Based on observation, staff and resident interviews, record reviews, and facility policy reviews, the facility failed to provide an ongoing weekend activity program to support residents in their choice of activities for two (2) of seventeen (17) sampled residents. Resident #18 and Resident #47. Findings Include: A review of the facility policy titled, Activity Program, dated 2001 revealed, Policy Statement: An ongoing program of activities is designed to meet the needs of each resident .Policy Interpretation and Implementation . 6. Individualized and group activities are provided that- a. Reflect the schedule, choices, and rights of the residents; b. Are offered at hours convenient to the residents, including evenings, holidays, and weekends; c. Reflect the cultural and religious interests of the residents . During the resident council meeting on 6/02/24 at 2:00 PM, several residents expressed they were disappointed the facility was not providing group activities on the weekend. The residents revealed that the facility leaves coloring books and puzzles for them, which makes them feel belittled and insulted because those are children's activities. Resident #18 On 6/5/24 at 9:10 AM, during an interview with Resident # 18, she revealed she regularly volunteers to do activities with the residents. She pointed out that activities on weekdays are not done consistently. They have not had services on Sunday in several weeks, despite it being listed on the calendar. She said that she and the others have repeatedly expressed to the Activities Director that they are offended by the puzzles and coloring sheet activities, because they are not second and third graders. She exclaimed that the people around here think because these residents are in the nursing home, they are brain-dead. They do not realize we are still adults with adult minds, so they need to provide better weekend activities that are more age appropriate. Record review of the admission Record for Resident #18 revealed the facility admitted the resident on 10/28/22 with diagnoses including Malignant Neoplasm of Upper Outer Quadrant of Right Breast and Osteoporosis. Record review of the Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/17/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #18 was cognitively intact. Review of Section F revealed it is very important to the resident to have books, newspapers, and magazines, listen to music, be around pets, keep up with the news, do things with groups of people, do her favorite activities, get outside and get fresh air, and participate in religious practices. Resident #47 On 6/2/24 at 10:00 AM, upon Sunday's arrival at the facility, Resident #47 was observed alone in the activity area, seated at a table, looking at a blank television screen while in his wheelchair. The observation revealed that there were no churches services being held, although it was scheduled on the calendar. During an in-room interview with Resident #47 on 6/02/24 at 02:42 PM, he revealed that on the weekends, he does not have much to do regarding activities. He stated that he likes being among people and going outside but doesn't get to do that as much as he would like. On 6/3/24 at 12:22 PM, in an interview with Resident # 47, he indicated he is bored on the weekends, does not like to do puzzles or coloring, and wished there were more fun stuff to do. Record review of the admission Record for Resident #47 revealed the facility admitted the resident on 4/24/24 with diagnoses that included Hypertension and Chronic Kidney Disease. Record review of the admission MDS, with an ARD of 5/1/24, revealed a BIMS score of 10, which indicated Resident #47 had moderate cognitive impairment. Review of Section F revealed it was very important to the resident to do things with groups of people, perform his favorite activities, go outside to get fresh air when the weather is good, listen to music, and have books, newspapers, and magazines to read. On 6/2/24 at 10:28 AM, in an interview with the Activity Director, she indicated she does not come in on Saturdays or Sundays, and there is no other staff assigned to do activities on the weekend. She mentioned that a Certified Nursing Assistant (CNA) or nurse is supposed to do the morning exercises with residents, but there is no specific assignment. She also mentioned that, as referenced on the monthly activity calendar, there are coloring sheets and word puzzles for the residents to entertain themselves on the weekends. On 6/4/24 at 9:20 AM, in an interview with the Activity Director, she indicated they have not had church services in several weeks because the pastor, who used to come passed away. She added that they have been working on getting someone else scheduled. On 6/5/24 at 10:43 AM, during an interview with CNA #1, she revealed she has worked in the facility for the last seven years and confirms working in the facility on the weekends from time to time. She indicated that many residents watch television on the weekends, and some of them may do puzzles for activities. She also stated that no nurses or CNAs perform any type of activity with the residents from what she has observed while working on the weekends. On 6/5/24 at 10:46 AM, in an interview with the Administrator, she revealed activities are very important to their residents and that having activities can help keep them alive and going. She indicated she cannot say when the Activities Director has last reassessed the current residents to ensure the puzzles and color sheets meet their desired form of activity on the weekends. A record review of the Activity Calendar, for the month of June revealed that on both weekend days (Saturday and Sunday), the activities listed were an 8:30 AM Sit and Fit Exercise program, at 2:00 PM, there were independent activities listed, with in-room materials available at the nurse's desk, and at 6:00 PM, the activity listed was Word Puzzles/Coloring Sheets. There was an additional activity listed for Sunday, which included church services at 10:00 AM.

