident's admission record. She confirmed that it was important for documentation to be accurate for each resident in order for staff to provide patient centered care and that inaccurate documentation could result in care for the resident that was not directed towards the needs and strengths of the resident at either the facility or at other admitting facilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to complete a Significant Change in Status Assessment (SCSA) after a return from the hospital with a newly inserted PEG (Percutaneous Endoscopic Gastrostomy) tube and a Stage IV sacral pressure ulcer for one (1) of (20) sampled residents, Resident #33. Findings include: A review of the facility's Minimum Data Set (MDS) policy, revision date 9/25/2017, revealed, .The center conducts initial and periodic standardized, comprehensive and reproducible assessments no later than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and or/state required RAI (Resident Assessment Instrument) . On 03/24/25 at 3:59 PM, Resident #33 was observed with enternal feeding flowing at 50 cc (cubic centimeters)/hour. The head of the bed was elevated to 45 degrees. The resident was lying in bed with eyes closed. On 03/26/25 at 4:28 PM, during an interview with the Corporate Nurse, she stated she was aware that Resident #33 returned from the hospital with a sacral wound and a PEG tube. On 03/27/25 at 12:04 PM, during an interview with Registered Nurse (RN) #1, who also serves as the MDS and Care Plan Nurse, she stated she forgot to complete a Significant Change in Status Assessment for Resident #33. She explained that a significant change assessment is completed to notify staff of a resident's care needs and acknowledged it should have been completed when the resident returned from the hospital with a PEG tube and Stage IV sacral wound. Record review of the re-entry MDS dated [DATE] revealed the resident returned from a short term general hospital but there was not a Significant Change MDS completed. A record review of Resident #33's admission Record revealed an admission date of 09/11/18 with diagnoses including Osteomyelitis of vertebra sacral and sacrococcygeal region. A record review of Resident #33's Physician Orders dated 03/14/25 revealed continuous Glucerna 1.5 at 50 ml(milliliters)/hour with 120 ml water flush every four hours, providing 1800 kcal (kilocalories), 100 grams of protein, and 910 ml of free water. Orders also included PEG tube feedings twice a day for dietary support. Wound care orders included cleansing the sacral wound with normal saline or wound cleanser, patting dry, applying normal saline wet-to-dry gauze, and covering with a bordered dressing. A review of Resident #33's Annual MDS with an Assessment Reference Date (ARD) of 01/01/25 revealed severely impaired cognition.

Based on observation, interview, record review, and facility policy review, the facility failed to accurately complete the Minimum Data Set (MDS) resident assessment, as evidenced by Resident #47 was coded for enteral feeding incorrectly and Resident #7 was not accurately coded as having a diagnosis of schizophrenia for two (2) of (20) sampled residents. Findings Include: A review of the facility's MDS policy, revision date 9/25/2017, revealed, .The center conducts initial and periodic standardized, comprehensive and reproducible assessments no later than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and or/state required RAI (Resident Assessment Instrument) . Resident #47 A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 02/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section K erroneously indicated in item K0520 Nutritional Approaches that the resident had a feeding tube. On 03/25/25 at 8:46 AM, during an observation and interview with Resident #47 she revealed she had never had a feeding tube since being admitted to the facility. She stated she ate whatever she wanted and had no problems with swallowing. On 03/25/25 at 2:55 PM, during an interview with Licensed Practical Nurse (LPN) #3, she explained Resident #47 had never had a feeding tube since she had been in the facility. She stated the resident had plenty of snacks and ate what she wanted. On 03/26/25 at 3:30 PM, during an interview with Certified Nurse Aide (CNA)#1, she confirmed Resident #47 ate well, had never had a feeding tube, and ate snacks regularly. On 03/26/25 at 3:50 PM, during an interview with Registered Nurse (RN)#1, she explained each interdisciplinary team member completed their assigned Minimum Data Set (MDS) sections, and she only signed off to mark the assessment as complete, but did not ensure accuracy. After reviewing Resident #47's Quarterly MDS with an ARD of 02/26/25, she confirmed the resident was incorrectly marked as having a PEG tube. She stated the resident had never had a PEG tube since admission. On 03/26/25 at 4:00 PM, during an interview with the Dietary Manager, she confirmed she completed Section K (nutrition) of the MDS for each resident and had held this position at the facility for five (5) years. She explained her usual process involved reviewing resident weights and physician orders prior to completion. She reviewed the Quarterly MDS with an ARD of 02/26/25 for Resident #47 and confirmed she erroneously marked the resident as having a PEG tube, explaining she must have confused the resident's record with another and selected the item in error. On 03/27/25 at 12:30 PM, during an interview with RN #1, she confirmed the MDS error was due to an incorrect entry by the Dietary Manager. She stated her expectation was that MDS assessments reflect residents' actual conditions. She explained that inaccurate assessments could lead to incorrect reimbursement, but this MDS had already been corrected and would not impact reimbursement. A record review of Resident #47's admission Record revealed the facility admitted the resident on 11/02/22 with diagnoses including Personal History of Transient Ischemic Attack (TIA) and Cerebral Infarction Without Residual Deficits. A record review of the Order Summary Report with active orders as of 3/25/25 revealed no orders for tube feeding. Resident #47 had a regular diet, regular texture, and regular/thin liquids consistency. Resident #7: A record review of the admission Record revealed the facility admitted Resident #7 on 01/02/24 with a diagnosis of Schizophrenia, Unspecified. A record review of the 5-Day MDS with an ARD of 02/11/25 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Section I item I6000 was not coded for a diagnosis of Schizophrenia. On 03/24/25 at 1:30 PM, during an interview and confirmation with the Nurse Consultant, she confirmed Resident #7 had a diagnosis of Schizophrenia upon admission. On 03/27/25 at 2:23 PM, during an interview with RN #1, she confirmed the MDS was inaccurately coded regarding the resident's active diagnoses. She stated Resident #7 had a diagnosis of Schizophrenia, and it was missed in error.

Based on interviews, record reviews, and a review of the facility's policy, the facility failed to complete a Pre-admission Screening (PAS) accurately for a resident with a diagnosis of Schizophrenia on admission for one (1) of two (2) sampled residents for Preadmission Screening and Resident Review (PASRR) Level II. Resident #7. Findings include: A review of the facility's policy, Preadmission Screening and Resident Review (PASRR), with a revision date of 11/08/2021, revealed, . The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines . It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II are conducted and results obtained prior to admission . If it is learned that after admission that a PASRR Level II screening is indicated it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results . Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency . On 03/24/25 at 11:00 AM, during an interview with the Nurse Consultant, she explained the resident did have a PAS screening and did not require a PASRR Level II on admission. A record review of the PAS revealed the resident had a diagnosis of mental illness and had been taking medications. A record review of the resident's admission Record revealed the facility admitted the resident on 01/02/2024 with the diagnosis of Schizophrenia, Unspecified. The Proper Name discharge paperwork dated 01/01/2024 noted a diagnosis of Chronic Schizophrenia. A record review of the resident's 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/11/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section E revealed no behavior in the seven (7)-day lookback. Section I was not coded for Schizophrenia. On 03/24/25 at 01:00 PM, during a phone interview with a staff member from the Level II screening provider, she explained that the documentation provided at the time of the PAS screening did not include the diagnosis of Schizophrenia or the psychotropic medications. She stated the facility should have completed a Status Change once the resident had the diagnosis and after being admitted to an inpatient psychiatric unit. On 03/24/25 at 01:30 PM, during an interview with the Nurse Consultant, she confirmed that Resident #7 had a diagnosis of Schizophrenia on admission, and the PAS screen dated 01/02/2024 did not include this diagnosis. On 03/26/25 at 04:00 PM, during an interview with Social Services, she explained that the PAS screenings are completed prior to admission by the Corporate Office. On 03/27/25 at 12:15 PM, during a phone interview with a corporate staff member, she reported that she completes admissions and the PAS screenings for the facility. She did not remember the resident or the PAS screening but stated that she uses the information from the admission orders to complete the screening and acknowledged she missed the diagnosis of Schizophrenia. On 03/27/25 at 03:30 PM, during an interview with the Interim Administrator and the Nurse Consultant, both explained that the facility and management expect PAS screenings to be completed accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility policy review, the facility failed to send a Status Change for Preadmission Screening and Resident Review (PASRR) after a resident was admitted to an inpatient behavioral health unit for one (1) of two (2) sampled residents reviewed for PASRR, Resident #7. Findings included: A review of the facility ' s policy, Preadmission Screening and Resident Review (PASRR), with a revision date of 11/08/21, revealed .The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines .Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II are conducted and results obtained prior to admission .4. If it is learned that after admission that a PASRR Level II screening is indicated it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results .7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency . A record review of Resident #7's admission Record revealed the facility admitted the resident on 01/02/24 with the diagnoses of Schizophrenia, Unspecified. A Discharge summary dated [DATE] also noted Chronic Schizophrenia. A record review of Resident #7's Order Summary Report with active orders as of 03/26/25 revealed orders May refer to Behavioral Health Unit (BHU) order date 1/22/25 . May refer to (Name of local BHU) order date 4/02/24 . May transfer to (Proper Name of County Hospital) BHU order date 4/03/24. A record review of Resident #7's Discharge Minimum Data Sets (MDS) with Assessment Reference Dates (ARDs) of 04/03/24 and 01/23/25 revealed discharge to an inpatient psychiatric facility. On 03/25/25 at 3:25 PM, during an interview with Licensed Practical Nurse (LPN) #3, she explained that Resident #7 had exhibited ongoing behavioral issues toward both staff and residents. She stated that prior to the most recent transfer to the BHU, the resident had become upset with staff and broke the facility door. She added that the resident continues to curse at staff, particularly when denied cigarettes. She noted the resident used to refuse medications but has been more compliant since returning from the BHU. On 03/26/25 at 4:00 PM, during an interview with the facility's Social Services, she explained that PASRR Level I screenings are completed by the corporate office prior to admission. She stated that if a status change occurs, she is responsible for submitting a referral for a PASRR Level II, which should be done within seven (7) days of the resident's return. On 03/27/25 at 10:00 AM, during a follow-up interview with Social Services, she reviewed Resident #7's medical records and confirmed that the resident had been transferred to an inpatient BHU on 04/03/24 and again on 01/23/25. She acknowledged that no Status Change was submitted following either admission and stated it was an oversight. She reported that she had initiated an audit of all residents who may require a PASRR Level II. On 03/27/25 at 3:30 PM, during an interview with the Interim Administrator and the facility's Nurse Consultant, both stated that it is the facility's expectation that PASRR screenings be completed accurately and that Status Change referrals be submitted in a timely manner when required.

