Based on observation, staff interview, and record review, the facility failed to ensure a resident's right to a dignified experience, as evidenced by not providing a privacy covering for a urinary drainage bag for one (1) of nine (9) residents with an indwelling catheter. (Resident #17) Findings include: On 6/16/24 11:35 AM, during an observation, Resident #17 was lying in bed and a urinary catheter drainage bag was hanging from the right side of the lower bed. The urinary drainage bag was not covered and the urine in the bag was visible from the hallway. On 6/17/24 at 9:15 AM, in an interview and observation with Registered Nurse (RN) #2, she confirmed Resident #17 had an indwelling catheter and the drainage bag was not covered, making the urine visible. RN #2 explained the visible urine was a dignity issue for the resident. On 6/18/24 at 9:15 AM, in an interview with the Director of Nursing (DON), she revealed urinary drainage bags should have a privacy covering because it was a dignity issue for the resident. Record review of the admission Record revealed the facility admitted Resident #17 on 10/19/23 with current Paraplegia and Neuromuscular Dysfunction of Bladder. Record review of the Order Listing Report revealed Resident #17 had a Physician's Order, dated 5/10/24, for a Foley (Indwelling) catheter.

Based on staff interview, record review, and facility policy review, the facility failed to implement a Nurse Practitioner's (NP) recommendation for a specialty mattress for a resident with a pressure ulcer (PU) for one (1) of three (3) residents reviewed with PUs. Resident #32 Findings include: A review of the facility's policy Skin and Wound with revision date of 01/24/2022 revealed Policy: To provide a system for .implementing resident centered interventions to promote skin health, prevention, and healing of pressure injuries . A record review of a timeline provided by the facility of Resident #32's PUs revealed Resident #32 acquired a deep tissue injury (DTI) (a type of pressure injury) to the right and left heel and a left lateral heel DTI on 03/11/24. On 04/02/24, Resident #32 acquired a sacrum wound that was a Stage II PU. She received a specialty (air) mattress on 05/22/24. Record review of Resident #32's Progress Note Details of the wound care NP revealed 4/30/24 . Will order patient air mattress . 5/14/24 .patient has not received air mattress .5/21/24 .The patient has not received the air bed . A record review of the 5-Day (Reentry from an acute hospital) Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/24 revealed Resident #32 was severely cognitively impaired and had three (3) unstageable pressure wounds and indicated there were no pressure devices for her bed or chair coded in Section M for skin conditions. A record review of the Customer Portal maintenance list revealed Resident #32 received an APM2 (type of specialty air mattress) and pump on 5/22/24. On 06/19/24 at 4:30 PM, during an interview with the Director of Nursing (DON), she stated she did not understand or know why Resident #32 did not receive an air mattress after the nurse practitioner ordered it on 4/30/24. She explained she expected the staff to follow the NP's recommendations and to place orders as soon as possible. On 06/19/24 at 5:00 PM, during an interview with Licensed Practical Nurse (LPN) #2/Wound Care nurse she confirmed the NP indicated in her progress notes on two (2) different dates that Resident #32 did not have an air mattress in place. She explained she remembered the NP asking about the air mattress, but it was forgotten about or maybe it was on order from maintenance. On 06/20/24 at 11:45 AM, during an interview with the Maintenance Director, he explained the facility always had low air loss mattresses in-house. The facility placed orders for new mattresses in November 2023. He explained currently there were four (4) low air loss mattresses that are available for use. He stated he always tries to keep one or two low air loss mattresses available but if the facility did not have any mattresses in house, he could order them and have them available the next day. On 06/20/24 at 2:00 PM, during an interview with the Wound Care NP, she explained when Resident #32 first got the PUs, she mentioned to LPN #2/Wound care nurse a verbal order to get the resident a low air loss mattress and after seeing resident a few more times she mentioned the air loss mattress again. She confirmed that she did not follow up on the reason why Resident #32 did not have a specialty mattress. Record review of the admission Record revealed the facility admitted Resident #32 on 01/03/24 with current diagnoses including of Unspecified Dementia.

