**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, ceilings, and floors. The facility census was 46. 1. Review of the facility's Homelike Environment policy, date February 2021, showed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting to include a clean, sanitary, and orderly environment. 2. Observation on 12/10/24 at 10:30 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom contained multiple areas of black stains in the tile around the toilet. Observation showed the tiles lifted from the floor. Observation on 12/10/24 at 11:10 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom contained multiple areas of black stains in the tile around the toilet. Observation showed the tiles lifted from the floor. The wall by the sink with damaged sheetrock which exposed metal edges at the corner joint. 3. Observation on 12/10/24 at 10:39 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom had a sticky dried yellow substance on the bathroom tile, and the room contained a strong odor. 4. Observation on 12/10/24 at 10:45 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom tiles broken with exposed concrete below with sharp edges and had a strong odor. 5. Observation on 12/11/24 at 11:07 A.M., showed resident occupied room [ROOM NUMBER]'s ceiling near the window patched contained cracks, brown stains, and black material which protruded from a hole. 3. During an interview on 12/13/24 at 8:17 A.M. Certified Medication Technician A said if they see damage in the building there is a maintenance log to write it down. He/She said they also try to tell the Maintenance Director in person. During an interview on 12/13/24 at 8:22 A.M., Housekeeper I said he/she tells the housekeeping supervisor if damage is found. During an interview on 12/13/24 at 8:25 A.M., the Maintenance Director said he/she looks at the repair log to learn what repairs are need. Staff are to write the repair needs in the log. He/She said they were aware of the damage to walls and the flooring in the rooms. The maintenance director said he/she has been working around the building trying to keep up. During an interview on 12/13/24 at 9:27 A.M., the administrator said damage to the rooms could be a risk to residents. He/She said the facility has been too full to move residents when repairs are being done. The administrator said the Maintenance Director is responsible for making sure the repairs are finished.

Based on observation, interview, and record review, facility staff failed to store medications in one out of two medication storage rooms in a safe and effective manner. The facility census was 46. 1. Review of the facility's policy titled Medication Labeling and Storage, dated February 2023, showed if the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner. 2. Observation on 12/11/24 at 10:17 A.M., showed the 100 hall medication storage room contained the following: -One bottle of Aspirin 325 milligram (mg) with an expiration date of 09/24; -One bottle of Magnesium Oxide 400 mg with an expiration date of 09/24; -Three bottles of Vitamin D 10 mg with an expiration date of 09/24; -One Diclofenac Sodium topical Gel 100 gram tube with an expiration date of 04/24. During an interview on 12/13/24 at 8:16 A.M., Certified Medication Technician (CMT) A said expired or damaged medication are returned to the pharmacy or destroyed. During an interview 12/13/24 at 8:34 A.M., Licensed Practical Nurse (LPN) B said the night shift nurse is responsible for monitoring the medication storage room. Expired medications should be returned to the pharmacy or destroyed by facility staff and then reordered. All nurses and CMT's are to check for medication issues. During an interview on 12/13/24 at 9:26 A.M., the administrator said the Director of Nursing (DON) and the CMT's are responsible for monitoring the medication storage room. There should not be any expired medications in the room because of the risk to resident's health. During an interview on 12/13/24 at 9:43 A.M., the DON said all nursing staff are responsible for medication storage and for checking for expired medications. The medications should be destroyed due to the risk to the residents if they received the expired medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility staff failed to propell two residents (Resident #7, and #44) when staff did not use wheelchair footrests. Facility staff failed to provide safe mechanical lift transfers for three residents (Resident #15, #21, and #33), and failed to store hazardous materials in a safe manner in one shower room, one dining room and one storage cabinet. The facility census was 46. 1. The facility did not provide a policy for wheelchair safety. 2. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent wheelchair; -Diagnosis of cerebrovascular accident, bipolar, schizophrenia, and macular degeneration. Observation on [DATE] at 2:59 P.M., showed Certified Nurse Aid (CNA) E propelled the resident in a wheelchair from the nurses desk to the Physical Therapy room. Observation showed the wheelchair did not contain foot rests and the residents feet slid along the floor while being propelled. During an interview on [DATE] at 3:01 P.M., CNA E said he/she couldn't find the foot rests for the wheelchair and had to propel the resident without them. He/She said it is safer with footrests on the wheelchair. 3. Review of Resident #44's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Substantial assistance wheelchair; -Diagnosis of dementia, and anxiety. Observation on [DATE] at 9:18 A.M., showed the administrator propelled the resident from the nurses desk to the resident's room. Observation showed the wheelchair did not contain footrests. Observation showed the residents foot on and off the floor while being propelled. 4. Review of the facility's Lifting Machine, Using a Mechanical policy, dated 2001, showed staff the purpose of the procedure is to establish the general principles of safe lifting using a mechanical lifting device it is not a substitute for manufacturer's training or instructions and make sure the lift is stable and locked. 5. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Dependent on staff for all transfers; -Diagnosis of stroke. Observation on [DATE] at 01:05 P.M., showed NA D and CNA E transferred the resident from the wheelchair with a mechanical lift and the leg base of the lift open, NA D raised the resident from the wheelchair, closed the leg base, pushed the resident over the bed and lowered the resident onto the bed. During an interview on [DATE] at 01:43 P.M., NA D said the leg base should be open wide to keep the lift stable. NA D said when using a mechanical lift the legs should be open to the widest position for stability otherwise the lift could tip over. He/She said he/she did not think about it. 6. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Dependent on staff for all transfers; -Diagnosis of dementia. Observation on [DATE] at 10:43 A.M., showed License Practical Nurse (LPN) C and the housekeeping supervisor transfered the resident from the wheelchair with a mechanical lift and the leg base of the lift open. LPN C raised the resident from the wheelchair, closed the leg base, pushed the resident over the bed and lowered the resident onto the bed. During an interview on [DATE] at 08:15 A.M., LPN C said mechanical lift training is done by therapy and nursing at least every three to four months. He/She said staff should keep the leg base open during the transfer for stability but the room size makes it difficult. LPN C said the leg base should be kept open or the lift could go off balance and the resident could fall. 7. Review of Resident #33's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Transfer total dependence; -Diagnosis of dementia. Observation on [DATE] at 10:00 A.M., showed CNA J and LPN C used a mechanical lift to transfer the from a wheelchair to a bed. LPN C operated the lift while CNA J steadied the resident. LPN C opened the legs of the mechanical lift and positioned it over the wheel chair. LPN C removed the wheelchair, closed the legs of the lift, pivoted the lift towards the bed, pushed the lift over the bed and lowered the resident. During an interview on [DATE] at 10:15 A.M., LPN C said the legs of the lift can not be opened because of the lack of space in the room. He/She said the legs should be open for stability and resident safety. 8. During an interview on [DATE] at 09:15 A.M., the Administrator said during mechanical lift transfers, staff should keep the leg base open for the stability of the machine. He/She said staff are trained on the operation of the lifts by the therapy department. The DON is responsible for the oversight of the nursing staff. During an interview on [DATE] at 09:30 A.M., the DON said for safety reasons, staff should keep the leg base open during transfers with a mechanical lift for better balance. He/She said staff are trained during on the floor assistance and observations. The DON said the ADON and DON do daily hall checks for issues. 