Based on interviews, record review, and facility policy review, the facility failed to implement the baseline care plan related to pain medications for one (1) of (1) residents reviewed for baseline care plan implementation. (Resident #169). Findings included: A review of the facility's policy, Plans of Care, with a revision date of 09/27/17, revealed, . An individual person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements . Procedure: . Develop and implement an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, and other areas needed 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 . A record review of the Baseline Care Plan dated 03/22/25 revealed a goal for Resident #169 to maintain comfort to the highest degree possible. Interventions included monitoring for pain, administering pain medications as ordered, and eliminating or reducing causative factors. A record review of Resident #169's admission Record revealed the facility admitted the resident on 03/22/25 with diagnoses including Functional Quadriplegia, Generalized Anxiety Disorder, and Low Back Pain. A record review of Resident #169's Hospitalist admission History and Physical dated 01/12/25 revealed diagnoses of Neck Pain and Pain. A record review of Resident #169's Order Summary Report with active orders as of 03/25/25 revealed Oxycodone HCL 10 mg PO every four (4) hours as needed for severe pain; and Oxycodone HCL 20 mg PO every four (4) hours as needed for pain. A record review of the Medication Administration Record (MAR) revealed no Oxycodone was administered until 03/25/25 at 9:05 AM with a documented pain level of 10. On 03/22/25 and 03/23/25, medications were not administered or marked as refused. A record review of Resident #169's admission Data Collection dated 03/22/25 at 04:16 (AM) revealed .B. Cognition . alert, oriented to person, place, time, memory okay L. Resident experiencing pain. If yes, complete additional pain evaluation .N1. Contractures .Fingers, hand, wrist, elbow, shoulder of dominant side/Non Dominat side .Strength .Weakness, paresis, paralysis of upper extremity . Resident arrived at the facility at approximately 4:00 AM and required assistance d/t (due to) paralysis of upper extremities. There was no record of an additional pain evaluation noted as required in Section L (Pain). A review of Resident #169's Progress Notes from 03/22/25 to 03/28/25 revealed multiple complaints about pain and lack of medications. Notes from 03/22/25 through 03/24/25 document ongoing complaints about pain and the lack of medication, with the first administration of Oxycodone recorded on 03/25/25 at 9:05 AM. On 03/24/25 at 11:45 AM, during an interview and observation, Resident #169 was observed lying in bed, alert and oriented to person, place, and time. The resident reported being admitted on Saturday, 03/22/25, at 5:45 AM and stated he had experienced a difficult weekend and planned to leave the facility as soon as possible. He further explained he had not received his pain medications all weekend because the pharmacy did not deliver them. He stated that while the Duragesic patch was acceptable, he required his other medications, specifically Oxycodone. He reported that therapy staff said they would follow up on the medications, but he had not seen them again. On 03/26/25 at 3:50 PM, during an interview with the Care Plan Nurse, she confirmed the presence of a pain care plan but stated it was the responsibility of the staff to follow the plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to adhere to accepted standards of practice for the timely replacement of oxygen tubing for one (1) of four (4) residents observed with oxygen in use, Resident #18. Findings included: A review of the facility policy Equipment Change Schedule, dated 11/30/14, revealed: Policy: An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer ' s recommendations and standards of practice. Procedure: Equipment/When Changed . Nasal Cannula, every seven (7) days or when contaminated . On 03/24/25 at 12:58 PM, during an observation, Resident #18 was lying in bed. Oxygen was flowing at two (2) liters per minute via nasal cannula. The oxygen tubing was dated 02/10/24. There was no signage posted on the door indicating oxygen was in use. On 03/24/25 at 5:45 PM, during an interview and observation with the Licensed Practical Nurse (LPN)/Infection Preventionist (IP) in Resident #18 ' s room, she confirmed there was no oxygen-in-use signage on the door and that the tubing was dated 02/10/24. She stated the tubing is supposed to be changed every Sunday on night shift and acknowledged the tubing may be nasty. The tubing was discolored and cloudy. The LPN/IP confirmed signage should be posted to make staff and visitors aware that oxygen was in use. A review of Resident #18's admission Record revealed the resident was admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD). A review of Resident #18's Physician Orders revealed an order for oxygen at two (2) liters per minute via nasal cannula as needed for oxygen saturation less than 92% or dyspnea. A review of Resident #18's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/25 revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete an interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the needs of the residents for one (1) of (20) sampled residents, with the potential to affect all residents, Resident #67. Findings included: A record review of a signed statement, undated, from the Interim Administrator revealed: Facility staffs according to census, acuity and/or facility assessment based on resident needs. A review of the Facility assessment dated [DATE] revealed: .Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff to meet each resident ' s needs . Licensed nurses providing direct care equaled 9, Nurse Aides equaled 21, Other Nursing personnel (e.g., those with administrative duties) equaled 3 . Describe your general staff plan to ensure that you have sufficient staff to meet the needs of the residents at any given time . Director of Nursing (DON) . 1 Registered Nurse (RN) DON . 1- RN as Assistant DON (ADON) . 1 Staff dev. Licensed Practical Nurse (LPN) . 1 wound care LPN . RN Charge 7-3 (1) 3-11 (1) 2 LPN days and evening and 2 LPN nights . Direct care staff days 8 . evening 7 . nights 6 . Resident #67 On 03/24/25 at 12:38 PM, during an interview and observation with Resident #67, she was observed lying in bed with visible hair under her chin. The resident stated she wanted her chin hair shaved and explained that her last shower was on the prior Thursday. The room had a strong odor of urine. She stated she used to receive bed baths three times per week. A review of Resident #67 ' s admission Record revealed an admission date of 02/25/25 with diagnoses including Muscle weakness, other reduced mobility, and Lack of coordination. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was cognitively intact. Section GG revealed the resident was dependent for bathing and showers. On 03/24/25 at 4:10 PM, during an interview with Certified Nurse Aide (CNA) #2, she stated she worked part-time on both the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts. She explained that the number of CNAs varied by day and shift, ranging from as few as three (3) to as many as ten (10). When only three CNAs were present, it was difficult to check and change residents every two (2) hours, and residents had to wait longer for care. On 03/25/25 at 9:10 AM, during an interview with CNA #3, she reported caring for an average of sixteen (16) residents per shift, depending on staffing. She explained the average number of CNAs was five (5), but there were days with fewer. On those days, residents often had to wait longer for care and might not receive scheduled showers. On 03/25/25 at 1:10 PM, during an interview with CNA #6, she stated she typically worked eight (8)-hour shifts but had recently worked more twelve (12)-hour shifts due to staffing shortages. She cared for six (6) to (10) residents per shift. She reported that residents may have to wait longer than two hours to be changed or repositioned when staffing was low, and showers were sometimes delayed when a designated shower aide was unavailable. On 03/25/25 at 2:55 PM, during an interview with Licensed Practical Nurse (LPN) #3, she reported working (12)-hour shifts on a rotating schedule. She cared for over (30) residents and sometimes more, depending on the census. She explained she had worked extra hours and days to help cover due to ongoing staffing shortages among nurses and CNAs. On 03/26/25 at 8:24 AM, during an interview with LPN #2, she stated she worked in medical records but was currently working the medication cart due to low staffing. She stated, I worked last night, went home for a couple of hours, and I'm back this morning. On 03/26/25 at 10:05 AM, during an interview with CNA #4, she reported working all shifts and was called in to work that day. She cared for approximately (15) residents per shift. She stated that some days there was a designated shower aide and other days there was not. She explained that due to low staffing, residents had to wait extended periods for care and noted that only small gloves were available, which made providing care difficult. On 03/26/25 at 11:50 AM, during an interview with CNA #5, she stated she worked part-time, primarily on the 7:00 AM-3:00 PM shift. She reported having over (20) residents on some shifts when only (3) CNAs were present. On those days, residents were often not gotten out of bed and had to wait extended periods to be changed. On 03/26/25 at 12:48 PM, during an interview with CNA #7, who also worked in restorative care, she stated that due to CNA shortages, she worked on the hall in addition to her restorative and whirlpool duties. She worked as a restorative aide (2) to (3) days per week and as a floor CNA the remainder of the week. On 03/26/25 at 4:10 PM, during a follow-up interview with LPN #2, she confirmed she had worked the cart the night before from 7:00 PM to 2:00 AM and returned the next morning to work the cart again. She stated there was no regular nurse scheduled for that rotation, and the on-call nurse often had to work the cart. On 03/27/25 at 11:30 AM, during an interview with the Nurse Consultant, she stated the Director of Nursing (DON) had been off that week due to a family emergency. She confirmed that the DON created the nursing schedule and the Staff Developer created the CNA schedule. On 03/27/25 at 11:50 AM, during an interview with LPN #5, she confirmed she had worked full-time in her current role since April 2024 and part-time at the facility for over (2) years. She confirmed that she created the CNA schedule and the DON created the nurse schedule. She stated staffing was short and that many staff only worked a few hours to assist as needed. She explained that LPNs usually worked twelve (12)-hour shifts and CNAs worked eight (8)-hour shifts. She confirmed that the Medical Records nurse had worked both night and day shifts due to call-ins, which was a frequent pattern. She reported that residents had complained about waiting long periods to be changed or cleaned due to low staffing. A review of the staffing schedules and staffing grids for March 2025 revealed the following: On 03/06/25, three (3) CNAs were assigned to care for (67) residents on the 7:00 AM-3:00 PM shift. On 03/09/25, only two (2) CNAs were assigned to care for (67) residents on the 11:00 PM-7:00 AM shift. On 03/21/25, 03/22/25, and 03/23/25, only (3) CNAs were scheduled for the 7:00 AM-3:00 PM shift, with resident counts ranging from (67) to (69). On 03/15/25, three (3) CNAs were scheduled for the 3:00 PM-11:00 PM shift and (2) CNAs for the 11:00 PM-7:00 AM shift, for (67) residents. On 03/27/25 at 2:00 PM, during an interview with the Interim Administrator, he stated he had only been at the facility for three (3) weeks and was still learning about the facility, staff, and residents. He explained that he expected the facility to follow federal staffing regulations and conduct staffing assessments.

Based on staff interviews, record reviews, facility policy review and Plan of Correction (POC) review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by repeat deficiencies originally cited during the recertification survey conducted on 03/07/2024, for three (3) of (17) deficiencies cited on the current recertification survey. Findings included: A review of the facility's QAPI policy, with a revision date of 10/24/22, revealed The center and organization has a comprehensive data-driven Quality Assurance Performance Improvement Program that focuses on indications of the outcome of care and quality of life. Important functional areas may include but are not limited to .c. Resident Assessments .d.Quality of care .e. Quality of Life . F677 - ADL Care During the recertification survey conducted on 03/07/2024, the facility failed to provide Activities of Daily Living (ADL) care to a dependent resident. F641 - Significant Change Assessment During the recertification survey, the facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who returned from the hospital with two significant changes. F725 - Sufficient Staffing During the recertification survey, the facility failed to provide sufficient staffing to meet residents' care needs. On 03/27/25 at 2:12 PM, during an interview with the Corporate Nurse (CN) and the Interim Nursing Home Administrator (INHA), the INHA stated he had been in the facility for three (3) weeks and was aware of the past survey results. He stated the facility had conducted QAPI meetings to address the repeated citations. The CN acknowledged awareness of the repeated concerns and explained that they stemmed from the facility's noncompliance with regulations. The CN stated the facility had held both QAPI and Performance Improvement Project (PIP) meetings related to these concerns and now conducts QAPI meetings monthly. The CN also stated that the QAPI policy is reviewed annually.

Based on observation, interview, record review, and facility policy review, the facility failed to implement appropriate infection prevention and control practices during medication administration for one (1) of one (1) medication pass observations (Resident #169). Findings included: Record review of the facility policy titled Administering Medication, dated April 2019, revealed Medications are administered in a safe and timely manner and as prescribed . 25. Staff follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable . On 03/26/25 at 8:45 AM, during the administration of morning medications to Resident #169, Licensed Practical Nurse (LPN) #2 was observed entering the resident's room. The resident asked to see the medications prior to taking them. At this time, the nurse poured the medications into her bare, ungloved hand, and the resident proceeded to take the medications after inspecting them. On 03/26/25 at 8:55 AM, during an interview, LPN #2 confirmed she had placed the medications into her ungloved hand and stated she should have worn gloves during the exchange to prevent contamination. She acknowledged it posed a risk of spreading infection to the resident, particularly since she had not performed hand hygiene before entering the room. On 03/27/25 at 10:40 AM, during an interview with the Infection Prevention (IP) Nurse, LPN #1, she explained that the nurse should have worn gloves prior to handling the resident's medications. She stated gloves are necessary to prevent spreading infections, including respiratory illnesses, to residents. On 03/27/25 at 10:56 AM, during an interview with the Corporate Nurse, she stated the nurse should have either discarded the contaminated medications and replaced them with new, uncontaminated ones or worn gloves prior to handling them. She explained that staff could transmit infections and bacteria to residents when medications are contaminated due to improper handling or lack of hand hygiene. She stated it was her expectation that staff follow basic infection control guidelines during medication administration. A record review of Resident #169's admission Record revealed the facility admitted the resident on 03/22/25 with diagnoses including Functional Quadriplegia, Generalized Anxiety Disorder, and Low Back Pain.