Based on observation, staff interview, and record review, the facility failed to maintain proper placement of urinary drainage tubing to prevent the possible spread of infection for one (1) of nine (9) residents with an indwelling catheter. (Resident #17) Findings include: Review of the facility's policy, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, revised 9/2017, revealed, . The purpose of this procedure is to provide guidelines for the prevention of catheter-associated urinary tract infections (CAUTIs) .Steps in Procedure .6 .Do not place the drainage bag on the floor . Record review of the Order Listing Report revealed Resident #17 had a Physician's Order, dated 5/10/24, for a Foley (Indwelling) catheter. On 6/16/24 at 11:35 AM, during an observation, Resident #17 was lying in bed and a urinary catheter drainage bag was hanging from the right side of the lower bed and the drainage tubing on the floor. On 6/17/24 at 9:15 AM, in an interview and observation with Registered Nurse (RN) #2, she confirmed Resident #17 had an indwelling catheter and the drainage tubing was on the floor of the resident's room. RN #2 stated the tubing on the floor was an issue with infection control. On 6/18/24 at 9:15 AM, in an interview with the Director of Nursing (DON), she revealed catheters could be a cause of infection and the tubing should not touch the floor. She stated it was the responsibility of all nursing staff to ensure catheter drainage tubing was not touching the floor. Record review of the admission Record revealed the facility admitted Resident #17 on 10/19/23 with current diagnoses that included Paraplegia and Neuromuscular Dysfunction of Bladder.

Based on observation, staff interview, and facility policy review, the facility failed to ensure the chemical sanitizer for a low-temperature dishwasher had a concentration of at least 50 parts per million (ppm) for (1) of two (2) dishwasher observations. Findings include: A review of the facility's policy, Isolation/Infection Control - Non-Disposal Service Ware, Effective Date 11/30/2014, revealed, Policy: Isolation and Infection Control guidelines issued by the Center for Disease Control are followed .Procedure .Low temperature dish machines .use a chemical sanitizer .The required chemical sanitizer concentration is 50 ppm for a chlorine based sanitizer . On 6/17/24 at 10:07 AM, during an interview and observation with the Dietary Manager (DM), the low-temp dishwasher Hypochlorite (chlorine) on the dish surface final rinse was below 10 ppm. The DM confirmed the chlorine ppm was registering below 10. The DM explained adequate chlorine levels were important to help with infection control and stated she would call the Maintenance Director regarding the sanitation concentration. On 6/17/24 at 10:36 AM, an interview with the Maintenance Director revealed the low-temperature dishwasher chlorine was registering below 10 ppm. He advised he would contact the manufacturer to provide further maintenance and a representative would come to the facility. On 6/20/24 at 11:40 AM, an interview with the Administrator, he stated he was aware the low temperature dishwasher chlorine level was below 10 ppm when SA observed the DM test the sanitation on 6/17/24. The Administrator stated he planned to personally in-service the staff on requirements for dishwasher sanitation.

Based on staff interview, record review and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) regarding anticoagulant medication for one (1) of 18 residents reviewed. Resident #10 Findings include: A record review of the facility's policy MDS with a revision date of 09/25/2017 revealed Policy: The center conducts initial and periodic standardized, comprehensive and reproducible assessments .Procedure .Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy . Record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 05/15/24 indicated Resident #10 received anticoagulant medication for seven (7) days during the look back period. Record review of Resident #10's .Order Review Batch Update revealed she had Physician's Orders for Aspirin 81 milligram (mg) (non-steroid anti-inflammatory medication) and Plavix Tablet 75 mg (anti-platelet medication). There were no orders for anticoagulant medications. On 06/19/24 at 2:00 PM, during an interview with the MDS Nurse/Licensed Practical Nurse (LPN) #1, she confirmed the MDS with an ARD of 05/15/24 for Residents #10 was inaccurately coded because she did not receive anticoagulant medications. On 6/19/24 at 2:15 PM, during an interview with the MDS Coordinator/Registered Nurse #1, she explained the facility completes a scrub report prior to submitting the MDS. She confirmed Resident #10's MDS was coded in error and missed on the review. On 6/19/24 at 3:20 PM, during an interview with the Director of Nursing (DON), she confirmed the MDS was coded inaccurately for Resident #10, and she expected all MDS assessments to be coded accurately. Record review of the admission Record revealed the facility admitted Resident #10 on 11/02/2006 with diagnoses including Hemiplegia and Hemiparesis.