9. The facility did not provide a policy for the storage of hazardous materials. Observation on [DATE] at 11:42 A.M., showed the 100 hall shower room unattended and door unlocked. Observation showed the shower room cabinet unlocked with an open disposable razor container. Observation showed staff were not present in the hallway by the unlocked door. Observation on [DATE] at 9:18 A.M.,showed the 100 hall shower room unattended and door unlocked. Observation showed the shower room cabinet unlocked with an open disposable razor container. Observation on [DATE] at 9:57 A.M., showed the 300 hall resident dining room contained two bottles of nail polish remover in a plastic bin. Observation showed unattended residents sat in the dining room. 10. During an interview on [DATE] at 1:52 P.M., CNA K said wheelchairs should have the footrest on before a resident is pushed because it could injure the resident without the footrest. Mechanical lifts should be closed during transfers. He/She said hazardous chemicals and razors should be locked to prevent resident access for their safety. During an interview on [DATE] at 1:43 P.M., LPN F said staff should not push residents in a wheelchair without the footrests on. There could be injuries if the footrests are not on the wheelchair. Mechanical lifts should be done with the legs spread to the widest position or a resident could be injured. All hazardous materials or razors should be locked when not in use. During an interview on [DATE] at 9:19 A.M., the Administrator said residents should not be pushed without the footrests on or they could be injured. The administrator said staff are educated on this wheelchair safety. He/She said all hazardous chemicals or razors should be locked for resident safety.

Based on observation, interview and record review, facility staff failed to ensure the dish washer machine operated according to manufacturer's instructions in a manner adequate to prevent cross contamination of kitchen wares. The facility census was 46. 1. Review of the facility's Sanitization policy, revised November 2022, showed dishwashing machines are operated according to manufacturer's instructions. General recommendations for low temperature dishwashers (chemical sanitization) are wash temperature of 120 degrees Fahrenheit (F) and final rinse with 50 parts per million (ppm) hypochlorite (chlorine). Review of the facility's Dish Machine - PPM Sanitizer Record Logs for the period of 10/01/24 through 12/12/24 showed staff documented morning and afternoon machine temperatures of 98 degrees F on all days. Observation on 12/10/24 at 10:20 A.M., showed the front of the dish machine contained a label which indicated minimum wash and rinse temperatures of 120 degrees F. Observation on 12/10/24 at 11:06 A.M., showed Dietary Dish Aide M ran a food processor bowl, lid, and blade through the dish machine. Observation showed the maximum water temperature reached was 101 degrees F. Observation on 12/10/24 at 11:10 A.M., showed the Dietary Manager (DM) used a food processor to puree chicken and broth. Observation showed the DM rinsed the food processor parts, added the parts to a dish machine rack, and ran the items through the dish machine. Observation showed the maximum water temperature reached was 109 degrees F. Observation on 12/10/24 at 11:23 A.M., showed Dietary Dish Aide M ran a food processor bowl, lid, and blade through the dish machine. Observation showed the maximum water temperature reached was 102 degrees F. Observation on 12/10/24 at 12:20 P.M., showed Dietary Dish Aide M prewashed and ran a rack of dishes through the dish machine. Observation showed the maximum water temperature reached was 106 degrees F. Observation on 12/12/24 at 9:03 A.M., showed a test run of the dish machine indicated a maximum temperature of 104 degrees F. Observation showed the dish machine temperature gauge and a calibrated digital thermometer indicated the same temperature during the test run. During an interview on 12/12/24 9:01 A.M., Dietary Dish Aide M said he/she checked the dish machine water temperature in the morning and afternoon. He/She said the dish machine water temperature should be 98 to 100 degrees F. He/She said he/she documented water temperatures on the dish machine log. He/She said he/she was trained to check water temperatures and sanitizer concentrations by the previous DM. During an interview on 12/12/24 9:16 A.M., [NAME] L said the dish machine temperature usually ran around 98 degrees F. [NAME] L said the water temperature should be between 98 and 100 degrees F. [NAME] L said staff checked water temperatures daily and notified the vendor if there was a problem. [NAME] L said the vendor never said anything about the dish machine water temperature. During an interview on 12/12/24 at 9:12 A.M., the DM said he/she was responsible for making sure the dish machine operated correctly and staff were trained on proper use and function. The DM said he/she was not aware the dish machine water was not getting hot enough. The DM said he/she thought the water temperature should be 110 degrees F. During an interview on 12/12/24 at 10:50 A.M, the maintenance director said he/she used the dish machine temperature gauge to observe water temperatures. The maintenance director said the dish machine gauge never reached 120 degrees and that was okay because the machine used low temperature sanitizer chemicals. The maintenance director said he/she had read the instructional signage on the dish machine but he/she never thought about it. During an interview on 12/12/24 at 11:40 A.M., the administrator said the facility used a low temperature dish machine but he/she did not know the specific water temperature of the machine. The administrator said the DM was responsible for ensuring staff followed the dish machine manufacturer's instructions. The administrator said he/she was not aware the dish machine was not being operated in accordance with manufacturer's instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to position an indwelling catheter of one resident (Resident #11) out of two sampled residents off the floor. The facility census was 46 1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed: The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit; -Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Legionella Water Management Plan, reviewed 09/27/24, showed: -The plan introduction indicated the name of another facility; -The portion of the plan related to responsible personnel indicated the name of another facility; -The plan indicated maintenance personnel were to dismantle, clean and descale all showerheads and spray nozzles quarterly; -The water heaters will be flushed every six months; -The written description of the building water system indicated water entered the facility from a municipal water line from a town which is located more than 90 miles from the facility; -The written description of the building water system indicated the facility had three separate water systems, which consisted of six water heaters; -The plan table of contents indicated the plan contained a building water system flow diagram. Review showed the plan did not contain a flow diagram. Observation on 12/11/24 during the Life Safety Code tour showed the facility contained three water heaters. Observation showed two water heaters located in the mechanical room near the laundry room and one water heater in the 300-hall mechanical room. Review of the facility's Legionella control measures for the period of January 2024 through November 2024 showed the documentation did not include: -Semiannual water heater flushes; -Quarterly shower head and spray nozzle cleaning and descaling. During an interview on 12/12/24 at 10:50 A.M., the maintenance director said he/she was responsible for Legionella control in the facility. The maintenance director said the Legionella plan should include an accurate description of the facility water system. The maintenance director said he/she never cleaned shower heads because he/she thought staff cleaned them. The maintenance director said the facility contained three water heaters and he/she did not know why the Legionella plan indicated six water heaters. The maintenance director said he/she did not flush water heaters. The maintenance director said he/she reviewed the Legionella plan, but never read the plan thoroughly. During an interview on 12/12/24 at 11:40 A.M., the administrator said the Legionella Water Management plan was in place when he/she started. The administrator said he/she and maintenance staff were responsible for ensuring the Legionella plan was accurate and was followed. The administrator said the Legionella plan should have accurate facility water system descriptions. The administrator said he/she was not aware of all required components of a water management plan. 2. Review of the facility's Urinary Catheter Care policy, dated 2001, showed the policy did not contain direction for positioning of an indwelling catheter off the floor. 