Based on observation, interview, record review, and policy review, the facility failed to ensure a resident's right to dignity and communication by not providing an accessible call light for one (1) of twenty (20) sampled residents (Resident #169). Findings included: A review of the facility ' s policy titled Resident Rights with an effective date of 11/30/14 revealed .The facility will ensure that the resident is not deprived of his/her rights . A resident shall be treated with dignity and respect . On 03/24/25 at 11:45 AM, during an observation and interview, Resident #169 was in bed with a touch call light at the foot of the bed. The resident explained he could not use that call light, as he was unable to raise his chin or head to activate the button. He stated he had experienced long wait times for staff assistance with repositioning. On 03/24/25 at 4:10 PM, during an observation and interview with Certified Nurse Aide (CNA) #1, observed Resident #169's push call light lying on the floor. CNA#1 stated this was her first time working with the resident and confirmed call lights are to remain within the resident's reach at all times. Resident #169 told her he could not use the type of call light provided. On 03/25/25 at 2:25 PM, during an interview with CNA #3, she explained that it was her first day working with the resident. She had reviewed the resident's medical record and spoken with the nurse regarding care. She confirmed the resident told her he could not use the call light due to paralysis, but the CNA stated she had not yet looked at the resident's call light. On 03/25/25 at 3:30 PM, Resident #169 was observed lying in bed. He explained he had not been provided with a call light he could use. On 03/26/25 at 2:45 PM, Resident #169 was again observed in bed. He explained that he still did not have an accessible call light and was dependent on staff checking in on him. He said his roommate sometimes helped at night, but during the day he had no assistance. The call light was observed lying on the floor between the two beds. On 03/26/25 at 4:10 PM, during an interview and observation with Licensed Practical Nurse (LPN) #2, she confirmed the resident's call light was lying on the floor and not within reach. She stated she was unaware of any other call light options at the facility besides the regular and touch button types. The resident explained that at previous facilities he used a blow-call light. On 03/27/25 at 10:00 AM, during an interview with Social Services #1, she stated she was not aware the resident had requested a room closer to the nurse's station or that he had no call light he could use. On 03/27/25 at 11:50 AM, during an interview with the facility Nurse Consultant, she asked whether the resident was paralyzed and stated she had not been informed that he needed a blow-call light. On 03/27/25 at 12:40 PM, during a phone interview with Registered Nurse (RN) #2, the Weekend Supervisor for Night Shift, she confirmed she provided the resident with a push button call light but did not assess whether the resident could use the touch button. She stated the resident was admitted as a paraplegic and could not use his hands. A record review of Resident #169's admission Record revealed the facility admitted the resident on 03/22/25 with diagnoses including Functional Quadriplegia. A record review of Resident #169's admission Data Collection dated 03/22/25 revealed the resident was alert and oriented to person, place, and time, with memory noted as okay. The assessment noted contractures and paralysis.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents' rights to a clean, safe, homelike environment for three (3) of (20) sampled residents, as evidenced by unclean floors and bathrooms in resident rooms (Resident #11 and Resident #44) and improper handling of personal belongings (Resident #60). Findings include: A record review of the facility policy, Cleaning and Disinfection of Environmental Surfaces, revised 8/19, revealed, Policy Statement . Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard . Policy Interpretation and Implementation . 1 . 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled . A review of the facility policy, Your Rights with no date, revealed, Dignity and Self-Determination . You have the right to: Be treated with consideration . Receive reasonable accommodation of your individual needs . Keep and use your personal possessions . Resident #11 On 03/24/25 at 11:25 AM, during an observation and interview with Resident #11, the floor in his room was noted to be dirty with dried food smeared on both his side and his roommate's side of the room. The resident stated the room was filthy and had been that way since his admission. He added that it smelled like urine and reported that when he requested cleaning, staff would ignore him. An observation of the resident's bathroom revealed dried fecal matter inside the toilet bowl and dried urine stains. On 03/24/25 at 1:11 PM, during an interview with the Laundry and Housekeeping Supervisor, she stated that the housekeeping department was fully staffed and that staff work Monday through Friday from 7:00 AM to 2:30 PM. She explained that cleaning is completed during the first half of the shift and then staff return after lunch to touch up rooms, including bathrooms and trash cans. She confirmed that all rooms should have been cleaned by the time of the interview. She walked with the State Agency (SA) to Resident #11's room and confirmed the floor had dried food smeared on it and the bathroom toilet contained dried fecal material. A record review of Resident #11's admission Record revealed the facility admitted the resident on 01/17/2025 with diagnoses including Unspecified Hearing Loss and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Right Dominant Side and Abnormalities of Gait and Mobility. A record review of Resident #11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/25 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was rarely or never understood. Resident #44 On 03/24/25 at 12:01 PM, during an observation and interview with Resident #44, the resident's room floor was observed to be dirty with trash on the floor and full trash cans. The resident stated the room was often like that. He also reported that he had three (3) pairs of size 40P pants that were sent to the laundry and never returned. He stated his brother had recently purchased the pants, and when he notified laundry staff, they stated they would look for the items, but he had not received any further information. On 03/24/25 at 1:11 PM, during an observation and interview with the Laundry and Housekeeping Supervisor of Resident #44's room she confirmed that the floor was very dirty and had trash scattered throughout. The supervisor stated she was unsure why the rooms had not been cleaned, as they were supposed to be done by that time. On 03/26/25 at 3:16 PM, during an interview with Resident #44's Resident Representative, he stated he visits monthly due to living out of town. He reported that during his visits, the facility was visibly dirty, with trash on the floors and debris stuck to the floor. He stated the bed sheets often appeared unclean and that he had seen roaches in the facility. On 03/27/25 at 9:01 AM, during an observation and interview with Resident #44, the resident stated that the floors were cleaner but added, That's only because you're here. Once you leave, it'll go back to how it was. A record review of Resident #44's admission Record revealed the facility admitted the resident on 02/11/2022 with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. A record review of Resident #44's quarterly MDS with an ARD of 12/4/24 revealed a BIMS score of 12, which indicated the resident was cognitively intact. On 03/27/25 at 9:30 AM, during an interview with the Administrator, he stated that he expects the facility to be a homelike environment. He explained, We keep our homes clean, so this is the residents' home and should be kept clean as well. Resident #60 A record review of Resident #60's admission Record revealed the facility admitted the resident on 01/17/25 with diagnoses including Idiopathic Neuropathy and Abnormalities of Gait and Mobility. A record review of the MDS with an ARD of 02/08/25 revealed a BIMS score of 10, which indicated moderate cognitive impairment. The resident could participate in interviews. On 03/27/25 at 11:09 AM, in an interview with Resident #60, she stated that staff had not replaced her missing gray pants or her black pajama shirt with a bear design. She explained she had sent both items to the laundry after spilling ice cream on them, but they never came back. She stated she informed the Laundry Aide, who told her she would look for the clothing but never provided an update. Resident #60 expressed sadness about the missing clothing, especially since she had not worn the new pants much and felt that her personal belongings were not valued. On 03/27/25 at 11:12 AM, during an interview with a Laundry Aide, she confirmed that Resident #60 reported missing items to her. She stated she searched for them and told the resident she could not locate them. She also reported the issue to her supervisor. On 03/27/25 at 11:15 AM, during an interview with the Laundry and Housekeeping Supervisor (LHS), she stated she was only aware of the missing pajama shirt. She reported searching for the item without success. When asked about the next step, she acknowledged that the incident should have been reported to the Director of Nursing (DON) or the Administrator, but she had not done so. She stated that had she followed proper protocol, the items may have been replaced. She acknowledged that the loss of personal items could cause distress to the resident. On 03/27/25 at 11:28 AM, during an interview with the Administrator, he stated he had not been informed of the missing items. He confirmed that if it had been reported, the facility would have replaced the missing clothing.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to provide a resident who was unable to carry out activities of daily living (ADLs) with the necessary services to maintain good grooming and personal and oral care for one (1) of (20) sampled resident reviewed for personal hygiene and grooming, Resident #67. Findings included: A review of the facility ' s policy titled Activities of Daily Living, dated 02/01/22, revealed Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, cuing, and assistance as necessary. ADL includes bathing, dressing, grooming, hygiene, toileting . On 03/24/25 at 12:38 PM, during an interview and observation, Resident #67 was observed lying in bed with a moderate amount of gray hair under her chin. She stated she wanted her chin hair shaved and reported her last shower was on Thursday. She stated she used to receive bed baths three (3) times per week. On 03/25/25 at 8:55 AM, during an observation, Resident #67 was observed lying in bed with her eyes closed. A strong odor of urine was noted in the room. On 03/25/25 at 3:15 PM, during an interview and observation, Resident #67 was observed with visible hair on her chin. A faint odor of urine was again noted in the room. The resident stated she had not received a bath that day. On 03/27/25 at 10:10 AM, during an interview, Resident #67 stated she would not receive a bath or be shaved until later that evening. On 03/27/25 at 2:33 PM, during an interview, Resident #67 stated that no staff had asked her about receiving a bed bath or shower during the current week. On 03/28/25 at 5:28 PM, during an interview, the Corporate Nurse confirmed she was aware of the care concerns related to Resident #67. A record review of Resident #67's admission Record revealed the facility admitted the resident on 2/25/25 with diagnoses including Muscle Weakness, Other Reduced Mobility, and Lack of Coordination. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident's cognition was moderately impaired. Section GG documented that Resident #67 required total assistance/dependent for bathing and showering. A review of Resident #67's Comprehensive Care Plan revealed no documentation related to refusals of care. The care plan indicated the resident required substantial to maximal assistance with activities of daily living.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the facility had adequate supplies for residents for four (4) of (20) sampled residents, with the potential to affect all residents in the facility. (Residents #13, #34, #41, #60) Findings included: A review of the facility's policy titled Purchasing Department, with an effective date of 11/30/2014, revealed, The Company has established a corporate purchasing department. Its purpose is to ensure that we receive standardized quality goods and services at the lowest available price . On 03/24/25 at 11:00 AM, the State Agency (SA) observed strong odors of urine and body odor noted upon entering the facility and walking to the conference room down the 400 Hall. Several residents were observed still in bed and others sitting in their wheelchair sitting around the nurse's station. Resident #13 On 03/24/25 at 2:24 PM, during an interview with Resident #13, she stated she wears a 2XL brief, but the staff only provided her with extra-large briefs. She explained that she has to place a pad inside the briefs to avoid wetting herself and said she uses the bathroom independently. An observation of her room revealed extra-large pull-ups. On 03/25/25 at 10:28 AM, in an interview with a Licensed Practical Nurse (LPN)#4, who was assigned to Resident #13, confirmed that the extra-large briefs presented were too small for the resident. She stated central supply was responsible for stocking the supplies. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2024 revealed Resident #13 was admitted by the facility on 7/25/2024, she had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact), and had current diagnoses including Diabetes Mellitus. Resident #34 On 03/25/25 at 03:30 PM, during an interview and observation with Resident #34, resident observed lying in the bed with shirt and brief on. Resident #34 explained he get up every day and goes to therapy and does not get laid back down until about 3 PM every day. He does use his urinal at times but when he is up it's difficult and needs to be changed. He is usually soaked and sometimes through his pants when he gets back in bed. On 03/26/25 at 10:40 AM, observed Resident #34 in the therapy room involved in activities. Resident #34 was well-groomed and no odors noted. Resident #34 reported that the facility did not have briefs last night to fit him and this has happened several times since he was admitted to the facility a month ago. He explained that he is a huge man and needs at least 2XL briefs. A record review of Resident #34's admission Record revealed the facility admitted the resident on 02/28/25 with the diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side. A record review of Resident #34's admission MDS with an ARD of 03/07/25 revealed a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Section H indicated the resident was occasionally incontinent of bladder. Resident #41 On 03/25/25 at 8:50 AM, Resident #41 explained that the pull-up he was wearing was too small, but he was told that was the only size the facility had available. A record review of Resident #41's admission Record revealed the facility admitted the resident on 01/09/24 with the diagnoses that included Other Sequelae of cerebral infarction. A record review of Resident #41's Quarterly MDS with an ARD of 02/04/25 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Section H revealed the resident was frequently incontinent of bladder. Resident #60 On 03/24/25 at 12:46 PM, Resident #60 stated that they ran out of pull ups and was out for one week. She stated her daughter bought her some. On 03/27/25 at 10:27 AM, during a phone interview with the Resident Representative (RR) for Resident #60, she stated her mother had called her in February to report the facility was out of briefs. She confirmed she purchased and brought briefs to the facility herself. She stated this had occurred once. A record review of Resident #60's admission Record revealed the facility admitted the resident on 01/17/25 with diagnoses including Other Abnormalities of gait and mobility, Pain in right leg, Muscle Weakness (Generalized), and Difficulty in walking, not elsewhere classified. A record review of Resident #60's MDS with an ARD of 02/08/25 revealed a BIMS score of 10, which indicated the resident was moderately cognitively impaired. On 03/25/25 at 9:10 AM, during an interview with Certified Nurse Aide (CNA)#3, she explained there have been problems with supplies including briefs, gloves, and wipes mostly for the past month. There is never enough of the size of briefs the residents need and have to use smaller briefs that do not fit, causing residents to complain and have clothes soiled more frequently. The gloves are never the size needed and either too small and can barely get on or are too large that makes care difficult. On 03/25/25 at 9:30 AM, during an interview with Licensed Practical Nurse (LPN)#4, she explained that the facility had experienced supply shortages in recent months. She stated the facility's corporate operations filed bankruptcy, and she was unsure if that contributed to the issues. She added the facility had run out of briefs, gloves, and wipes, and that a nurse previously had to purchase briefs locally. She also stated the correct sizes were often not available, resulting in smaller briefs being used that did not fit properly. On 03/25/25 at 10:32 AM, during an interview with the Central Supply Coordinator, he stated there were 2XL briefs in the outdoor storage room. An observation of the storage area revealed one box of 2XL daily wear briefs. He confirmed that was all the briefs available in that size at the time. On 03/25/25 at 02:55 PM, during an interview with LPN#3, she explained the facility has had continuous problems with supplies in the past couple months. The facility does not have enough briefs, wipes, and gloves at times. She has had residents complaining about not having their size and briefs and have noticed residents waiting longer periods of time for changing and positioning due to not being able to find the correct size of briefs for the residents. The Director of Nursing (DON) has explained that the shipping company has had problems and would only get partial of the orders and the orders have been a hit and miss. The DON did go out and buy some briefs before but that was only a temporary fix and then the facility would be out again. On 03/25/25 at 3:50 PM, during an interview with CNA#1, she stated the facility had experienced shortages of gloves, briefs, and wipes over the past few months. She explained that truck deliveries had been inconsistent. She reported that available gloves were usually too small and that pull-ups were used in place of briefs by tearing the sides. She stated residents had complained about the lack of preferred products. On 03/26/25 at 10:05 AM, during an interview with CNA#4, she explained she has witnessed shortage of supplies mostly in the last few weeks it was the worst. The facility only had the pull-ups for residents and not the correct size and some residents don't like the pull-ups some days. Due to lack of supplies some residents have to wait for extended periods to be changed. There were only small gloves that did not fit and this made care difficult. She reported the wipes were also not available, but she used wash clothes and towels. The shortage was reported to the DON and was told to use what you had. On 03/26/25 at 11:50 AM, during an interview with CNA #5, she explained the facility has run out of gloves, briefs, and wipes recently in the past month making it difficult to care for the residents as needed. The facility runs out of extra-large briefs more than anything else and the resident have to wear briefs that are too small causing leaks and residents needing to be changed more frequently. On 03/26/25 at 2:00 PM, during an interview and observation with the Central Supply Coordinator/Ward Clerk, he explained he was responsible for retrieving supplies from the shed and central supply room. He stated that since being hired, he had not placed any orders but was instructed to take inventory on the 1st and 15th of each month and to leave the supply list in the DON's mailbox. He reported that after submitting the most recent inventory list, the DON informed him on 03/23/25 that the list had been lost. He stated there had been no recent deliveries of gloves, briefs, or wipes, and he was unable to confirm if items were out of stock or if orders had been placed. He reported numerous staff and residents had complained about supply shortages. An observation of the shed revealed several loose and opened packages of briefs with no organization. The shed was unsecured. On 03/26/25 at 2:30 PM, during an interview with the Wound Care Nurse/LPN#1, she explained that the DON had previously purchased briefs for residents, but she was unsure of the date of the last purchase. On 03/27/25 at 11:50 AM, during an interview with LPN#5, reported that the facility has been running out of supplies including gloves and briefs. Incontinent wipes have also not been available, but she has instructed staff to use soap and water and clothes. The briefs do not fit the residents properly causing more irritation and complaints. The residents have complained that they had to wait for extended periods to be changed or cleaned due to no supplies. On 03/27/25 at 12:45 PM, during an interview with the Nurse Consultant, she stated she was not aware of any supply shortages. She explained it was her expectation that the facility maintains adequate supplies for all residents at all times. On 03/27/25 at 2:00 PM, during an interview with the Interim Administrator, he explained that he had only been in the position for three (3) weeks and was not aware of any supply shortages. He stated he had only approved one supply order during his tenure. He reported that his expectation was for the facility to always have appropriate supplies readily available to provide quality care, uphold residents' rights, and maintain respect. A record review of a signed statement provided by the Interim Administrator revealed Quality of Care: Facility follows policy related to the specific area of care. A record review of the facility's Supplier Invoice dated 02/28/25 revealed an order for two (2) cases of large gloves, twelve (12) packs of 3XL Prevail briefs, two (2) cases of medium gloves, three (3) cases of Per-Fit 360 2XL briefs, and three (3) cases of 3XL Per-Fit 360 briefs. A record review of the facility's Purchase Order dated 03/03/25 revealed orders for four (4) cases each of large gloves, medium gloves, large Per-Fit 360 briefs, and 3XL Prevail briefs. A record review of the facility's Purchase Order dated 03/13/25 revealed (1) case of 3XL Prevail briefs, eight (8) packs of 3XL Per-Fit 360 briefs, and additional orders for protective underwear and briefs. No gloves were included in this order. A record review of the facility's Supply Order List dated 03/01/25 revealed items not on the shelf included adult diapers in sizes medium through 2XL and gloves in sizes medium through extra-large. A record review of the Supply List dated 03/15/25 revealed items needed included yellow diapers (58-73 inches), blue diapers (46-62 inches), bariatric white diapers, and gloves in medium and large sizes. During an interview with the Central Supply staff on 03/27/25 at 2:30 PM, he stated the DON had misplaced the inventory list, possibly causing a delay in ordering supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the presence of a Registered Nurse (RN) for at least eight (8) hours a day, seven (7) days a week as required, for eight (8) of (19) days reviewed. Findings included: On 03/27/25 at 11:50 AM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that she had been told by the facility's Nurse Consultant that the Director of Nursing (DON) could be counted as the RN and that she, as the LPN, could also be included on the staffing grid. She stated that at a previous facility, she was not allowed to count the DON or herself on the staffing report unless they completed direct care hours. She confirmed that the DON is the only RN in the facility Monday through Friday, although another RN occasionally serves as Charge Nurse. LPN #1 explained that the DON often counts herself as both the Charge Nurse and the DON and helps where needed, including acting as Charge Nurse when no one else is available. A record review of the facility's staffing grids and nurse/Certified Nursing Assistant (CNA) schedules for the week of 03/06/25 through 03/24/25 revealed eight (8) days where no RN coverage was documented for a full 24-hour period. On 03/27/25 at 12:20 PM, during an interview with the Nurse Consultant, she explained that she was not aware the DON had been counting herself as the Charge Nurse during the week. She believed the DON could be counted if the census was low, regardless of licensed bed capacity. She also believed the Staff Development Nurse counted toward RN coverage. The Nurse Consultant confirmed that on the days in question, the facility's census was greater than sixty (60). On 03/27/25 at 2:00 PM, during an interview with the Interim Administrator, he explained that he had only been in the facility for three (3) weeks and was still learning the facility's operations, staff, and residents. He stated that he expected the facility to follow federal staffing regulations and its own staffing assessment. A review of a signed statement, undated, provided by the Interim Administrator revealed Facility staffs according to census, acuity and/or facility assessment based on resident needs. A review of another signed statement from the Interim Administrator revealedQuality of Care: Facility follows policy related to the specific area of care. A review of the facility's Facility assessment dated [DATE] revealedEvaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff to meet each resident's needs . Licensed nurses providing direct care equaled 9, Nurse Aides equaled 21, Other Nursing personnel (e.g., those with administrative duties) equaled 3 . Describe your general staff plan to ensure that you have sufficient staff to meet the needs of the residents at any given time . DON . 1 RN DON .

Based on interviews, record review, and facility policy review, the facility failed to ensure a resident was treated with dignity and respect for one (1) of 18 sampled residents. Resident #1 Findings include: A record review of the facility's Verification of Investigation, dated 2/8/24, revealed an allegation on 2/7/24 at 9:00 PM, that Certified Nurse Aide (CNA) #3 cursed resident about not being his job to put her in bed and used cursed words. A record review of the handwritten statement, dated 2/9/24, and signed by CNA #3 revealed, When I made it to work at 7 PM the aid I relieved gave me report on what she had done on the hall. I made the comment that I didn't come to work to put nobody in the bed because I had just got everybody up at 7 AM. I went to the resident room (Resident #1) and told her that she was going to have to stop procrastinating and let the shift that was here put her in the bed . On 3/04/24 at 3:48 PM, in an interview with Resident #1, she stated she could not remember much about what the CNA said to her, but she remembered that it happened. She was unable to recall if the CNA used curse words but remembered she had asked for that CNA not to take care of her anymore. She reported she was satisfied with how the facility handled the situation. On 03/07/24 at 7:34 AM, in an interview with the Administrator, he stated that when he was made aware of the incident, he immediately started investigating, interviewing, and suspended the CNA pending the investigation. When the Administrator interviewed the CNA, he was terminated because he had been disrespectful toward the resident. The Administrator explained the facility would not tolerate staff being disrespectful to residents and a resident can choose to lie down or get up whenever they want. On 03/07/24 at 7:59 AM, in a phone interview with CNA #3, he stated that he was working a 12-hour shift on 2/8/24 and reported to work at 7 PM and got off at 7 AM. He confirmed that he went to Resident #1's room around 7:20 PM. He explained the resident was still up sitting in her wheelchair and she was normally in bed for the night by that time. He stated that he never cursed the resident, but he did tell her that she needed to stop procrastinating because they were short staffed, and he wanted to get her in bed. He said the day shift should have put her back to bed and the day shift aide could have gotten someone else to do it if she could not. CNA #3 was unsure if he had ever received training related to resident rights. Review of the facility's document, Subject: Employee Acknowledgement of Resident - Patient Rights, effective 4/2007, revealed, These Resident Rights ensure that each resident admitted .9. Is treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and in care for his/her personal needs . The acknowledgement was signed by CNA #3 on 1/18/23. A record review of the admission Record revealed the facility admitted Resident #1 on 5/21/2018 and she had current diagnoses including Hemiplegia and Hemiparesis. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 2/16/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact.