Based on interview, record review, and facility policy review the facility failed to ensure a resident had access to personal funds on the weekend for one (1) of 19 sampled residents with potential to affect 64 residents with resident trust fund accounts of 87 total residents in the facility. Resident #8. Resident#8 Review of the facility's policy, Resident Trust Fund-Overview, with a revision date of 4/22/2019, revealed the care center will maintain all residents trust fund accounts in compliance with Federal and State regulations and with generally accepted accounting practices. An interview on 12/12/22 at 10:03 AM with Resident #8 revealed the resident had a trust fund account but was unable get money on the weekends because the office was closed on weekends. An interview on12/14/22 at 10:30 AM with the Social Service Director (SSD) revealed she previously issued the money in the business office, but Receptionist Central Supply (RCS) now keeps up with the money. The SSD stated when she was responsible for the money, residents had access to it on the weekends. An interview on 12/14/22 at 10:34 AM with RCS stated residents have access to their funds any time of the day and can get their funds anytime she is at work. She revealed that she works Monday through Friday 8AM to 5PM. RCS stated she is the only one that deals with the money and that if the residents need money on the weekend she tries to get them taken care of before the weekend. She confirmed that there is no other person here that gives out money on the weekends. On 12/14/22 at 03:40 PM in an interview with Administrator stated normally resident funds are available Monday thru Friday. She stated the residents are not able to get their money on Saturday and Sunday as the office staff is not present on Saturday and Sunday. She stated she was not aware of regulations concerning resident funds being available seven days a week. A review of Resident #8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/22/22, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on staff interview, record review. and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two (2) of 19 residents reviewed. Resident #9 and Resident #11. Findings include: A record review of the facility's policy MDS with a revision date 09/25/2107 revealed The center conducts initial and periodic standardized, comprehensive and reproducible assessment no less than every three months for each resident including, but not limited to, the collection of date requiring functional status, strengths, weaknesses, and preferences using the federal and/or state required RAI (Resident Assessment Instrument). Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy . Resident #9 Record review of Resident #9's admission Record revealed the facility admitted resident on 11/02/2006 with the diagnoses including Hemiplegia and Hemiparesis following other Cerebrovascular Disease affecting right dominant side. Record review of Resident #9's Quarterly MDS with an Assessment Reference Date (ARD) of 11/23/2022 revealed in section N-N0410 Medications received revealed resident received seven (7) days of anticoagulant medication in the seven (7) day look back period. Record review of Resident #9's Order Summary Report orders for active orders as of 10/25/2022 revealed the resident was prescribed Aspirin Tablet Chewable give 81 milligram (mg) via Peg-tube one time a day for circulation. There were no anticoagulant medications ordered. Record review of Resident #11's admission Record revealed the facility admitted resident on 04/13/2016. The resident had current diagnoses including Angina Pectoris Unspecified and Pain in Left Arm. Record review of Resident #11's Order Summary Report active orders as of 11/28/22 revealed an order for Aspirin EC Tablet Delayed Release 81 mg give one tablet by mouth one time a day. There were no anticoagulant medications ordered. Record review of Resident #11's Quarterly MDS with an ARD of 12/05/2022 section N N0410 Medications received revealed resident received seven (7) days of anticoagulant medication in the seven (7) day look back period. On 12/15/22 at 2:00 PM, during an interview with MDS nurse/Licensed Practical Nurse (LPN) #1, she confirmed the MDS for both Resident # 9 and Resident #11 were coded for anticoagulant given. LPN #1 stated she thought Aspirin was classified as an anticoagulant. She stated she continues to learn by going through the RAI manual to complete the MDS assessment and confirmed the MDS's were coded inaccurately for anticoagulant use. On 12/15/22 at 2:20 PM, during an interview with the Director of Nursing (DON), she confirmed Aspirin was not an anticoagulant. She expects the MDS nurse to code the assessment accurately. She confirmed both MDS for Resident #9 and Resident #11 were coded inaccurately.