3. Review of Resident #11's MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Dependent on staff for toilet hygiene; -Used an indwelling catheter; -Diagnosis of stroke and urine retention. Observation on 12/10/24 at 10:27 A.M., showed the resident in bed. His/Her indwelling catheter on the floor. Observation on 12/11/24 at 09:05 A.M., showed the resident in bed. His/Her indwelling catheter on the floor. Observation on 12/12/24 at 09:03 A.M., showed the resident in bed. His/Her indwelling catheter on the floor. During an interview on 12/11/24 at 09:05 A.M., the resident said he/she has had the catheter a long time. He/She said the staff hook the catheter to the bed when he/she lays down. During an interview on 12/12/24 at 01:55 P.M., Certified Nursing Assistant (CNA) G said catheters should be hooked to the bed below the bladder and never touch the floor because the floor is dirty and could get bacteria inside the bag. During an interview on 12/13/24 at 08:15 A.M., the Assistant Director of Nursing (ADON) said catheter bags should be kept off the floor for infection control reasons. During an interview on 12/13/24 at 08:30 A.M., the Infection Preventionist said residents with catheters should be kept off the floor because the floor is dirty and could cause an infection. The Infection Preventionist said there is training for infection control and the DON and ADON complete staff competencies of pericare during actual resident care. During an interview on 12/13/24 at 09:15 A.M., the Administrator said catheters should not be laid on the bed or on the floor due to risk for infections. He/She said the DON is responsible to oversee the process. During an interview on 12/13/24 at 09:30 A.M., the DON said catheters should not be placed on the floor due to bacteria potential. He/She said there has not been catheter training lately and is his/her responsibility to ensure staff are following proper procedure. He/She said the ADON and DON complete daily hall checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to meet professional standards of quality and practice when they failed to provide consistent documentation in regard to residents' Advance Directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for four residents (Resident #3, #7, #30, and #43). Additionally, staff failed to obtain physician orders for dialysis (purification of blood, as a substitute for normal kidney function) for two residents (Resident #27 and #38), failed to follow physician orders for oxygen for one resident (Resident #47) and failed to provide consistent documentation in regard to diet orders for one resident (Resident #31). The facility census was 49. 1. Review of the facility's Do Not Resuscitate Order (DNR), (a type of advance directive in which a person states that healthcare providers should not perform cardiopulmonary resuscitation (CPR) if his or her heart or breathing stops) Policy, showed: -DNR orders must be signed by the resident's attending physician on the physician's order sheet (POS) maintained in the resident's medical record; -A DNR order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in front of the resident's medical record; -The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. Further review showed the facility did not have a policy for Advance Directives. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/24/22, showed staff assessed the resident as: -Severely Cognitively Impaired; -Understood; -Diagnoses of cancer, diabetes, hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood), and Alzheimer's Disease (a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain). Review of the resident's POS, dated August 2022, showed an order for a DNR code status. Review of the resident's medical record showed it did no contain a DNR order form per facility policy. 3. Review of Resident #7's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Severely Cognitively Impaired; -Usually Understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Diagnoses of cancer, diabetes, hyperlipidemia, and Alzheimer's disease. Review of the resident's medical record showed: -The current POS did not have an order for DNR; -A DNR order form was in the front of the resident's medical record; -The resident's Care Plan dated 5/24/22 stated the resident wished to have orders for DNR. Review of the resident's POS, dated August 2022, showed it did not contain an order for the resident's code status. Review of the resident's care plan, dated 5/24/22, showed staff documented the resident had a DNR code status. 4. Review of Resident # 30's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Understood; -Diagnoses of Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), Congestive Heart Failure (CHF), Depression, and Anxiety. Review of the resident's POS, dated August 2022, showed it did not contain an order for the resident's code status. Review of the resident's care plan, dated 5/14/22, showed staff were directed the resident wished to be a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). During an interview on 8/11/22 at 3:07 P.M., the resident said he/she wanted to be a full code at this time. 5. Review of Resident #43's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately Cognitively Impaired; -Understood, -Diagnoses of hypertension (high blood pressure), and hyperlipidemia. Review of the resident's POS, dated August 2022, showed it not contain an order for the resident's code status. Review of the resident's care plan, dated 7/26/22, showed staff were directed the resident wished to be a full code. During an interview on 8/12/22 at 3:17 P.M., the Assistant Director of Nursing (ADON) said a resident's code status should be listed at top of the POS. He/She said if a code status is not on the orders he/she would expect staff to clarify the code status with the physician and obtain an order. He/She said he/she didn't know some of the residents did not have an order for their code status. During an interview on 8/12/22 at 3:38 P.M., the Director of Nursing (DON) said advanced directives, including code status are reviewed on admission and quarterly during the care plan conferences with the resident and/or family, and with changes in resident status. He/she said all residents are considered a full code until a signed DNR physician's order is obtained. He/She said he/she didn't know resident #3, #7, #30 and #43 did not have code status orders. During an interview on 8/12/22 at 3:55 P.M., Licensed Practical Nurse (LPN) E said a resident's code status should be listed at the top of the POS. He/She said he/she didn't know some residents did not have orders for code status. 6. Review of the facility's End-Stage Renal Disease (ESRD) (a disease affecting kidney function) policy, dated September 2010 showed: -Residents with ESRD will be cared for according to currently recognized standards of practice; The policy did not contain direction for staff related to physician orders for access site care, scheduling of treatments including number and days per week, or timing and administration of medications, particularly those before and after dialysis. 7. Review of Resident #27's Significant Change in Status MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had diagnosis of ESRD; -Receives dialysis. Review of the resident's current POS, showed it did not contain orders for dialysis, access site care, or schedule including the number of treatments and days per week. 8. Review of Resident #38's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Moderately cognitively impaired; -Had diagnosis of ESRD. -Receives dialysis. Review of the resident's POS, dated June 2022 through August 2022, showed it did not contain orders for dialysis, access site care, or schedule including the number of treatments and days per week. During an interview on 8/12/22 at 3:17 P.M., the ADON said he/she would expect to see an order for dialysis and dialysis care on the residents' orders. He/She said he/she knows where the residents' ports are located due to the weekly skin assessments and nurse to nurse report. During an interview on 8/12/22 at 3:38 P.M., the DON said there should be a physician's order for dialysis and the nurses are responsible for obtaining them. He/she said he/she expects the night shift nurse to review new orders for accuracy and the DON to follow up the next day. He/she said resident #38's dialysis changed but there should have had an order. He/She said he/she didn't know resident #27 and #38 did not have an order for dialysis. During an interview on 8/12/22 at 3:55 P.M., LPN E said a resident who receives dialysis should have an order for it. He/She said the order should contain direction for access site care. He/she said he/she knew how to care for the residents from nursing knowledge and said staff know how to care for the residents through nurse to nurse report. He/She said he/she didn't know the residents didn't have orders for dialysis. 9. Review of the facility's Oxygen Administration Policy, revised October 2010, showed: -Verify that there is a physician's order for this procedure; -Review the physician's orders or facility protocol for oxygen administration. 