Based on observation, interviews, and record review, the facility failed to provide accommodation for a resident who required a larger bed for one (1) of 18 sampled residents. Resident #57 Findings Include: On 03/05/24 at 09:50 AM, in an interview and observation of Resident #57, she stated she needed a bigger bed because it was difficult for her to turn or reposition in bed. She explained that she had reported her needs to the facility staff, but nothing had been done about it. Record review of the admission Record' revealed the facility admitted Resident #57 on 7/20/23 and she had current diagnoses including Morbid (Severe) Obesity. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/24 revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. Record review of the Admission/readmission Data Collection document, dated 7/20/23, revealed Resident #57 weighed 434 pounds upon admission to the facility. Record review of the Weight Summary revealed Resident #57 most recent weight, dated 2/4/24, revealed she weighed 452 pounds. On 03/06/24 at 3:30 PM, in an interview with Maintenance Director, he stated the facility rented bariatric beds, but they did not keep them stored at the facility. He reported that he had not been informed Resident #57 needed a bigger bed. On 03/06/24 at 4:00 PM, in a with the Human Resources associate, she stated the Administrator notified her of resident equipment needs and she placed the order. She explained that it took about 3-4 days to receive the bariatric bed once it has been ordered. She stated she was not notified Resident #57 needed a bariatric bed. On 03/07/24 at 10:28 AM, in an interview with Certified Nursing Aide #1 (CNA), she stated she had notified the nurses that Resident #57 needed a bariatric bed due to her size. On 03/07/24 at 10:40 AM, in an interview with Business Development Coordinator/ admission (BDCA), she explained that before a resident was admitted to the facility, the facility reviewed the referral package, which included a diagnostic report that specified the potential resident's weight and height. She stated that all members of management discussed new admissions prior to their arrival in the morning stand up meeting and any equipment the resident would need was set up prior to their arrival. She confirmed that any resident that weighed over 300 pounds would require a bariatric bed and Resident #57 should have had a bed upon arrival at the facility. She also confirmed that she was responsible for obtaining the weight and height of all new admissions upon their arrival at the facility. On 03/07/24 at 11:00 PM, in an interview with the Director of Nursing, she stated it was her responsibility to make sure residents' needs are met. She stated she was not aware Resident #57 needed a bariatric bed.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure the residents' right to receive mail when delivered on Saturday for two (2) of 11 residents reviewed in resident council. This had the potential to affect all 60 residents who reside in the facility. Resident #6 and Resident #51 Findings include: A record review of the facility's policy Mail, dated 11/01/21, revealed . Mail will be delivered to the resident on the day it was delivered by the postal service . On 03/05/24 at 1:30 PM, during the Resident Council meeting, Resident #6 and Resident #51 reported they do not receive mail that is delivered on Saturdays because there was no one at the facility to get it out of the mailbox. Resident #6 explained he received packages on Saturdays when they are shipped by United Parcel Service (UPS), but he did not receive anything from the regular mail. On 03/05/24 at 2:05 PM, during an interview with the Administrator, he explained he was not aware that residents were not getting mail that was delivered on Saturday. He stated that he expected the residents to get their mail. He reported that the Activities Director was responsible for ensuring residents received their mail timely. At 02:20 PM on 03/05/24, during an interview with Activities #1, she explained the facility did not have a system in place to deliver mail on Saturdays to the residents because she was not at the facility. She confirmed she got the mail out of the mailbox on Mondays when she returned to the facility and stated she was unaware the facility was required to deliver mail to the residents on Saturdays. Resident #6 A record review of the admission Record revealed the facility admitted Resident #6 on 09/08/2017 with current diagnoses including Unspecified Injury at Unspecified Level of Cervical Spinal Cord. A record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 12/25/23 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Resident #51 A record review of the admission Record revealed the facility admitted Resident #51 on 11/02/22 with current diagnoses including Heart Failure. A record review of the Annual MDS with an ARD of 12/06/23 revealed Resident #51 had a BIMS score of 15, which indicated she was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to provide advanced beneficiary notices for a resident who had completed therapy services for one (1) of three (3) residents reviewed for advanced beneficiary notices. Resident #55 Findings Include: Record review of the facility's policy, SNF (Skilled Nursing Facility) Advance Beneficiary Notification (SNF) & The Notice of Medicare Provider Non-Coverage, revised 5/1/2018, revealed, The SNF Advance Beneficiary Notification .will be used to properly notify a Medicare Part A resident and/or responsible party of the clinical team decision that the resident, no longer meets the Medicare criteria for daily skilled services .SNF's must provide the Notice of Medicare Provider Non-Coverage and the SNF ABN to Medicare beneficiaries no lather than two days (48 hours) before the effective date of the end of the coverage that their Medicare coverage will be ending . Record review of Resident #55 SNF Beneficiary Notification Review form revealed the facility did not provide the resident with a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage or a Notice of Medicare Non-coverage form. On 03/07/24 at 12:00 PM, during an interview with the Business Office Manager (BOM), she explained the facility had recent turnover in positions including the Minimum Data Set (MDS) and Social Service departments. Resident #55 remained in the facility and was discharged from skilled services with skilled days remaining. The resident did not receive advanced notice and the form was missed due to the staff changes and no follow-through. On 03/07/24 at 12:15 PM, during an interview with Therapy Director, she explained Resident #55 was discharged from therapy when she reached her maximum potential. She stated the therapy department was not responsible for providing notification to the resident that their coverage was ending. On 03/07/24 at 12:25 PM, during an interview with the Administrator, he explained he expected the facility staff to notify residents in advance and complete the notification forms when a resident discontinued therapy services with skilled days remaining. Record review of the admission Record revealed Resident #55 was admitted by the facility on 10/18/23 and she had current diagnoses including Vascular Dementia.

Based on staff interview, record review, and facility policy review, the facility failed to provide written notification to the resident and/or Responsible Representative (RR) the reason for a transfer to an acute hospital in a language they understand for one (1) of one (1) resident reviewed for hospitalization. Resident #66 Findings include: A record review of the facility's policy Transfer/Discharge Notification & Right to Appeal, revised 10/24/22 revealed . Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to the Federal and/or State regulatory requirements . Record review of the admission Record revealed the facility admitted Resident #66 on 02/06/24 with diagnoses including Subdural Hemorrhage. Record review of the facility's .Hospital Transfer Form ., with the Date of Transfer listed as 2/13/24, revealed the reason for Resident #66's transfer was Decreased LOC (Level of Consciousness) - drooping left side of face - rales (type of abnormal breath sound) left lung fields. Record review of the facility's notification of transfer, dated 2/13/24, revealed Resident #66 was transferred to an acute hospital due to . An immediate transfer or discharge is required by the residents' urgent medical needs . Further review of the notification revealed the Registered Nurse (RN) #2 indicated she provided the information to Verbal. At 11:35 AM on 03/07/24, during an interview with RN #2, she confirmed she completed the notification of transfer form for Resident #66 on 2/13/24. She acknowledged that she did not provide the resident or the RR a copy of the written notification and had documented verbal because she had called the RR about the transfer. She stated the resident had a decreased level of consciousness, but she did not indicate that as the reason for the transfer on the written notification form but had checked it was due to the resident's urgent medical needs. On 03/07/24 at 11:43 AM, during an interview with Corporate Nurse Consultant, she confirmed the facility was unable to provide any documentation the written notification was provided to Resident #66 or the RR in writing and also confirmed the reason for the transfer was a generic statement checked on the form for residents who transfer to the hospital.

Based on observation, interviews, and record review, the facility failed to accurately code a Minimum Data Set (MDS) related to a resident who smokes for one (1) for 18 sampled residents. Resident #53 Findings include: A record review of the admission Record revealed the facility admitted Resident #53 on 12/22/22 and he had diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction. On 03/05/24 at 2:28 PM, during an observation and interview, Resident #53 was outside in the designated smoking area. The resident stated that he has been smoking since he was admitted to the facility. The facility staff assisted the resident with lighting his cigarette. A record review of the Annual Minimum Data Set, with an Assessment Reference Date (ARD) of 12/26/23 revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. A review of Section J was coded as No for tobacco use. On 03/05/24 at 2:55 PM, in an interview with Registered Nurse (RN) #1/MDS/Care Plan nurse, she stated she's currently filling in and helping the facility with the MDS due to recent turnover in the position. She confirmed the MDS for Resident #53 was not accurate because it should have indicated Yes for tobacco use. On 03/05/24 at 3:02 PM, in an interview with the Administrator, he stated that expected the MDS to be coded accurately and explained there had been staff turnover in the MDS/Care Plan position. A record review of the facility's job description for the MDS Transitional Care Nurse LPN, dated October 2019 revealed, .Duties and Responsibilities .1. Coordinate the RAI (Resident Assessment Instrument) process, which includes the .MDS .7. Possess the ability .that are necessary for ensuring accurate and timely completion of the RAI documents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident with Post Traumatic Stress Disorder (PTSD) for one (1) of 18 sampled residents. Resident #13 Findings include: A review of the facility's policy, Plans of Care, revised 9/25/2017 revealed, .An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable .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 that are identified in the comprehensive assessment . A review of the facility's policy, Trauma Informed Care, effective 10/24/22, revealed, .Residents will be evaluated to identify a history of trauma, triggers and cultural preferences. Resident-centered interventions are initiated based on the resident triggers and preferences to decrease the risk of re-traumatization .Procedure .1. Residents are evaluated for trauma, triggers .on admission/readmission, quarterly and annually. 2. Develop resident-center interventions based on trauma triggers. 3. Develop a care plan and add interventions to the nurse aide [NAME] . Record review of the admission Record revealed the facility admitted Resident #13 on 1/5/2024 and she had a diagnosis of PTSD with an onset date of 1/5/2024. A record review of the facility's Admission/readmission Data Collection document, dated 1/5/24, revealed Resident #13 had a history of PTSD. A record review of the admission Minimum Data Set with an Assessment Reference Date of 1/17/24, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review revealed Section I Active Diagnoses, she had a diagnosis of PTSD. A review of the medical record revealed there was no comprehensive care plan regarding Resident #13's diagnosis of PTSD, including interventions to identify triggers to prevent re-traumatization of the resident. On 03/06/24 at 9:30 AM, in an interview with Certified Nurse Aide (CNA) #1, she stated the Resident #13 moved to her hall a couple of days ago and she was not sure what type of previous trauma the resident had or what things might trigger the resident to cause re-traumatization. She said that any information regarding how to care for the resident was located on the [NAME] (summary of resident information). CNA #1 went to a kiosk in the hallway, signed in, and reviewed Resident #13's information. She confirmed there was no information regarding the resident's triggers that may cause re-traumatization. On 03/06/24 at 9:40 AM, in an interview with Licensed Practical Nurse (LPN) #1, she confirmed Resident #13 was new to her hall and she was not aware of any triggers that may cause re-traumatization to the resident. She stated that behavior interventions would be on the resident's care plan, and she signed in on the computer on the medication cart to review the care plan. She confirmed there was no care plan in place that provided information related to the resident's diagnosis of PTSD or what triggers the resident. On 03/06/24 at 9:45 AM, an interview with Registered Nurse (RN) #1, who was the MDS/ Care Plan nurse, confirmed that a care plan was not developed for Resident #13 related to her diagnosis of PTSD, including information regarding the resident's triggers. She reviewed the electronic medical record and stated she would review her information and develop a care plan for the resident. On 03/06/24 at 9:50 AM, during an interview with the Social Services (SS) Designee, confirmed that a care plan with interventions would be helpful for staff to know how to care for the resident to avoid re-traumatization. On 03/06/24 at 9:55 AM, in an interview with the Director of Nursing (DON), she stated she expected the facility to develop comprehensive care plans related to residents with PTSD so they would know what the triggers were for a resident. She also stated that she expected the care plan to contain interventions to prevent re-traumatization of the residents. On 03/06/24 at 11:14 AM, in an interview with the facility's Administrator, he stated that he expected a diagnosis of PTSD to be addressed on the care plan, including triggers to ensure that a resident is not re-traumatized. He explained that there has been recent changes in staffing and turnover in the MDS/Care Plan position.