Based on interviews and record review of the Certification and Survey Provider Enhanced Reports (Casper) reporting data review, the provider failed to ensure their Payroll Based Journal (PBJ), (information on the staffing hours for the appropriate care of the residents) had been corrected before submitting to the Center for Medicare and Medicaid Services (CMS) for the first Quarter of the 2024 Fiscal Year (October 1, 2023-December 31, 2023). Findings Include: Review of the provider's [NAME] reporting data revealed the facility triggered excessively low weekend staffing for the first quarter of the 2024 fiscal year. Record review of facility policy titled, Staffing Policy, revised October 2017 revealed,Policy Statement: Our facility provides sufficient numbers of staff with skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment. Policy interpretation and implementation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and skill requirements of direct care staff are determined by the needs of residents based on each plan of care . 4. Direct care staffing information per day . is submitted to CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter . On 06/03/24 at 1:45 PM, an interview with the Director of Nurses (DON) revealed she is responsible for making schedules monthly for Certified Nurse Aides (CNA) and Nurses. She explained the facility nurses operate on 8 (eight) hour shifts, with staffing 4 -5 (four to five) CNAs on the 7:00 AM to 3:00 PM shift; 3-4 (three to four) CNAs work on during the 3:00 PM to 11:00 PM shift, and 2-3 (two-three) CNAs work on the 11:00 PM to 7:00 AM shift. The facility has 2 (two) Licensed Practical Nurses (LPNs) that serve as medication carts nurses on each shift and a Registered Nurse (RN)/Charge Nurse that works 7:00 AM to 3:00 PM on weekdays and 6:00 AM to 6:00 PM on Saturdays and Sundays. The DON also revealed that the facility has PRN (as needed) staff to fill in gaps on weekends. A record review of facility staffing of the facility staffing grid and working schedule for October 1, 2023-December 31, 2023, revealed sufficient staffing. During an interview on 6/03/24 at 2:13 PM, the Administrator and HR Generalist confirmed the facility failed to accurately report there were sufficient staff to meet the facility needs. She revealed the HR (Human Resource) Generalist is responsible for putting staffing hours into the system. However, the HR Specialist was new and unaware that she was supposed to submit documentation to the corporate office regarding the staff that worked and salaried employees that work additional hours as needed to meet the needs of the residents, and any overtime hours. The Administrator explained that the facility system data is submitted to the Corporate office, and that, along with any additional staffing hours submitted by the HR Specialist, are added to adjust the hours prior to the Corporate office submitting the PBJ to CMS. The Administrator confirmed she was not aware the PBJ triggered low weekend staffing for the first quarter for excessively low weekend staff. The HR Generalist confirmed that after working with the corporate office to investigate the issue regarding the reported low weekend staffing during the first quarter of the 2024, the facility had failed to accurately report additional staffing hours that were worked to corporate. Those addition staffing hours would have been added by the corporate office to the system prior to submission of the PBJ to CMS.