Based on Interview and Record Review, the facility failed to ensure resident grievances regarding food were resolved in a timely manner for nine (9) of 9 residents who regularly attended resident council meetings (Resident #8, Resident#12, Resident #13, Resident #14, Resident #15, Resident #19, Resident #20, Resident #53, and Resident #62) and a grievance regarding missing money for one (1) sampled resident. Resident #8. Findings Include: A record review of the facility's policy Complaint/Grievance with a revised date of 08/09/2018 revealed . Purpose: To support each resident's right to voice grievances; resulting in a follow-up and resolution while keeping the resident apprised of its progress toward resolution . The Grievance Office/designee shall act on the grievance an begin follow-up of the concerns or submit it to the appropriate department director for follow-up . On 12/13/22 at 10:55 AM, the SSA conducted a resident council meeting with nine (9) residents in attendance including the Resident Council President. During the meeting, the residents complained about food not being palatable, either not seasoned or overly salty, and sometimes not thoroughly cooked. Residents stated complaints had been made at resident council meetings and the concerns were discussed but never addressed except for asking what the residents would like for meals. All residents attending the resident council meeting stated the facility never let them know of anything being done to address their grievances regarding food. On 12/15/22 at 2:00 PM during an interview with the Administrator, she confirmed the residents had been complaining about the food and grievances were supposed to be by Social Services. The administrator stated if the residents continue to complain about the food, the grievance is not resolved, and she had not reviewed the grievance logs. The Administrator stated staff needed additional training and in-services on dealing with grievances and resolving them. On 12/15/22 at 2:20 PM, during an interview with the Dietary Manager, she confirmed residents had complained about food, but she has not attended any resident council meeting. She confirmed that residents do still complain about food. An interview on 12/15/22 at 3:15 PM with the SSD revealed the SSD did attend some resident council meetings and was the Grievance Contact person for the facility. The SSD stated grievances were discussed and she was responsible for ensuring grievances were addressed and ultimately resolved with some assistance at times from the Director of Nursing (DON). The SSD confirmed residents complain about food during resident council meetings. She agreed if the residents continued to complain about the food, the grievances were not resolved. On 12/15/22 at 3:30 PM, during an interview with Activity Director, she confirmed the residents complained about food in resident council meetings. She stated she did not always write the complaints on the minutes of the council meeting regarding food because the residents continue to bring it up and there was no need to continue writing what had already been discussed. She agreed the complaints regarding food had not been resolved. Resident #8 An interview on 12/12/22 at 09:42 AM with Resident #8 revealed she was admitted to the hospital in July 2022 and had a stay of over 2 weeks. Resident #8 stated when she came back from the hospital she noticed that items had been moved around in her room. Resident #8 stated prior to her hospitalization she had $160.00 in a small cardboard box that was sealed up with tape under her Sunday school book and her Bible was on top of the box. Upon return from the hospital her Bible had been moved and the money was missing. Resident #8 stated she informed the Social Service Director (SSD) that her money was missing. A review of the facility's grievance log revealed Resident #8's missing money was listed on the grievance log on July 18, 2022. A review of the grievance investigation report regarding Resident #8's missing money revealed the SSD looked for the money in the resident room and could not find it. There was no indication the money was replaced by the facility. An interview on 12/14/22 at 3:53 PM with the SSD confirmed when Resident #8 returned from her hospital stay, the resident told the SSD her money was missing that had been under her Bible in an envelope. The SSD stated she looked for the money but could not find it. The SSD stated she spoke with the resident's niece (Niece #1) regarding the lost money and the resident's niece told her the resident probably misplaced it, and not to worry about replacing it. In an interview on 12/14/22 at 4:34 PM with Niece #1 she denied anyone at the facility had contacted her regarding any missing money. Niece #1 stated she gives resident money when she visits with the resident and had given money to the resident in July. Niece #1 stated she knew it was over $100.00 but she wasn't sure exactly how much. An interview on 12/14/22 at 4:42 PM with Resident #8's niece (Niece #2) revealed Resident #8 told her about money missing from her room after she returned from a hospitalization. Niece #2 confirmed Niece #1 gives the resident money when she visits. Niece #2 stated no one from the facility had spoken to her about the resident missing any money. Review of Resident #8's admission Record revealed the resident was admitted by the facility on 9/27/20 with medical diagnoses including Essential Primary Hypertension and Recurrent Depressive Disorder. Review of Resident #8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/22/22, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively Intact.