Based on observation, interviews, record review, and the facility policy review, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADL), including shaving, received those services for one (1) of 18 sampled residents. Resident #40 Findings include: A record review of the facility's policy, Activities of Daily Living, dated 2/01/2022, revealed . To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, cuing, and assistance as necessary. ADLs includes bathing, dressing, grooming, hygiene . On 03/04/24 at 12:10 PM, during an observation, Resident #40 had long, gray facial hair. On 03/06/24 at 10:00 AM, during an interview with Licensed Practical Nurse (LPN)#1, she explained the Certified Nurse Aides (CNAs) should shave residents when they are performing the resident's showers or baths. She confirmed Resident #40 had long facial hair. At 10:45 AM on 03/06/24, during an interview with CNA #2, she confirmed Resident #40 has long facial hair and that he had received a shower on Monday (3/4/24), but he was not shaved because there were two (2) CNAs working the building. On 03/06/24 at 04:21 PM, during an interview with the Director of Nursing (DON), she explained she expected all residents to be shaved on their shower and baths days. Record review of admission Record revealed the facility admitted Resident #40 on 10/15/20 and he had current diagnoses including of Parkinson's Disease. Record review of the Documentation Survey Report v2 for March 2024 revealed Resident #40 required one-person physical assistance with bathing and it was documented that he received a bath on 3/4/2024. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/23 revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 01, which indicated his cognition was severely impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure triggers and resident specific interventions were identified and initiated for a resident with Post Traumatic Stress Disorder (PTSD) for one (1) of 18 sampled residents. Resident #13 Findings include: A review of the facility's policy, Trauma Informed Care, effective 10/24/22, revealed, .Residents will be evaluated to identify a history of trauma, triggers and cultural preferences. Resident-centered interventions are initiated based on the resident triggers and preferences to decrease the risk of re-traumatization .Procedure .1. Residents are evaluated for trauma, triggers .on admission/readmission, quarterly and annually. 2. Develop resident-center interventions based on trauma triggers. 3. Develop a care plan and add interventions to the nurse aide [NAME] . Record review of the admission Record revealed the facility admitted Resident #13 on 1/5/2024 and she had a diagnosis of PTSD with an onset date of 1/5/2024. A record review of the facility's Admission/readmission Data Collection document, dated 1/5/24, revealed Resident #13 had a history of PTSD. A record review of the admission Minimum Data Set with an Assessment Reference Date of 1/17/24, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review of Section I for Active Diagnoses revealed she had a diagnosis of PTSD. A record review of the admission Social Service Progress Review, dated 1/7/24, revealed Social Service Intervention Status .1. Describe resident's status .Specifically address problem areas or interventions that social services is currently reviewing was documented as none. A review of the medical record revealed there was no documentation that indicated Resident 13 was evaluated to identify triggers and resident specific interventions regarding her history of PTSD. In an interview on 03/06/24 at 9:30 AM, Certified Nurse Aide (CNA) #1 stated Resident #13 moved to her hall a couple of days ago and she was not sure what type of previous trauma the resident had or what things might trigger the resident to cause re-traumatization. She said that any information regarding how to care for the resident was located on the [NAME] (summary of resident information). CNA #1 went to a kiosk in the hallway, signed in, and reviewed Resident #13's information. She confirmed there was no information regarding the resident's triggers that may cause re-traumatization. In an interview on 03/06/24 at 9:40 AM, with Licensed Practical Nurse (LPN) #1, she confirmed Resident #13 was new to her hall and she was not aware of any triggers that may cause re-traumatization to the resident. She stated that behavior interventions would be on the resident's care plan, and she signed in on the computer on the medication cart to review the care plan. She confirmed there was no care plan in place that provided information related to the resident's diagnosis of PTSD or what triggers the resident. During an interview on 03/06/24 at 9:50 AM, with the Social Services (SS) Designee, she stated that when Resident #13 was first admitted to the facility, she did not open up to her about her history regarding the type of trauma she had suffered. The SS stated that over time, the resident would talk to her and the resident revealed the type of trauma she suffered as sexual abuse and discord in her childhood. She stated the resident expressed that she was not sure what exactly made her feel unsafe and commented that loud noises may be a trigger for her. She stated that she did not document the history of the trauma or the triggers when the resident discussed those with her so that other staff would be aware of her history. During an interview on 03/06/24 at 9:55 AM, the Director of Nursing (DON), stated she expected the facility to provide trauma informed care for residents with PTSD so they would know what the triggers were for residents to prevent re-traumatization. During an interview on 03/06/24 at 11:14 AM, with the facility's Administrator, stated that he expected a resident who had PTSD to receive trauma informed care to ensure that a resident is not re-traumatized.

Based on observation, interviews, record review, and review of the Facility Assessment Tool, the facility failed to provide sufficient nursing staffing resulting in incontinent care, grooming, and baths not being provided for six (6) of 18 sampled residents. Resident #15, Resident #20, Resident #40, Resident #44, Resident #57, and Resident #59. Findings include: A review of the facility's statement signed by the Administrator revealed the facility did not have a staffing policy and the facility was staffed according to census, acuity, and/or the Facility Assessment. A record review of the Facility Assessment Tool, dated 3/4/24, revealed .Part 3: Facility Resources Needed to Provide Competent Support and Care four our Resident Population Every Day and During Emergencies .3.2 Based on your resident population and needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time . For Licensed nurses providing direct care, the total number needed was indicated as 6-10. For Nurse aides, the total number needed was indicated as 10-16. Further review revealed Individual staff assignment revealed The staff assignments are based off of resident acuity with assigning specific positions/halls/rooms varying between nurses and CNAs (Certified Nurse Aides). Record review of the Complaint Investigation (CI) intake for CI MS #24298, which was reported to the State Agency (SA) anonymously revealed, .it's been times when I've visited and only one CNA was on the unit The Date of the Alleged Event was 2/24/24 on the evening (3-11) shift. A record review of the Staffing Grid completed by the Corporate Nurse Consultant revealed on 2/24/24 (Saturday), the facility had a census of 64 residents and there were three (3) Registered Nurses (RNs), one (1) Licensed Practical Nurse (LPN), and four and one-half (4.5) CNAs on the 7-3 shift. There was one (1) RN, one and one-half (1.5) LPNs, and two (2) CNAs on the 3-11 shift. There were no (0) RNs, two (2) LPNs, and two (CNAs) on the 11-7 shift. Record review of the CI intake for CI MS #24299, which was reported to the SA anonymously revealed, .Today when I visited my Dad around supper there was not one aide scheduled to work the other residents told me that there was only 2 aides in the entire building this morning . The Date of the Alleged Event was 2/25/24. A record review of the Staffing Grid completed by the Corporate Nurse Consultant revealed on 2/25/24 (Sunday), the facility had a census of 64 residents and there was one (1) Registered Nurse, two (2) LPNs, and two (2) CNAs on the 7-3 shift. There were no (0) RNs, two (2) LPNS, and two (2) CNAs on the 3-11 shift. There were no (0) RNs, two (2) LPNs, and two (CNAs) on the 11-7 shift. Record review of the CI intake for CI MS #24337, which was reported to the SA anonymously revealed, .There is absolutely no CNA's nor nurses in the entire facility today not one CNA . The Date of the Alleged Event was 2/28/24. A record review of the Staffing Grid completed by the Corporate Nurse Consultant revealed on 2/28/24 (Wednesday), the facility had a census of 62 residents and there were three (3) RNs, three (3) LPNS, and no (0) CNAs on the 7-3 shift. There was one (1) RN, one and one-half (1.5) LPNs, and five (5) CNAs on the 3-11 shift. There were no (0) RNs, four (4) LPNs, and three (3) CNAs on the 11-7 shift. Resident #15 In an interview on 03/04/24 at 11:32 AM, with Resident #15, she stated that she received bed baths because there was not enough staff at the facility to provide a tub bath. She reported there was one (1) CNA in the facility last night. She expressed that it was important to her to get a tub bath and have her hair fixed. The facility had been short-staffed in the last couple of weeks, especially on the weekend. A record review of the admission Record revealed the facility admitted Resident #15 on 3/6/2019 and she had diagnoses including Cerebral Infarction. A record review of the Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/8/24 revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Resident #20 On 3/04/24 at 2:25 PM, in an interview with Resident #20, he stated there were problems with staffing at times because he had been told by staff there was only one (1) aide working on certain shifts. He said he gets a bath when he wants one, but it took staff longer to answer call lights when they were short-staffed. A record review of the admission Record revealed the facility admitted Resident #20 on 10/25/2021 and he had current diagnoses including Hypertension. A record review of the Quarterly MDS with an ARD of 12/07/23 revealed Resident #20 had a BIMS score of 14, which indicated he was cognitively intact. Resident #40 On 03/04/24 at 12:10 PM, during an observation, Resident #40 had long, gray facial hair. At 10:45 AM on 03/06/24, during an interview with CNA #2, she confirmed Resident #40 has long facial hair and that he had received a shower on Monday (3/4/24), but he was not shaved because there were two (2) CNAs working the building. Record review of admission Record revealed the facility admitted Resident #40 on 10/15/20 and he had current diagnoses including of Parkinson's Disease. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/23 revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 01, which indicated his cognition was severely impaired. Resident #44 On 3/4/24 at 11:45 AM, in an interview with Resident #44, she explained she had not received showers as often as she would like lately because the facility was short staffed. She said the staff used a lift to transfer her and it took two (2) staff members to take her to the shower, so she has been getting wash downs in her bed. Resident #44 stated she also had to wait to be changed at times and CNAs have told her that they were the only one working. A record review of the admission Record revealed the facility admitted Resident #44 on 2/14/23 and she had current diagnoses including Cerebral Infarction. A record review of the Annual MDS with an ARD of 2/15/24 revealed Resident #44 had a BIMS score of 15, which indicated she was cognitively intact. Resident #57 On 3/04/24 at 2:00 PM, in an interview with Resident #57, she complained the facility had been short staffed and the staff are slow answering call lights. She explained that when there were not enough aides, she was unable to get bathes as she preferred. Record review of the admission Record' revealed the facility admitted Resident #57 on 7/20/23 and she had current diagnoses including Morbid (Severe) Obesity. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/24 revealed Resident #57 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated she was cognitively intact. Resident #59 On 03/06/24 at 1:00 PM, in an interview with Resident #59, he stated he has been left soiled for long periods of time. He explained this occurred on weekends as well as weekdays, but most recently on a weekend. He reported that things have gotten better since last Friday (3/1/24) and the Director of Nursing (DON) had spoken to him and apologized. Resident #59 said one time recently the Certified Occupation Therapy Assistant (COTA) had to provide perineal care so that he could go to therapy. He could not recall the exact date this occurred, but he had used his call light to get assistance to be changed and cleaned up so he could go to therapy, and the staff kept telling him they were coming, but they did not. On 03/06/24 at 3:50 PM, in an interview with the COTA, he stated Resident #59 needed to come to therapy, but he was soiled, and he was upset that staff would not change his brief. The COTA explained Resident #59 was on skilled services and was at the facility for therapy. He stated that he and another therapist completed perineal care and changed the resident so he could participate in therapy. A record review of the admission Record revealed the facility admitted Resident #59 on 1/18/24 and he had current diagnoses including Gout. A record review of the admission MDS with an ARD of 1/25/24 revealed Resident #59 had a BIMS score of 14 which indicated he was cognitively intact. An observation and record review on 3/4/24 at 11:15 AM, of the Daily Nursing Staffing Form, dated 3/4/24, and posted on the bulletin board at the nurses station revealed there were three (3) RNs, three (3) LPNs, and two (2) CNAs scheduled for 3/4/24. On 03/04/24 at 01:30 PM, during an interview with CNA #2, she explained there were two (2) CNAs working today and it had been like that for some time. She explained she was responsible for three (3) halls and the other CNA was responsible for (3) halls. She stated that it was hard to complete all the duties on some days due to staffing being short, but she tried to meet the residents' immediate needs. On 03/07/24 at 07:59 AM, in an interview with CNA #3, he stated there were times when there have been two (2) aides during the 3-11 shift, and he was asked to work overtime approximately 3-4 times a week. On 03/07/24 at 12:58 PM, in an interview with the Administrator, he stated he was aware there were staffing challenges and there were days in which there were staffing shortages. He explained the facility had recently experienced turnover in key positions, including the DON position. He reported the staff pull together to meet the resident's needs and the corporate Nurse Consultant and himself have worked the floor recently to ensure the resident's needs were met. He explained the facility was going to implement sign-on bonuses to help with recruitment and there are some staff who had previously left the facility that are returning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to provide a written notice of transfer to the Resident Representative (RR) for two (2) of two (2) residents reviewed. Resident #5 and Resident #24. Findings include: A record review of the facility Policy and Procedures with the Subject listed as Transfer/ Discharge Notification & Rights to Appeal, with a revision date of 3/26/2018 revealed, .Notice Before Transfer: Before a center transfers or discharges a resident the center must: Notify the resident and resident representative(s) of the transfer or discharge and the reason for the move in writing (in a language and manner they understand) . Resident #5 Record review of the Transfer/Discharge Report revealed the facility admitted Resident #5 on 6/26/21. Record review of the Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 1/12/22 revealed Resident #5 was transferred to an acute hospital on 1/12/22. Record review of the nurse Progress Note dated 1/12/22 at 3:57 AM, revealed notified Physician. recommends to send him out to (Local Hospital) .notified RP (Responsible Party). Record review of Physician Orders dated 1/12/22 revealed Resident # 5 had an order to be transported a local hospital emergency room for evaluation and possible admit. Record review of the medical record for Resident #5 revealed there was no record of a written notice of transfer/discharge. Resident #44 Record review of the admission Record revealed the facility admitted Resident #44 on 7/18/2017. Record review of the MDS with ARD dated 10/19/21 revealed Resident #44 was transferred to an acute care hospital. Record review of Resident #44's Nurse notes revealed he was transferred to a Behavioral Health hospital on [DATE]. Review of the MDS with and ARD dated 11/5/21 revealed Resident #44 was transferred to a psychiatric hospital. Record review of the nurse notes dated 11/5/21 revealed Resident #44 was transferred sent a psychiatric hospital. Record review of the medical record for Resident #44 revealed there was no record of a written notice of transfer/discharge for the transfers on 10/19/21 and 11/5/21. On 1/19/22 at 1:35 PM, in an interview with Social Services, she stated that no one has been notifying the family regarding a transfer or discharge in writing, but the nurse calls the family at the time of transfer. She only notifies the Ombudsman in writing of any transfers and discharges. Social Services confirmed she did not notify the Resident Representative (RR) of the transfer in writing for Resident #5 and Resident #44. On 1/20/22 at 3:30 PM, in an interview with the Director of Nursing, she confirmed the nurses contact the family by phone when residents are transferred to the hospital, and no one has been notifying the RR in writing.