Based on observation, interview, record review, and facility policy review the facility ailed to implement the comprehensive care plan related to oral hygiene and positioning for one (1) of 15 sampled Residents. Resident #35 Findings Include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revealed A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The facility failed to develop a care plan for hand rolls for a resident with bilateral upper extrememity and hand contractures. Review of the resident's care plan revealed no care plan for hand rolls. Observation on 05/21/23 at 02:54 PM revealed contractures of bilateral upper extremities. The resident's fingers and hand were bent in toward the wrist. Nails were short and not pushing into the hand of the resident. No open areas noted. No hand rolls in hands. Resident nods when asked if she would like to use a hand roll for the contractures in bilateral upper extremities (BUE). Observation with Resident #35, Director of Nurses (DON), and Charge Nurse on 05/22/23 at 01:57 PM revealed Resident was observed with contractures bilaterally. When the resident was asked about hand rolls she nodded yes, she would like hand roles. On 05/23/23 at 09:43 AM, an interview with the occupational therapist (OT) revealed resident wore hand roles for a while but that she when she was readmitted from hospital the hand rolls were not restarted. He stated the resident used to wear the hand rolls from late evening through the night. He says she has not been wearing them lately. Review of Resident #35's care plan revealed the facility failed to implement the care plan for personal hygiene. Care Plan review revealed Resident is at risk for complications r/t almost totally dependent on staff for all her ADLs (Activities of Daily Living) following CVA (stroke). Observation on 05/21/23 at 02:49 PM revealed Resident #35 had mouth odor present. Teeth and mouth had build up of white sticky substance. Observation revealed approximate 0.5 inch of hair growth on chin. Interview with Resident #35 on 05/21/23 at 02:49 PM revealed she was interviewable by nodding and shaking head to yes and no questions. The resident nodded yes that she would like her mouth cleaned. On 05/22/23 at 09:50 AM, observation revealed Resident's mouth remained coated with white sticky substance and hairs remained on chin. Resident nodded when asked if she would like her mouth clean. Resident shook her head when asked if she likes to leave hairs on chin. On 05/22/23 at 01:57 PM, observation revealed resident's chin had been shaved. Record review of the Minimum Data Set (MDS) reviewed an Brief Interview for Mental Status score of 99 and was coded as responds adequately to simple direct communication only. Interview with DON revealed care plan should be followed. The DON stated the resident was under PT currently since returning from the hospital. She stated restorative would pick up once the resident comes off the PT schedule.

Based on observation, interview, record review, and facility policy review, the facility failed to provide mouth care for a dependent resident for one (1) of 15 sampled residents. Findings Include: Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, revealed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Observation on 05/21/23 at 02:49 PM revealed Resident #35 had mouth odor present. Teeth and mouth were not clean as evidenced by the resident's mouth had build up of white sticky substance. Observation also revealed approximate 0.5 inch of hair growth on chin. Interview with Resident #35 on 05/21/23 at 02:49 PM revealed she was interviewable by nodding and shaking head to yes and no questions. The resident nodded yes that she would like her mouth cleaned. On 05/22/23 at 09:50 AM, observation revealed Resident's mouth remained coated with white sticky substance and hairs remained on chin. Resident nodded when asked if she would like her mouth clean. Resident shook her head when asked if she likes to leave hairs on chin. On 05/22/23 at 01:57 PM, observation revealed resident's chin had been shaved. Interview, on 05/22/23 at 01:57 PM, with the Director of Nurses, DON, and Charge Nurse revealed resident's chin had been shaved this morning and mouth care had been provided. The charge nurse nodded that the care had been provided. The DON stated mouth care must be done frequently because the resident drools and requires and towel to prevent the soaking of the resident's clothing. Observation revealed towel present to protect clothing. Record review of the Minimum Data Set (MDS) reviewed an Brief Interview for Mental Status score of 99 and was coded as responds adequately to simple direct communication only.