10. Review of Resident #47's medical record showed staff assessed the resident as: -admitted [DATE]; -Cognitively intact; -Diagnoses of COPD, morbid obesity, and CHF; -Required extensive to total assistance from staff with Activities of Daily Living (ADL's); -Used oxygen. Review of the resident's POS, dated August 2022, showed: 8/4/22: Oxygen at 4 Liters Per Minute (LPM) via nasal cannula (NC) as needed (PRN) for oxygen saturation (SpO2), (a measure of the amount of oxygen-carrying hemoglobin in the blood relative to the amount of hemoglobin not carrying oxygen) (SpO2) to stay above 90%. Observation on 8/9/22 at 12:42 P.M., showed the resident had his/her oxygen on at 5 LPM via NC. Observation on 8/10/22 at 3:23 P.M., showed the resident had his/her oxygen on at 5 LPM via NC. Observation on 8/11/22 at 8:25 A.M., showed the resident had his/her oxygen on at 5 LPM via NC. Observation on 8/11/22 at 1:05 P.M., showed the resident had his/her oxygen on at 5 LPM via NC. Observation on 8/12/22 at 9:53 A.M., showed the resident had his/her oxygen on at 5 LPM via NC. During an interview on 8/9/22 at 2:37 P.M., the resident said his/her oxygen has been set to 5 LPM since he/she was admitted . During an interview on 8/12/22 at 3:17 P.M., the ADON said residents should have orders for oxygen use and it's the nurses' job to make sure the order is followed. He/She said he/she didn't know the resident's oxygen was set to 5 LPM. During an interview on 8/12/22 at 3:38 P.M., the DON said nurses are expected to obtain orders for oxygen and the order should be followed. During an interview on 8/12/22 at 3:55 P.M., LPN E said residents on oxygen should have orders for its use, and nurses should ensure the resident receives the ordered amount. 11. Review of the facility's Food and Nutrition Services Policy, dated October 2017 showed: -Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -A resident-centered diet and nutrition plan will be based on the assessment of each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating nutritional intake and utilization. 12. Review of resident #31's the POS, dated 7/7/22 through 8/6/22, showed an order dated 7/26/22 to change the resident's diet order from Regular consistency to Mechanical Soft consistency related to difficulty chewing. Review of the physician orders, dated 8/7/22 through 9/6/22, showed they did not contain the change in diet from Regular Consistency to Mechanical Soft. During an interview on 8/12/22 at 3:38 P.M., the DON said the night shift nurse is responsible for checking new orders for accuracy. The DON said he/she is responsible for reviewing the orders the next day. He/she said he/she didn't know their was and order discrepancy. During an interview on 8/12/22 at 3:17 P.M., the ADON said he/she didn't know what the resident's diet order was. He/She said an order could be received and not carry over to the POS. During an interview on 8/12/22 at 3:55 P.M., LPN E said he/she didn't know what the resident's diet order was. He/She said it was not carried over to the most recent POS. 13. During an interview on 8/12/22 at 3:17 P.M., the ADON said all the nurses are responsible for obtaining and transcribing physician orders. He/She said he/she is responsible for reconciling orders obtained the previous day. He/She said the DON and MDS coordinator do the monthly change over and reconcile the orders. During an interview on 8/12/22 at 3:55 P.M., LPN E said nurses are responsible for obtaining physician orders and entering them into the charts. He/She said there is a folder for physician's orders so a 24 hour chart check can be completed. He/She said the MDS coordinator is responsible for reconciling the orders monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to assist residents with Activities of Daily Living (ADLs) (everyday tasks), for four residents (Resident #33, #35, #37, and #45). The facility census was 49. 1. Review of the facility's Activities of Daily Living (ADLs), Supporting policy, dated [DATE], showed: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs); -Resident 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; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care); -If residents with cognitive impairment or dementia (loss of cognitive functioning resulting in deceased ability to complete ADL's independently) resist care, staff will attempt to identity the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. 2. Review of Resident #33's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required total assistance from one staff member for personal hygiene; -Did not reject care. Review of the resident's care plan, dated [DATE], showed staff documented the resident needed extensive to total assistance from staff with most ADLs. Observation on [DATE] at 1:53 P.M., showed the resident had long hair in his/her ears, and yellow dark debris under his/her long fingernails. Observation on [DATE] at 8:32 A.M., showed the resident had long hair in his/her ears, yellow dark debris under his/her long fingernails. Observation on [DATE] at 4:38 P.M., showed the resident had long hair in his/her ears, yellow dark debris under his/her long fingernails, and his/her second and third finger had a red substance under the entire nail. During an observation and interview on [DATE] at 4:38 P.M., the resident pointed to his/her ears and nodded when asked if he/she was pointing to hair in his/her ears. Additionally, when asked if the ear hair bothered him/her, the resident nodded. During an interview on [DATE] at 3:16 P.M., Certified Nurse Aide (CNA) C said the resident had declined showers, but no other ADLs. During an interview on [DATE] at 3:17 P.M., the Assistant Director of Nursing (ADON) said the resident refuses care often and it should be documented in the nurses' notes. During an interview on [DATE] at 3:38 P.M., the Director of Nursing (DON) said the resident's fingernails are stained but he/she should have this addressed in his/her plan of care. During an interview on [DATE] at 3:55 P.M., Licensed Practical Nurse (LPN) E said the resident refuses to have his/her nails trimmed and it should be documented in his/her nurses' notes. 3. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance from one staff member for personal hygiene; -Did not reject care. Review of the resident's care plan, dated [DATE], showed it did not contain direction for staff related to the resident's facial hair preferences. Further review showed the resident required extensive assistance with his/her ADLs. Observation on [DATE] at 11:55 A.M., showed the resident had facial hair on his/her upper lip and chin, and brown bottom teeth. Further observation, showed he/she didn't have his/her upper teeth and had debris under his/her long fingernails. Observation on [DATE] at 8:39 A.M., showed the resident had facial hair on his/her upper lip and chin, and brown bottom teeth. Further observation, showed he/she didn't have his/her upper teeth and had debris under his/her long fingernails. Observation on [DATE] at 9:50 A.M., showed the resident had brown bottom teeth. Further observation, showed he/she didn't have his/her upper teeth and had debris under his/her long finger nails. Observation on [DATE] at 4:40 P.M., showed the resident had brown bottom teeth. Further observation, showed he/she didn't have his/her upper teeth and had debris under his/her long fingernails. During an interview on [DATE] at 3:16 P.M., CNA C said the resident doesn't refuse care. He/She said the resident brushes his/her teeth daily with assistance. He/She said he/she didn't know how often the resident sees a dentist and he/she had noticed the resident's upper teeth were missing, but did not ask about it. During an interview on [DATE] at 3:17 P.M., ADON said he/she hadn't noticed the resident's fingernails. He/She said the resident's upper dentures should be in his/her top drawer. During an interview on [DATE] at 3:38 P.M., the DON said he/she didn't know the resident had issues with his/her teeth. He/She said if he/she had known he/she would have arranged for dental services. He/she said he/she knew the resident was not wearing his/her upper dentures but the resident never complained about it. He/She said he/she expects the resident's nails clipped and facial hair removed during showers. 4. Review of Resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required total assistance from one staff member for personal hygiene; -Did not reject care. Review of the resident's care plan, dated [DATE], showed staff documented the resident required extensive assistance with most ADL's. Further review showed it did not contain direction for staff in regard to the resident's facial hair preferences. Observation on [DATE] at 11:19 A.M., showed the resident had facial hair on his/her chin. Observation on [DATE] at 8:07A.M., showed the resident had facial hair on his/her chin. Observation on [DATE] at 8:04 A.M., showed the resident had facial hair on his/her chin. Observation on [DATE] at 4:36 P.M., showed the resident had facial hair on his/her chin and a yellow substance on his/her bottom lip. During an interview on [DATE] at 3:16 P.M., CNA C said the resident doesn't like to shower, but he/she doesn't refuse. He/She said the resident doesn't refuse to be shaved. During an interview on [DATE] at 3:17 P.M., ADON said he/she had not noticed the resident's facial hair. He/She said the resident refuses care. During an interview on [DATE] at 3:38 P.M., the DON said the resident can be challenging at times but he/she expects the CNA's to shave the resident during showers. 