Based on staff interview, record review and facility policy review, the facility failed to maintain accurate Minimum Data Set (MDS) assessments for four (4) of 21 MDS reviewed. Resident #2, #3, #23, and #48. Findings include: Review of facility policy titled, Minimum Data Set (MDS), revised 9/25/17, revealed, .using the federal and/or state required RAI. Procedure .Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy . Resident #2 A record review of Resident #2's admission Record revealed the facility admitted Resident #2 on 9/11/18 with diagnoses including Schizophrenia, Unspecified Psychosis not due to a substance or known Physiological condition, Major Depressive Disorder, and Anxiety. A record review of Resident #2's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/25/21 indicated a No response to question A-1500 which indicated Resident #2 did not have a serious mental illness. Resident #3 Review of the Transfer and Discharge Report for Resident #3 revealed an admission date of 5/21/18. Resident was diagnosed with Schizophrenia on 7/1/2019. Record review of the significant change Minimum Data Set (MDS) with Assessment Reference Date (ARD)of 3/19/21 indicated a No response for A-1500 which indicated Resident #3 did not have a serious mental illness. Resident #23 A record review of Resident #23's admission Record revealed the facility admitted Resident #23 on 9/29/19 with diagnoses including Psychotic Disorder with Delusions due to known Physiological Condition, Unspecified Psychosis, Major Depressive Disorder, and Anxiety disorder. A record review of Resident #23's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/21 indicated a No response to question A-1500 which indicated Resident #23 did not have a serious mental illness. On 1/19/22 at 2:33 PM, in an interview with Licensed Practical Nurse #1 (LPN)/ MDS nurse, she confirmed that Resident #2, Resident #3, and Resident #23 did have a diagnosis of a serious mental illness and she had made an error in coding the MDS. She stated she should have coded Section A-1500 as yes for these residents. Resident #48 Record review revealed the facility admitted Resident # 48 on 11/11/2011 per the admission Record, with diagnoses including: End Stage Heart Disease (ESHD), Brain Degeneration and Chronic Respiratory Failure. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/24/21 revealed Hospice care was not marked in Section O for Resident # 48. Record Review of the Comprehensive Care Plan for Resident #48 revealed she was admitted to (Proper Name of Hospice Service) on 7/8/21 with a terminal diagnosis of ESHD secondary to degeneration of brain at routine level of care. During an interview on 1/19/22 at 4:00 PM, License Practical Nurse (LPN) #1 confirmed she failed to check yes on the MDS (ARD of 12/24/21) which indicated Resident #48 was receiving hospice care. LPN #1 verified Resident #48 was receiving hospice services during the look back period referenced.

Based on observation, staff interview, record review and facility procedure review, the facility failed to properly clean a wound for one (1) of one (1) wound care observations. Resident # 205. Findings Include: Review of the facility's procedure, Dressings, Dry/Clean, undated, revealed Steps in the Procedure .15. clean from the least contaminated area to the most contaminated area (usually from the center outward) . On 1/19/22 at 3:45 PM, during an observation of wound care for Resident #205, Registered Nurse (RN) #1 did not wash or sanitize her hands between changing her gloves after she had removed the soiled dressing and before she cleaned the wound. RN #1 cleaned the wound bed by using moistened gauze in a circular motion beginning from the outer portion of the wound bed moving toward the center of the wound. RN #1 also did not wash or sanitize her hands between changing her gloves after she cleaned the wound and before she applied calcium alginate to the wound bed. On 1/19/22 at 4:07 PM, in an interview with RN #1, she stated she should have cleaned the wound from the center of the wound which is the least contaminated and moved toward the outer portion of the wound bed which is the most contaminated area. On 1/19/22 at 4:12 PM, in an interview with the Director of Nursing (DON), she confirmed RN #1 should have cleaned the wound starting in the center and moving outward and RN #1's actions could have caused Resident #205 to acquire a wound infection. Record review of Resident #205's admission Record revealed the facility admitted the resident on 1/6/22 and had a diagnosis of Pressure Ulcer of Right Buttock, Unstageable. Record review of the Physician Orders dated 1/6/22 revealed pressure ulcer right buttock: clean with wound cleaner, apply calcium alginate, cover with bordered gauze every other day and as needed. Record review of the RN #1's Transcript revealed the course name Basics of Hand Hygiene with a Completed date of 5/12/21, course name Preventing Pressure Injuries/Ulcers with a Completed date of 6/26/2019, and course name Infection Control: Essential Principles with a completed date of 5/12/21 revealed RN #1 received training on hand hygiene, pressure ulcers, and infection control. Record review of Clean Dressing Competency Skills Checklist dated 10/18/21 revealed clean dressing competency skills was completed by RN#1.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure staff followed infection control measures during wound care for one (1) of one (1) resident observed for wound care. Resident # 205. Findings Include: Review of the facility's policy tilted, Policies and Practices - Infection Control, with a revision date of 10/2018, revealed Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe sanitary, comfortable environment to help prevent and manage transmission of disease and infection . Review of the facility's Policies and Procedures, dated 11/30/2014 revealed Subject: Handwashing .Policy: An essential component of infection control is handwashing . On 1/19/22 at 3:45 PM, during an observation of wound care for Resident #205, Registered Nurse (RN) #1 did not wash or sanitize her hands between changing her gloves after she had removed the soiled dressing and before she cleaned the wound. RN #1 cleaned the wound bed by using moistened gauze in a circular motion beginning from the outer portion of the wound bed moving toward the center of the wound. RN #1 also did not wash or sanitize her hands between changing her gloves after she cleaned the wound and before she applied calcium alginate to the wound bed. On 1/19/22 at 4:07 PM, in an interview with RN #1, she stated she should have cleaned the wound from the center of the wound which is the least contaminated and moved toward the outer portion of the wound bed which is the most contaminated area. She said she had forgotten to bring the hand sanitizer into the room to use between glove changes and she confirmed she should have washed or sanitized her hands after removing her gloves. She confirmed her actions could have caused the resident to have a wound infection. On 1/19/22 at 4:12 PM, in an interview with the Director of Nursing (DON), she stated that RN #1 should have washed or sanitized her hands after removing her gloves during wound care. She also confirmed RN #1 should have cleaned the wound starting in the center and moving outward and RN #1's actions could have caused Resident #205 to acquire a wound infection. Record review of Resident #205's admission Record revealed the facility admitted the resident on 1/6/22 with a diagnosis of Pressure Ulcer of Right Buttock, Unstageable. Record review of the Physician Orders dated 1/6/22 revealed pressure ulcer right buttock: clean with wound cleaner, apply calcium alginate, cover with bordered gauze every other day and as needed. Record review of the RN #1's Transcript revealed the course name Basics of Hand Hygiene with a Completed date of 5/12/21, course name Preventing Pressure Injuries/Ulcers with a Completed date of 6/26/2019, and course name Infection Control: Essential Principles with a completed date of 5/12/21 revealed RN #1 received training on hand hygiene, pressure ulcers, and infection control. Record review of the certificate for Nursing Home Infection Preventionist Training Course (Web-based) from the Centers for Disease Control (CDC) revealed that RN #1 completed the course on 5/10/2021. Record review of RN #1's Skills Competency Assessment: Hand Hygiene and Clean Dressing Skill Competency Checklist, revealed that RN #1 satisfactorily completed the skills check offs on 10/18/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Revised 4/6/22 Upon secondary review with Centers for Medicare and Medicaid Services (CMS) Regional Office staff and State Quality Assurance, the State Survey Agency (SSA) determined the scope and severity of F565 was increased from a D to an E. Based on resident and staff interviews, a test meal tray, record review, and facility policy review, the facility failed to ensure Resident Council grievances related to food were resolved in a timely manner. This affected eight (8) of (52) residents who resided in the facility. Resident #18, Resident #19, Resident #22, Resident #23, Resident #27, Resident #32, Resident # 34, and Resident #37. Findings Include: The facility's grievance policy titled, Complaint/Grievances, dated 11/30/2014, revealed prior to or upon admission the resident's designated person will be informed of the right to file and the procedure for filing a complaint. If the resident or resident designated person feel or believe that the residents rights have been or are being violated by staff or another resident or in any other way, the resident and or resident designated person shall make his/her complaint known to the administrator. The residence shall permit and respond to oral and written complaints from a source regarding an alleged violation of resident's rights, quality of care or other matters without retaliation or the threat of retaliation. If the resident wishes to make a written complaint but needs assistance the residence will assist the resident in writing the complaint. the residents shall ensure investigation and resolution for complaints. A staff member will be designated to receive complaints. A log will be kept of all complaints and outcomes. Within two business days after the submission of a written complaint, a statue report shall be provided by the residents to the complainant the resident or residence designated person indicating the steps that will be taken to address the concerns. Within seven days after the submission of a written complaint, the residence will give the complainant and if applicable the designated person a written decision explaining the residence investigation findings and actions to be taken for resolution if the resident is not the complainant, the affected residents shall receive a copy of the decision unless contraindicated by the support plan. If the residence investigation validates the complaint allegations, a resident who could potentially be harmed or is designated personal shall receive a copy of the decision, with the name of the affected residents removed, unless contraindicated by the support plan. The facility's policy titled, Quality and Palatability, revised 9/2017 revealed, Policy Statement: Food will be prepared by methods that can serve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served a safe and appetizing temperature .Definitions: . Food palatability refers to the taste and flavor of the food. Proper safe and appetizing temperature reveal food should be at the appropriate temperature as determined by the type of food to ensure residents satisfaction and minimizes the risk for scalding and burns .Procedures: .1 Cooks are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 2. The cook prepares food in a sanitary manner utilizing the principles of hazards and analysis critical control point and time and temperature guidelines as outlined in the federal food code . 