Based on observation, interview, and record review, the facility failed to provide positioning hand rolls for a dependent resident with contractures for one (1) of 15 residents sampled. Findings Include: Observation on 05/21/23 at 02:54 PM revealed contractures of bilateral upper extremities. The resident's fingers and hand were bent in toward the wrist. Nails were short and not pushing into the hand of the resident. No open areas noted. No hand rolls in hands. Resident nods when asked if she would like to use a hand roll for the contractures in bilateral upper extremities (BUE). Observation with Resident #35, Director of Nurses, and Charge Nurse on 05/22/23 at 01:57 PM revealed Resident was observed with contractures bilaterally. The DON and Charge nurse stated the resident does not want roles placed in hands for positioning. When the resident was asked about hand rolls she nodded yes, she would like hand roles. The DON stated previously she did not like the type of roles in hands but that maybe a different type could be used. The resident nodded. The DON stated she was going to tell PT of the resident's wishes. On 05/23/23 at 09:43 AM, an interview with the occupational therapist (OT) revealed resident wore hand roles for a while but that she when she was readmitted from hospital the hand rolls were not restarted. He stated the resident used to wear the hand rolls from late evening through the night. He says she has not been wearing them lately. On 05/23/23 09:48 AM, an interview with Physical Therapist (PT), revealed the facility has a restorative program with the CNAs, The program has check offs for the CNAs to do and stated that Nursing is over the restorative program. The last restorative training provided by PT for the CNA staff was on 4/20/23 and this is completed annually. When asked if Resident #35 is gotten up out of bed, PT stated they are a awaiting a special wheelchair for her to be able to get up. The chair has been ordered with a Medical Supply. The facility was unable to provide an order request for the wheelchair. On 05/23/23 at 10:00 AM, an observation revealed the resident with hand role carrot role in right hand. No role was observed in left hand. Review of the resident's Minimum Data Set (MDS) with assessment reference date (ARD) of 3/17/23 revealed under Section G that resident was extensive assist and totally dependent on staff for positions and mobility. The resident Brief Interview for Mental Status (BIMS) score was 99.

Resident #42 Respiratory Care Based on observation, record review, and staff and resident interview, the facility failed to provide respiratory care consistent with professional standards of practice as evidence by a resident receiving oxygen therapy with no physician's order, monitoring or plan of care for one (1) of 15 sampled residents. Resident #43 Findings Include: An observation and interview on 05/22/23 at 03:20 PM revealed Resident #43 lying in bed with bilateral nasal cannula in nares, oxygen concentrator on administered at 2.5 Liters(L). Resident #43 noticed my observation of concentrator setting and commented the setting should be on 1.5L. A record review of Resident # 42's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/23/2023 revealed in Section O regarding O2 use, the resident was marked as not receiving O2 therapy. A record review of Resident #42's cumulative Physician's orders with an order review date of 04/15/2023 revealed the resident did not have an physician's order for the use of O2. A record review of Resident #42's care plan revealed the resident did not have a care plan related to O2 therapy. An Interview on 05/22/23 at 02:20 PM with Resident # 42 revealed she had been using O2 mostly just at night to assist with breathing. Resident #42 stated she believes she has sleep apnea but has never had a sleep study. When asked about who puts the O2 on and sets the concentrator rate, Resident #42 stated she does it herself and uses every night to help her sleep. An Interview on 05/23/23 at 11:20 AM with LPN #1 revealed she was aware Resident utilizes O2 at night when she has shortness of breath and it helps her sleep. An Interview on 05/23/23 at 11:42 AM with Registered Nurse (RN) #2 and the Director of Nursing (DON) revealed they were unaware the resident was using O2. The DON stated the resident's order for O2 was discontinued. Neither were aware the resident continued to use the O2. Both agreed there were no orders for the use of O2 and the resident was not being monitored for use of O2. Interview on 05/23/23 at 11:55 PM with the MDS nurse confirmed the resident was not assessed as using O2 and no care plan was developed for the use of O2. A record review of Resident # 42's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/23/2023 revealed the resident had a brief interview for mental status (BIMS) score of 15 and the resident was admitted by the facility on 01/03/2023 with active diagnoses including Morbid (SEVERE) Obesity with Alveolar Hypoventilation and Peripheral Vascular Disease.