5. Review of Resident #45's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required total assistance from one staff member with personal hygiene; -Did not reject care. Review of the care plan, dated [DATE], showed it did not contain direction for staff related to the resident's facial hair or ADL care. Observation on [DATE] at 1:10 P.M., showed the resident had facial hair on his/her upper lip and chin. Observation on [DATE] at 8:42 A.M., showed the resident had facial hair on his/her upper lip and chin. Observation on [DATE] at 8:35 A.M., showed the resident had facial hair on his/her upper lip and chin. Observation on [DATE] at 4:45 P.M., showed the resident had facial hair on his/her upper lip and chin. During an interview on [DATE] at 3:16 P.M., CNA C said the resident had refused to have his/her facial hair shaved. He/She said he/she didn't know why. During an interview on [DATE] at 3:38 P.M., the DON said he/she expects staff to shave the resident during their shower. During an interview on [DATE] at 3:55 P.M., LPN E said he/she had noticed the resident's facial hair but had not had time to assist the resident. 6. During an interview on [DATE] at 3:16 P.M., CNA C said nail care and shaving should be completed when it's needed. He/She said staff should encourage resident's who refuse care, and follow up at a later time to try again. He/She said if a resident refuses it should be reported to the charge nurse. During an interview on [DATE] at 3:05 P.M., CNA I said residents' teeth should be brushed after meals. He/She said residents who are able to assist with cares should be encouraged or helped as needed and dependent residents should have their teeth brushed by the staff. He/She said if a resident refuses care he/she tries to encourage the resident, and if they still refuse, he/she said staff should try again. He/She said if the resident continued to refuse care, he/she would report it to the nurse. He/She said it is the aides' responsibility to provide care for residents' nails and to shave the residents. He/She said nail trimming and shaving should be completed during the resident shower. He/She said if he/she noticed a resident with long dirty fingernails or facial hair he/she would trim their nails or shave them. During an interview on [DATE] at 3:17 P.M., the ADON said the shower aides are supposed to shave the residents and trim their nails. He/She said the residents teeth should be brushed every morning, every evening, and after every meal. He/She said if a resident refused care staff are supposed to try another approach, or have another staff member try. He/She said refusals should be documented in nurses' notes. He/She said the Social Services Director (SSD) is responsible for scheduling dental appointments and said there had been a long wait for appointments. During an interview on [DATE] at 3:38 P.M., the DON said he/she expects the CNA's to complete shaves, and nail care during showers. He/She said staff should report dental issues to the nurses, who should then refer the resident to social services for follow-up and appointments. He/she said if a resident refused care it should be reported to the charge nurse so it can be addressed. During an interview on [DATE] at 3:55 P.M., LPN E said all nursing staff should help with shaves and nail trims. He/She said it should the resident should be checked for facial hair and the need for nail trims during their shower. He/She said resident's teeth should be brushed every morning, after each meal and before bed. He/She said he/she didn't know how often the residents saw the dentist. He/She said the SSD should make the appointments. He/She said if the resident refused care it should be documented in the nurses' notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to properly store environmental hazards in the shower rooms and failed to properly propel seven residents (Resident #1, #23, # 28, #31, #39, #42 and #45) in wheelchairs in a manner to prevent accidents. The facility census was 49. 1. Review of the facility's Safety and Supervision of Residents Policy, dated July 2017, showed the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 2. Observation on 8/9/22 at 11:06 A.M., showed the 100 hall shower room unlocked and unattended. Further observation, showed an open and undated container of skin protectant sat on the back of the toilet. Additional observation, showed an open bottle of cleaner with bleach in an unlocked cabinet, with two unopened bottles, and a razor in an unlocked drawer. During an interview on 8/12/22 at 3:05 P.M., Certified Nurse Aide (CNA) I said he/she didn't know who was responsible for checking the shower rooms for accessible razors and chemicals. He/She said cabinets should be locked if they have razors or chemicals in them. During an interview on 8/12/22 at 3:38 P.M., the Administrator said he/she checked the shower rooms every morning for hazards. He/She said he/she expects razors, chemicals and creams to be in a locked up. He/she said it's everyone's responsibility to be mindful of hazards and lock things up. He/she said he/she did not know chemicals, and razors were not locked up. During an interview on 8/12/22 at 3:17 P.M., the Assistant Director of Nursing (ADON) said all staff are responsible for inspecting the shower rooms every day. He/She said razors should be kept locked in the room across from nurses station. He/She said razors are gathered with shower supplies, and should be disposed of in the shower room sharps container. During an interview on 8/12/22 at 3:55 P.M., Licensed Practical Nurse (LPN) E said the shower room should be checked by the house keepers every morning. He/She said it is everyone's responsibility to ensure all hazardous chemicals and razors are kept locked up. During an interview on 8/12/22 at 3:16 P.M., CNA C said shower rooms are inspected daily by staff. He/She said cabinet doors should be locked. 3. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/9/22, showed staff assessed the resident as: -Cognitively impaired; -Had disorganized thinking that comes and goes and changes in severity; -Dependent on one staff member for locomotion; -Uses a wheelchair; -Has diagnoses of coronary artery disease (damage to the hearts major blood vessels), diabetes, and dementia (a group of thinking and social symptoms that interferes with daily functioning). Observation on 8/10/22 at 11:33 A.M., showed an unidentified staff member propelled the resident in his/her wheelchair from room his/her room to the dining room without foot pedals. The resident's feet were close to the floor. 4. Review of Resident #23's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Has diagnoses of dementia, anxiety, and psychotic disorder (a mental disorder characterized by disconnection from reality); -Independent with locomotion on and off of the unit; -Had fluctuating disorganized thinking behaviors. Observation on 8/12/22 at 1:27 P.M., showed CNA C propelled the resident from the nurses station to room [ROOM NUMBER], approximately 40 feet, without foot pedals. 5. Review of Resident #28's Annual MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Had diagnoses of non-traumatic brain dysfunction, anemia, hypertension, diabetes, arthritis, anxiety disorder, depression, and dementia; -Required limited assistance from one staff member for locomotion on and off of the unit; -Had no behaviors. Observation on 8/12/22 at 12:55 P.M., showed CNA H propelled the resident from the nurses station down the hallway to the resident's room, without foot pedals. 6. Review of Resident #31's Significant change MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had diagnoses of dementia and anxiety; -Independent with locomotion on and off of the unit; -Had fluctuating inattention and disorganized thinking behaviors. Observation on 8/11/22 at 1:27 P.M., showed CNA C propelled the resident backwards in his/her wheelchair from the nurses station to his/her room, without foot pedals. Observation on 8/12/22 at 10:55 A.M., showed CNA C propelled the resident from the nurses station to the dining room without foot pedals. The resident's feet slid on the floor. Observation on 8/12/22 at 1:19 P.M., showed the ADON propelled the resident up 100 hall towards the nurses station, without foot pedals. 7. Review of Resident #39's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from one staff member for bed mobility; -Required total assistance from one staff member for transfers; -Uses a wheelchair. Observation on 8/11/22 at 12:46 P.M., showed an unidentified staff member propelled the resident without the use of foot pedals. 8. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had diagnoses of Macular degeneration (loss in the center field of vision), Diverticulitis (Inflammation or infection in one or more small pouches in the digestive tract), and Obstructive Uropathy (urine can not drain through the urinary tract; -Independent with locomotion on and off of the unit; -Had fluctuating disorganized thinking behaviors present. Observation on 8/11/22 at 8:21 A.M., showed CNA C propelled the resident from the dining room to the resident's room without foot pedals. 9. Review of Resident #45's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required total assistance from two staff members with bed mobility and transfers; -Uses a wheelchair for mobility. Observation on 8/10/22 at 8:22 A.M., showed LPN A propelled the resident without the use of foot pedals. 10. During an interview on 8/12/22 at 3:05 P.M., CNA I said when staff push a resident in their wheelchair they should use foot pedals. He/She said staff should not pull residents backwards in their wheelchairs. During an interview on 8/12/22 at 3:17 P.M., the ADON said residents should not be propelled in their wheelchairs without foot pedals. He/She said a resident should never be pulled backwards in their wheelchair. During an interview on 8/12/22 at 3:16 P.M., CNA C said foot pedals should be placed on wheelchairs before staff propel a resident to ensure their safety. He/She said the resident should always be propelled forwards while in their wheelchairs. He/She said he/she has propelled a resident without foot pedals and has seen other staff do it as well. During an interview on 8/12/22 at 3:38 P.M., the Director of Nursing (DON) said he/she expects foot pedals to be placed on wheelchairs before staff propel any resident During an interview on 8/12/22 at 3:38 P.M.,The Administrator said if staff pull a resident backwards in a wheelchair, it's probably because there are not foot pedals on the chair. He/She said he/she expects staff to place foot pedals on wheelchairs before they propel residents. During an interview on 8/12/22 at 3:55 P.M., LPN E said resident's in wheelchairs should have foot pedals on, their hands and arm in their lap, and sit straight. He/She said staff should never propel a resident backward.

Based on observation, interview, and record review, facility staff failed to use hand hygiene and provide perineal care in a manner to reduce the risk of infection for two residents (Resident #19 and #40) and failed to provide wound care in a manner to reduce the risk of infection for one resident (Resident #47). The facility census was 49. 1. Review of the facility's Hand Hygiene Policy, revised August 2019, directed staff to: -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: -When hands are visibly soiled; -Use an Alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with residents; -Before handling clean or soiled dressings, gauze pads, etc.; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc.; -After removing gloves. Review of the facility's Perineal Care Policy, revised February 2018, showed it did not contain direction for staff in regard to when to change gloves or proper cleansing wipe use. 2. Observation on 8/9/22 at 1:09 P.M., showed Certified Nurse Aide (CNA) F cleansed Resident #19's perineal area, removed his/her gloves, and reapplied new gloves, without hand hygiene. The CNA cleansed the resident's bottom, applied a clean brief and repositioned the resident, with the same soiled gloves on. Observation on 8/11/22 at 9:04 A.M., showed CNA C removed the resident's pants, and provided incontinence care. The CNA continued to wear the same soiled gloves and repositioned the resident. 3. Observation on 8/9/22 at 11:22 A.M., showed CNA F removed Resident #40's soiled brief, and touched the resident's legs with the same soiled gloves on. The CNA used the same wipe to wipe the resident multiple times, without using a different portion of the wipe. The CNA continued to wear the same soiled gloves and touched the resident's side. During an interview on 8/9/22 at 11:44 A.M., CNA F said staff are directed to perform hand hygiene before and after providing care, prior to going from a dirty to clean area, and before they exit a room. He/She did not think he/she missed a hand hygiene opportunity, or had used a wipe more than once. During an interview on 8/12/22 at 3: 55 P.M., Licensed Practical Nurse (LPN) E said staff are expected to perform hand hygiene before they apply gloves, when their gloves are soiled, when they move from a dirty to clean task, and before they leave the resident's room. During an interview on 8/12/22 at 3:17 P.M., the Assistant Director of Nursing (ADON) said staff should perform hand hygiene before and after direct resident contact, or if hands become soiled. He/She would expect staff to obtain a new wipe every time they wiped a resident. He/She would not expect staff to wipe a resident multiple times with the same wipe. He/She said staff should perform hand hygiene when they move for a dirty area to clean area. During an interview on 8/12/22 at 3:38 P.M., the Director of Nursing (DON) said he/she expects staff to wash or sanitize hands when they enter a room, when they remove their gloves, before they apply new gloves, and when they move from dirty to clean tasks. 4. Review of the facility's wound care policy, revised 6/2021, showed staff are instructed to: -Position the patient off affected area; -Gently cleanse area with Normal Saline (NS); -Apply Skin Prep (a liquid dressing that creates a clear barrier on the skin) to peri-wound (area of intact skin that surrounds a wound) and allow to dry (approximately 45 seconds); -For dry wounds apply one sixteenth (1/16) inch thick hydrogel and cover with cover dressing, change daily. Observation on 8/10/22 3:32 P.M., showed the ADON provided wound care to Resident #47's left heel. He/She cleansed the resident's peri-wound and then cleaned the wound bed (the open base of a wound) with the same soiled gauze. During an interview on 8/10/22 at 3:39 P.M., the ADON said he/she should not have used the same gauze to clean both areas due to cross contamination. During an interview on 8/12/22 at 3: 55 P.M., LPN E said staff are not expected to use the same gauze pad in the same area multiple times when they clean a wound. He/She said a new gauze pad should be used to prevent cross contamination. During an interview on 8/12/22 at 3:17 P.M., the ADON said staff should start cleansing a wound at the wound bed, and move outward. Staff should not go back over an area they have already cleansed with dirty gauze. During an interview on 8/12/22 at 3:38 P.M., the DON said wounds should be cleansed from the center of the wound outward. He/she said using the same gauze to clean the periwound and wound bed would cause the wound to be dirty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for eleven residents (Resident #3, #25, #35, #37, #44, #45, #47, #23, #28, #31, #38) to ensure their medical and nursing needs were met. The facility census was 49. 1. Review of the facility's Care Planning - Interdisciplinary Team policy, dated September 2013, showed: -The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team; -The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the residents care plan. Review showed it did not contain direction for staff in regard to when the care plan should be updated when the resident's needs changed. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/24/22 showed staff assessed the resident as: -Severe Cognitive Impairment; -Diagnoses of cancer, diabetes, hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood), and Alzheimer's Disease (a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain); -Totally dependent on one staff member for bed mobility, transfers, and toileting; -Had no impairment of Range of Motion (ROM) of extremities; -Bed rails not used. Review of the resident's care plan, dated 5/24/22, showed it did not contain strategies or interventions for the use of bed rails to maintain the resident's safety. Observation on 8/09/22 at 2:57 P.M., showed the resident's bed had bed rails up on both sides. Observation on 8/11/22 at 9:20 A.M., showed the resident's bed had bed rails up on both sides. Observation on 8/12/22 at 8:03 A.M., showed the resident's bed had bed rails up on both sides. During an interview on 8/12/22 at 3:05 P.M., Certified Nurse Aide (CNA) I said care plans were available to use, but were not needed to provide resident care. He/She said he/she did not know if bed rails were a part of the resident's care plan. During an interview on 8/12/22 at 3:16 P.M., CNA C said bed rail use should be listed in the care plan. He/She said he/she did not have access to care plans. He/She said the nursing staff informed him/her about the resident's preferences. During an interview on 8/12/22 at 3:17 P.M., the Assistant Director of Nursing (ADON) said he/she would expect bed rails to be on the resident's care plan and knew the resident had bed rails. During an interview on 8/12/22 at 3:38 P.M., the Director of Nursing (DON) said he/she expects positioning rails listed on a residents care plan if they are used. He/she said it's the MDS Coordinator's responsibility to update the care plans unless there is a new fall or telephone order. He/she said telephone orders are part of the care plan and reviewed nightly by the night nurses and reviewed the next day by the DON to ensure the interventions are appropriate and patient-centered. The DON said he/she was not aware bed rails were not on the care plan for this resident. During an interview on 8/12/22 at 3:55 P.M., Licensed Practical Nurse (LPN) E said he/she would expect bed rails to be addressed in the care plan. He/She said he/she was not aware the resident had a bed rail on one side of his/her bed. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address the use of bed rails. 3. Review of Resident #25's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of stroke and arterial fibromuscular dysplasia (progressive twisting of the blood vessels throughout the body); -Required extensive assistance from one staff member for dressing and personal hygiene; -Required limited assistance from one staff member for bed mobility, transfers, and toileting; -Has limited Range of Motion (ROM) to an upper extremity with an impairment on one side; -Bed rails not used. Review of the resident's care plan, dated 6/28/22, showed it did not contain strategies or interventions, for the use of bed rails, to maintain the resident's safety. Observation on 8/09/22 at 12:13 P.M., showed the resident's bed had one bed rail up. Observation on 8/11/22 at 8:15 A.M., showed the resident lay in bed with a bed rail up on one side. During an interview on 8/11/22 at 8:15 A.M., the resident said he/she used the bed rail to help with bed mobility. 4. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance from one staff member for personal hygiene; -Did not reject care. Review of the resident's care plan, dated 5/17/22, showed it did not contain a comprehensive person-centered care plan to direct staff on how to care for the resident's facial hair or teeth. Observation on 8/9/22 at 11:55 A.M., showed the resident had facial hair on his/her upper lip and chin, brown bottom teeth, no upper teeth or dentures, and dark debris under his/her long fingernails. Observation on 8/10/22 at 8:39 A.M., showed the resident had facial hair on his/her upper lip and chin, brown bottom teeth, no upper teeth or dentures, and dark debris under his/her long fingernails. Observation on 8/11/22 at 9:50 A.M., showed the resident had brown bottom teeth, no upper teeth or dentures, and dark debris under his/her long fingernails. Observation on 8/12/22 at 4:40 P.M., showed the resident had brown bottom teeth, no upper teeth or dentures, and dark debris under his/her long fingernails. During an interview on 8/12/22 at 3:16 P.M., CNA C said he/she knew the resident did not have upper teeth. He/She said the resident did not complain about the missing teeth, or voice concerns regarding difficulty eating. He/She said the resident occasionally refused to allow staff to shave his/her face. He/She said the care plan should address dentures, facial hair preferences, and refusal of care. During an interview on 8/12/22 at 3:17 P.M., the ADON said hygiene preferences should be addressed in the care plan. He/She said he/she didn't know where the resident's dentures were. During an interview on 8/12/22 at 3:38 P.M., the DON said he/she expects nail care and shaving to be a part of a residents shower. The DON said refusals of care should be reported to the charge nurse to address at the time of refusal. During an interview on 8/12/22 at 3:55 P.M., LPN E said he/she would expect personal hygiene preferences addressed on the care plan. He/She said he/she knew the resident did not have top teeth, but said the resident requested soft foods at meals. During an interview on 8/12/22 at 4:12 P.M., The MDS Coordinator said he/she didn't know if facial hair preferences should be listed on the care plan. 5. Review of Resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required total assistance from one staff member for personal hygiene; -Did not reject care. Review of the resident's care plan, dated 5/3/22, showed it did not contain a comprehensive person-centered care plan to direct staff how to care for the resident's facial hair. Observation on 8/11/22 at 8:04 A.M., showed the resident had facial hair on his/her chin. Observation on 8/10/22 at 8:07 A.M., showed the resident had facial hair on his/her chin. Observation on 8/12/22 at 4:36 P.M., showed the resident had facial hair on his/her chin and a yellow substance on his/her bottom lip. During an interview on 8/12/22 at 3:16 P.M., CNA C said facial hair preference should be listed on the resident's care plan. He/She said he/she would expect to see the resident's preferences listed, especially for those who are not able to voice what they want. He/She said he/she had never seen a care plan and didn't know if he/she had access. He/She said resident #37 does not refuse ADL care. 6. Review of Resident #45's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required total assistance from one staff member with personal hygiene; -Did not reject care. Review of the care plan, dated 5/19/22, showed it did not contain a comprehensive person-centered care plan to direct staff how to care for the resident's facial hair. Observation on 8/9/22 at 1:10 P.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 8/10/22 at 8:42 A.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 8/11/22 at 8:35 A.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 8/12/22 at 4:45 P.M., showed the resident had facial hair on his/her upper lip and chin. During an interview on 8/12/22 at 3:16 P.M., CNA C said resident #45 refuses to be shaved at times. 7. Review of Resident #44's Five Day Scheduled MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Received an antidepressant seven days out of the seven day look back period. Review of the resident's physician notes, undated, showed the physician documented a diagnosis of depression and an order for Citalopram (an antidepressant) 20 milligrams (mg) daily. Review of the care plan, dated 11/29/21, showed it did not contain direction for staff in regard to the residents use of the resident's antidepressant medication. During an interview on 8/12/22 at 3:17 P.M., the ADON said diagnoses such as depression, should be listed on the care plan with strategies and interventions for the resident's care. He/She said he/she didn't know the resident didn't and his/her use of an antidepressant addressed on the care plan. During an interview on 8/12/22 at 3:55 P.M., LPN E said he/she would expect a resident's pertinent diagnoses with medications used to be addressed on the care plan. He/She said he/she didn't know the resident's antidepressant use was not on care plan. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address anti-depressant medications. 8. Review of Resident #47's medical records showed staff assessed the resident as: -Cognitively intact; -Diagnoses of Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases hat block airflow and make it difficult to breathe), morbid Obesity, Congestive Heart Failure (CHF); -Required extensive to total assistance with Activities of Daily Living (ADLs); -admitted on [DATE]. Review of resident's medical record showed it did not contain a smoking assessment. Review of the resident's care plan, dated 8/9/22 showed it did not contain a comprehensive person-centered strategies or interventions, for smoking, to maintain the resident's safety. During an interview on 8/12/22 at 3:17 P.M., the ADON said smoking should be addressed on the resident's care plan. He/She said he/she didn't know smoking was not addressed on the resident's care plan. During an interview on 8/12/22 at 3:38 P.M., the DON said the care plan should address smoking. He/She said he/she expects the MDS Coordinators to update the care plans, and he/she didn't know it was not addressed on the resident's care plan. During an interview on 8/12/22 at 3:55 P.M., LPN E said he/she would expect smoking to be on a resident's care plan. He/She said he/she didn't know smoking was not addressed on the resident's care plan. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address if the resident smokes. 9. Review of the facility's Wandering and Elopement policy, dated March 2019, showed: -The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; -If a resident is identified as a risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. 