4. The cooks prepare food in accordance with the recipes and season for region and or ethnic preferences, as appropriate cooks use proper cooking techniques to ensure color and flavor retention. Record review of the Resident Council Minutes revealed on 8/17/21 under Old Business the food doesn't have season and under New Business the Issue is Food is Cold, Action Taken is Nursing and Dietary will work together on getting meals out prompt, and the Person Responsible is Dietary/Nursing. A review of the Resident Council Minutes on 9/16/21 under Old Business the food is cold and under New Business the Issue is Food Cold/Bland the Action Taken is Dietary working with nsg (nursing) on getting trays out in time. A record review of the Resident Meeting dated 10/14/21, revealed three residents complained of food cold. Record review of the Resident Council Minutes revealed on 11/24/21 under Old Business the food call (cold). Therefore, the residents have had complaints related to the food not being palatable or at an appetizing temperature for four consecutive months. On 01/18/22 at 02:01 PM, during an interview, the Resident Council Members complained that the food is cold, bland, and does not have any taste. The council members said the Activity Director recorded their grievances and said she would give their concerns to the Director of Nursing (DON). On 1/19/22 at 12:30 PM, the State Agency (SA) received a test tray with fried chicken, mashed potatoes, green beans, a roll and pear crisp. The fried chicken was cold and the mashed potatoes and green beans were also bland and cold. The SA received the food after the last tray was served on the floor. On 1/19/22 at 1:00 PM, during an interview with the Dietary Manager, she confirmed she was invited to the resident council meeting in May of 2021 where they discussed the food was cold, and at that time the DON started calling the nursing staff on the hall to let them know that the meal carts were ready to be distributed to the residents. The Dietary Manager was invited to the resident council meeting again in August of 2021 in which the residents complained that the food was still cold and bland. The Dietary Manager ordered Season Blend and [NAME] Chachere's seasonings at that time to season the food. The Dietary Manager confirmed that for the test tray meal obtained and tested by the SA, the cook placed butter and cheese in the mashed potatoes, but did not use any seasoning and for the green beans, the cook only added a small amount of [NAME] Chachere's seasoning and butter. During an interview on 1/19/22 at 1:00 PM, with the Activity Director, she confirmed the residents had complained in several meetings of bland and cold food. The Activity Director stated that she records the minutes for the residents every month in the council meeting and takes the complaints to the DON. However, the residents have continued to complain about the food being cold and bland every month. The Activity Director admitted she has eaten the food at the facility, and she agreed it was cold and bland. During an interview on 1/19/22 at 1:30 PM, with the DON, she confirmed the Activity Director brought the residents ' complaints to her about the food being bland and cold. The DON stated that she attempted to put more people out on the floor to assist with passing out trays to keep the food from getting cold. During an interview on 1/19/22 at 2:00 PM, with the Administrator, she revealed she did not know that the residents had complained repeatedly in the resident council meetings about the food being bland and cold. The Administrator said the Activity Director had talked to the DON about the concerns and she (the DON) was going to resolve them. The Administrator stated that in the Quality Assurance meetings, the facility had discussed getting the food out in a timely manner, but she did not know that the residents were still complaining about the food. Resident Council Members: The facility admitted Resident #18 on 11/08/2013 per the admission Record, with diagnoses that included: Diabetes Mellitus, Hypertension, and Seizures. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/20/21 revealed Resident#18 had a Brief Interview of Mental Status (BIMS) score of 12 that indicated Resident #18 has moderate cognitive impairment. The facility admitted Resident #19 on 9/20/2019 per record review of the admission Record, with diagnoses that included: Epilepsy, Cardiomegaly, and Hypertension. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/24/21 revealed Resident#19 had a Brief Interview of Mental Status (BIMS) score of 8 that indicated Resident #19 is moderately cognitively impaired. Record review of the admission Record revealed he facility admitted Resident #22 on 3/01/2016 with diagnoses that included: Peripheral Vascular Disease, Pain and Hypertension. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/02/21 revealed Resident#22 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated Resident #22 is cognitively intact. The facility admitted Resident #23 on 9/08/2017 per the admission Record, with diagnoses that included: Quadriplegia, Cervical Spinal Cord Sequela and Paraplegia. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/17/21 revealed Resident #23 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated #23 is cognitively intact. The facility admitted Resident #27 on 3/06/2019 per the admission Record, with diagnoses that included: Hypertension, Hemiplegia, and Overactive bladder. The admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/22/21 revealed Resident#27 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated #27 is cognitively intact. The facility admitted Resident #32 on 2/26/2010 per the admission Record, with diagnoses that included: Parkinson's Disease, Anxiety Disorder, and Peripheral Vascular disease The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 9/03/21 revealed Resident #32 had a Brief Interview of Mental Status (BIMS) score of 3 that indicated # 32 has severe cognitive impairment. The facility admitted Resident # 34 on 3/27/2019 per the admission Record, with diagnoses that included: Hypertension, Anemia, and Neuromuscular Dysfunction bladder. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/22/21 revealed Resident #34 had a Brief Interview of Mental Status (BIMS) score of 10 that indicated Resident #34 has moderate cognitive impairment. The facility admitted Resident #37 on 1/18/2005 per the admission Record, with diagnoses that included: Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, and Asthma. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/16/21 revealed Resident # 37 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated Resident #37 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Revised 4/6/22 Upon secondary review with Centers for Medicare and Medicaid Services (CMS) Regional Office staff and State Quality Assurance, the State Survey Agency (SSA) determined the scope and severity of F804 was increased from a D to an E. Based on observation, resident interview, staff interview, a test meal tray, written grievances review, record review and facility policy review, the facility failed to serve food that was palatable and at an appetizing temperature to eight (8) of (52) residents reviewed for food palatability. Resident #18, Resident #19, Resident #22, Resident #23, Resident #27, Resident #32, Resident #34, and Resident #37. Findings include: The facility's policy titled, Quality and Palatability, revised 9/2017 revealed, Policy Statement: Food will be prepared by methods that can serve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served a safe and appetizing temperature .Definitions: . Food palatability refers to the taste and flavor of the food. Proper safe and appetizing temperature reveal food should be at the appropriate temperature as determined by the type of food to ensure residents satisfaction and minimizes the risk for scalding and burns .Procedures: .1 Cooks are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 2. The cook prepares food in a sanitary manner utilizing the principles of hazards and analysis critical control point and time and temperature guidelines as outlined in the federal food code . 4. The cooks prepare food in accordance with the recipes and season for region and or ethnic preferences, as appropriate cooks use proper cooking techniques to ensure color and flavor retention. Record review of the Resident Council Minutes revealed on 8/17/21 under Old Business the food doesn't have season and under New Business the Issue is Food is Cold, Action Taken is Nursing and Dietary will work together on getting meals out prompt, and the Person Responsible is Dietary/Nursing. A review of the Resident Council Minutes on 9/16/21 under Old Business the food is cold and under New Business the Issue is Food Cold/Bland the Action Taken is Dietary working with nsg (nursing) on getting trays out in time. A record review of Resident Meeting dated 10/14/21 revealed three residents complained of food cold. Record review of the Resident Council Minutes revealed on 11/24/21 under Old Business the food call (cold). Therefore, the residents have had complaints related to the food not being palatable or at an appetizing temperature for four consecutive months. On 01/18/22 at 02:01 PM, during an interview, the Resident Council Members complained that the food is cold, bland, and does not have any taste. The council members said the Activity Director recorded their grievances several times and said she would give their concerns to the Director of Nursing (DON). On 1/19/22 at 12:30 PM, the State Agency (SA) received a test tray with fried chicken, mashed potatoes, green beans, a roll and pear crisp. The fried chicken was cold, and the mashed potatoes and green beans were also bland and cold. The SA received the food after the last tray was served on the floor. On 1/19/22 at 1:00 PM, during an interview with the Dietary Manager, she confirmed she was invited to the resident council meeting in May of 2021 where they discussed the food was cold, and at that time the DON started calling the nursing staff on the hall to let them know that the meal carts were ready to be distributed to the residents. The Dietary Manager was invited to the resident council meeting again in August of 2021 in which the residents complained that the food was still cold and bland. The Dietary Manager ordered Season Blend and [NAME] Chachere's seasonings at that time to season the food. The Dietary Manager confirmed that for the test tray meal obtained and tested by the SA, the cook placed butter and cheese in the mashed potatoes but did not use any seasoning and for the green beans, the cook only added a small amount of [NAME] Chachere's seasoning and butter. During an interview on 1/19/22 at 1:00 PM with the Activity Director, she confirmed the residents had complained in several meetings of bland and cold food. The Activity Director stated that she records the minutes for the residents every month in the council meeting and takes the complaints to the DON. However, the residents have continued to complain about the food being cold and bland every month. The Activity Director admitted she has eaten the food at the facility, and she agreed it was cold and bland. During an interview on 1/19/22 at 1:30 PM, with the DON, she confirmed the Activity Director brought the residents' complaints to her about the food being bland and cold. The DON stated that she attempted to put more people out on the floor to assist with passing out trays to keep the food from getting cold. During an interview on 1/19/22 at 2:00 PM, with the Administrator, she revealed she did not know that the residents had complained repeatedly in the resident council meetings about the food being bland and cold. The Administrator said the Activity Director had talked to the DON about the concerns and she (the DON) was going to resolve them. The Administrator stated that in the Quality Assurance meetings, the facility had discussed getting the food out in a timely manner, but she did not know that the residents were still complaining about the food. Resident Council Members: Record review revealed the facility admitted Resident #18 on 11/08/2013 per the admission Record, with diagnoses that included: Diabetes Mellitus, Hypertension, and Seizures. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/20/21 revealed Resident#18 had a Brief Interview of Mental Status (BIMS) score of 12 that indicated Resident #18 had moderate cognitive impairment. Record review revealed the facility admitted Resident #19 on 9/20/2019 per the admission Record, with diagnoses that included: Epilepsy, Cardiomegaly, and Hypertension. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/24/21 revealed Resident#19 had a Brief Interview of Mental Status (BIMS) score of 8 that indicated Resident #19 is moderately cognitively impaired. The facility admitted Resident #22 on 3/01/2016 per record review of the admission Record, with diagnoses that included: Peripheral Vascular Disease, Pain and Hypertension. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/02/21 revealed Resident#22 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated Resident #22 is cognitively intact. The facility admitted Resident #23 on 9/08/2017 per record review of the admission Record, with diagnoses that included: Quadriplegia, Cervical Spinal Cord Sequela and Paraplegia. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/17/21 revealed Resident #23 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated #23 is cognitively intact. Record review revealed the facility admitted Resident #27 on 3/06/2019 per the admission Record, with diagnoses that included: Hypertension, Hemiplegia, and Overactive bladder. The admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/22/21 revealed Resident#27 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated #27 is cognitively intact. Record review of the admission Record revealed the facility admitted Resident #32 on 2/26/2010 with diagnoses that included: Parkinson's Disease, Anxiety Disorder, and Peripheral Vascular disease The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 9/03/21 revealed Resident #32 had a Brief Interview of Mental Status (BIMS) score of 3 that indicated Resident #32 has severe cognitive impairment. Record review revealed the facility admitted Resident # 34 on 3/27/2019 per the admission Record, with diagnoses that included: Hypertension, Anemia, and Neuromuscular Dysfunction bladder. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/22/21 revealed Resident #34 had a Brief Interview of Mental Status (BIMS) score of 10 that indicated Resident #34 has moderate cognitive impairment. Record review revealed the facility admitted Resident #37 on 1/18/2005 per the admission Record, with diagnoses that included: Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, and Asthma. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/16/21 revealed Resident # 37 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated Resident #37 is cognitively intact.