FACILITY Kitchen Based on observation, interview, and facility policy review, the facility failed to ensure supplemental nutritional shakes were thawed in a manner to prevent potential foodborne illness. This deficient practice had potential to affect four (4) of 4 residents who received nutritional shake supplements of 52 residents in the facility. Findings Include: A review of the Facility's Policy titled Food: Preparation states the cook(s) will thaw frozen items using one of the following methods: thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross-contamination; thawing the item in a microwave oven then transferring immediately to conventional cooking equipment; completely submerging the item under cold water (at a temp of 70 degrees Fahrenheit) or below that is running fast enough to agitate and float off loose ice particles; cooking directly from the frozen state, when directed. An observation on 05/21/23 at 02:35 PM during the Initial Brief Tour of the kitchen revealed approximately 24 tray of supplemental shakes, strawberry flavor, on a tray on a shelf in kitchen. The shakes were thawed and sitting at room temperature, about 84 degrees as read on thermometer. An interview with Dietary Staff (DS) #1 at 2:55 PM revealed another dietary staff person (DS #2) had pulled the shakes out to thaw and placed them on the tray prior to her leaving after the lunch meal. DS #1 stated he was supposed to put them in the refrigerator and forgot. DS #1 calibrated thermometer to 32 and tested temperature of one the shakes. The shake temperature was 69 degrees. DS #1 stated he was going to throw the shakes out as the temperature was too high for them to be served. He again stated they should have been in the refrigerator until serving time. A review of facility listing of therapeutic diets revealed four of 52 residents in the facility were prescribed supplemental Mighty Shakes. An interview on 05/22/23 @ 3:00PM with DS #2 confirmed she was the person who took the Mighty shakes out freezer to thaw. DS #2 states she put them on a tray and told DS #1 to put the tray in the refrigerator to thaw. DS#2 stated the normal way they thaw shakes is by putting them on a tray in the refrigerator and the milkshakes should be stored in refrigerator until time to serve. DS #2 , stated if shakes were too warm they may cause residents to have stomach upset, or could make them sick. DS #2 estimated the shakes were taken out between 11:30AM to 12:00PM DS #2 stated shakes should not have temp above 41 as they contain milk.

Based on observation, staff interview, record review, and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) related to medication, for one (1) of 21 MDS assessments reviewed, Resident #35. Findings include: Review of the RAI (Resident Assessment Instrument) manual for coding section N0410E, Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here. Review of the Resident #35's MDS with an Assessment Reference Date (ARD) of 9/24/19, revealed Section N0410E was coded 7, related to the number of days taking an anticoagulant. Review of Resident #35's physician orders, dated 9/17/19, revealed she was currently taking Plavix (clopidogrel) 75 milligram (mg) every day and ASA (Aspirin) 81 mg every day. Review of Resident #35's Medication Administration Record (MAR), for the look back period for the MDS, revealed resident received ASA 81 mg and Plavix 75 mg for the month of September 2019. During an interview on 10/29/19 at 4:08 PM, Registered Nurse (RN) #1, MDS Nurse, confirmed Resident #35 was on aspirin and Plavix, and had coded the MDS in error. She stated she was told to code the MDS the same as you would for an anticoagulant. She said she had a sticky note on her computer as a reminder to code Plavix as an anticoagulant. RN #1 reviewed the RAI manual and stated Plavix (clopidogrel) was not to be coded in Section N as an anticoagulant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to remove expired medication (med) from the storage room and medication cart for one (1) of five (5) med pass observations. Findings include: Review of a facility's Storage of Medication policy, dated [DATE], revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. On [DATE] at 11:15 AM, an observation with Licensed Practical Nurse (LPN) #1, of the medication storage room, revealed Fexofenadine Hydrochloride tablets USP 180 milligram (MG) Antihistamine 24 hour relief Allergy, with an expiration date of 06/2019. On [DATE] at 11:40 AM, an observation of Medication Cart A, with LPN #2, revealed Fexofenadine Hydrochloride tablets USP 180 MG/Antihistamine 24 hour relief Allergy, with an expiration date of 06/2019. Record review revealed a monthly medication room inspection by the pharmacist dated [DATE]. During an interview on [DATE] at 11:55 AM, the Director of Nursing (DON) stated the medication (Fexofenadine) should have been pulled on or by the expiration date. She stated medications are rotated when they come in, by the central supply staff. The DON stated the Pharmacist comes in the facility once a month to check the medication room.