Based on facility statement review, record review and staff interview, the facility failed to refer Resident #2 for a Level II Pre-admission Screening and Resident Review (PASRR) when the resident's status changed from being a Short Term Care (STC) resident to a Long Term Care (LTC) resident. This concern was identified for one (1) of 30 sampled residents reviewed. Findings include: Review of the untitled document on the facility's letterhead, dated 9/12/2019, provided and signed by the facility's Administrator, the facility does not have a Pre-admission Screening and Resident Review (PASRR) policy. The facility follows State guidelines. The document was provided when asked for a policy on the PASRR process. Review of Resident #2's medical record document titled, PAS Summary and Physician Certification (Electronic PAS), dated 7/31/2017, revealed the section of the PASRR review for the Level II Referral Criteria was noted to be blank. The document revealed a mark to indicate that a Level II evaluation was not indicated at this time. The document was signed and dated, on 8/1/2017, by Resident #2's physician. Review of the facility's document titled, Progress Notes, dated 10/17/2017 at 11:10 AM, and electronically signed by the Social Services Staff (SSS), revealed Resident #2 decided to become a Long Term Care (LTC) resident at the facility. The note revealed Resident #2 no longer felt safe at home, and that Resident #2 wanted to stay at the facility, because his brother would no longer be living with him. The note revealed Resident #2 stated, I don't want to fall and no one help me either. Review of the facility's document titled, Diagnosis Report, dated 9/12/2019, revealed all of Resident #2's diagnoses, the onset dates for each diagnosis, and each diagnosis' rank. The document revealed the Schizoaffective Disorder diagnosis had an onset date of 7/31/2017, and was Resident #2's primary diagnosis at admission. The diagnosis Unspecified Dementia with Behavioral Disturbance had an onset date of 7/31/2017, and was ranked as diagnosis #4. The 12th diagnosis was Generalized Anxiety with an onset dated of 7/31/2017. During an interview, on 9/11/2019 at 11:18 AM, with the Director of Nursing (DON), it was determined that the current PASRR located on Resident #2's chart, did not reflect Resident #2's current status. The DON stated Resident #2 was first admitted , on 7/31/2017, as a short term resident for therapy services. The DON stated Resident #2 later changed his mind and wanted to stay. The DON confirmed a new PASRR should have been done when Resident #2 changed from a Short Term Care (STC) resident to a Long Term Care (LTC) resident. During an interview, on 9/11/2019 at 2:02 PM, with the facility's Admissions Coordinator (AC), it was confirmed that the current PASRR did not reflect the resident's current Long Term Care (LTC) status. The AC stated that at the time of admission, on 7/31/2017, Resident #2's intention was only to stay at the facility for short term skilled therapy care. The AC stated it was decided at a later date, that Resident #2 would remain in the facility as a Long Term Care resident. The AC stated that because of the resident's mental diagnosis with the use of antipsychotic medications, a new Level II PASRR should have been sent for review. Review of the Face Sheet revealed Resident #2 was admitted by the facility, on 7/31/2017, with diagnoses to include Schizoaffective Disorder, Parkinson's Disease, and Unspecified Dementia with Behavioral Disturbances.