10. Review of Resident #23's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Had disorganized thinking that comes and goes and changes in severity; -Wandered four to six days during the seven day look back period; -Had no change in behavioral symptoms since prior assessment; -Independent with locomotion in wheelchair; -Had diagnoses of dementia, anxiety and psychotic disorder. Review of the resident's Elopement risk assessment, dated 6/28/22, showed: -History of elopement while at home; -Cognitive impairment with poor decision-making skills; -Not a risk for elopement/wandering. Review of the resident's Nurses' Notes showed staff documented: -7/26/22: Resident with increased wandering and attempting to exit different doors and unable to express why he/she wants to leave or who he/she is looking for; -7/26/22: Resident continues to wander around facility in self-propelling wheelchair and in other residents rooms; -7/30/22: Resident self-propelling wheelchair around unit and went into several other resident rooms. Review of the resident's care plan, dated 6/28/22, showed it did not contain wandering/elopement strategies or interventions to maintain the resident's safety as directed in the policy. Observation on 8/11/22 at 7:59 A.M., showed the resident propelled his/her wheelchair near the nurse's station. Observation on 8/12/22 at 2:15 P.M., showed the resident propelled his/her wheelchair on the 200 hall. During an interview on 8/12/22 at 3:16 P.M., CNA C said the resident has attempted to elope from the facility and wanders in his/her wheelchair. He/She said wandering should be addressed in the care plan. During an interview on 8/12/22 at 3:17 P.M., the ADON said the resident has not tried to elope. He/She said the resident wanders in his/her wheelchair down the halls, and is not exiting seeking. He/She said he/she would try to redirect the resident and call for help if he/she tried to elope. During an interview on 8/12/22 at 3:38 P.M., the Director of Nursing (DON) said he/she expects wandering and elopement addressed in care plans. He/she said the resident has never tried to leave or elope, but does wander with purpose through the facility. During an interview on 8/12/22 at 3:55 P.M., LPN E said the resident has gone to the door but has not tried to go out or be exit seeking. He/She said the resident is looking for his/her family, who work at the facility. He/She said he/she would expect residents to have elopement and wandering addressed in their care plans. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address if a resident exhibits wandering behavior. 11. Review of the facility's Safety and Supervision of Resident Policy, dated July 2017, showed: -The facility strives to make the environment as free from accident hazards as possible with resident safety, supervision and assistance to prevent accidents a facility-wide priority; -Safety risks and environmental hazards are identified on an ongoing basis through incident/accident data; -An individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents; -Implementing interventions to reduce accident risks and hazards shall include documenting interventions, ensuring interventions are implemented, and assigning responsibility for carrying out interventions. 12. Review of Resident #28's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had no behaviors; -Unsteady but able to reposition without assistance; -Used a walker for ambulation; -Required assistance from one staff member for transfers, ambulation, locomotion and toileting; -Had diagnoses of hypertension (elevated blood pressure), dementia, arthritis, and anxiety; -Had no falls since previous MDS assessment. Review of the residents nursing notes, dated 8/8/22, at 2:45 A.M., showed staff documented: -Staff heard resident calling for help and noted resident sitting on buttock on floor at end of bed and leaning on left arm. Assessment revealed a one inch laceration to the left side of his/her forehead. Review of the residents care plan, dated 7/5/22, showed it did not contain documentation or new interventions in regard to the resident's fall on 8/8/22. Observation on 8/9/22 at 10:59 A.M., showed the resident's left forehead/brow had a hematoma (blood pooled under the skin), a laceration, and was bruised. The resident sat on the edge of his/her bed. During an interview on 8/10/22 at 8:32 A.M., the resident said he/she fell in his/her room and hit his/her head on the dresser. During an interview on 8/12/22 at 3:16 P.M., CNA C said the resident's care plan should be updated with a new intervention after each fall. During an interview on 8/12/22 at 3:38 P.M., the DON said the resident does not always wait for assistance. He/She said they are attempting to get the resident speech therapy to help with his/her cognition, but they are waiting on insurance approval. During an interview on 8/12/22 at 3:55 P.M., LPN E said the resident had a fall and he/she is not sure what interventions have been added. He/She said staff will be informed once the care plan has been updated. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address falls and any new interventions put in to place. 13. Review of Resident #31's Significant Change of Assessment MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired: -Had behavioral symptoms not directed at others four to six days in the seven day look back period; -Required physical assistance from one staff member for bed mobility, transfers, and toileting; -Independent with locomotion; -Had unsteady balance when going from seated to standing; -Had no falls since last MDS Assessment; -Had diagnoses of dementia and anxiety. Review of the residents nurse's notes showed staff documented: -8/3/22: Resident was observed in the bathroom beside the dining room. He/she had his/her pants down around the ankles and was sitting on the bathroom floor with the wheelchair at his/her side; -8/7/22: Resident with increased anxiety as evidenced by screaming for help trying to go out exit doors and into peers rooms with verbal redirection ineffective; -8/9/22: Resident slipped from the wheelchair to the floor onto back/buttocks. Review of the resident's Physician Order Summary (POS), dated 7/26/22, showed an order for a mechanical soft diet related to the resident's difficulty with chewing. Review of the residents care plan, dated 7/12/22, showed it did not contain direction for staff in regard to the resident's mechanical soft diet, interventions related to his/her falls on 8/3/22 or 8/9/22, or his/her exit seeking behaviors. During an interview on 8/12/22 at 3:16 P.M., CNA C said the resident receives a mechanical soft diet. He/She said staff sometimes assist him/her with eating and encourage him/her other times. He/She said the care plan should address the resident's diet, fall interventions and interventions for exit seeking behavior. During an interview on 8/12/22 at 3:17 P.M., the ADON said the resident can't use the bathroom by the dining area and staff keep him/her in visual sight. He/She said staff are to complete an elopement assessment upon admission and it should be on the care plan. He/She said he/she didn't know the resident's diet, but he/she sometimes assisted with meals and would expect the care plan to address the resident's diet and need for assistance. During an interview on 8/12/22 at 3:38 P.M., the DON said the MDS Coordinator is responsible for updating the care plans. He/she said all interventions should be followed up on the following day to ensure they are appropriate and person-centered. He/she said the resident has been moved into a room closer to the nurses station for closer observation. During an interview on 8/12/22 at 3:55 P.M., LPN E said the resident had a fall but he/she was not sure what the new interventions were. He/She said the care plan should be updated with a new intervention after each fall. He/She said he/she would expect elopement to be on the resident's care plan. He/She said the resident is on a mechanical soft diet and sometime receives assistance from staff with eating, and should be addressed in the care plan. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address if the resident received a special diet. 14. Review of the facility's End Stage Renal Disease, Care of a Resident with policy, dated September 2010, showed: -Residents with End Stage Renal Disease (ESRD) (longstanding disease of the kidneys leading to kidney failure) will be cared for according to currently recognized standards of care; -The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. 15. Review of Resident #38's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Had diagnosis of ESRD; -Required dialysis (process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform these functions). Review of the resident's POS, dated June 2022 through August 2022, showed they did not contain orders for dialysis, including how often or duration of treatment, or access site care. Review of the resident's care plan, reviewed 7/18/22, showed: -5/16/22: Dialysis discontinued; -5/24/22: Dialysis as ordered; -8/8/22: Dialysis resumed two days per week. Further review of the care plan showed it did not contain direction for staff in regard to who to contact with dialysis related concerns or complications, monitoring of risk factors and managing complications such as hemorrhage, access site infection, hypotension and to whom to report concerns, assessment and care of the access site, including the use of PPE as necessary and other infection control measures, and approach to administering medications before or after dialysis according to practitioner's orders. During an interview on 8/12/22 at 3:17 P.M., the ADON said he/she would expect the resident's care plan to address dialysis. He/She said the resident's dialysis sheet contains the resident's vitals and port placement check. He/She said he/she knows where the resident's port is due to report (nurse to nurse report) and skin assessments. During an interview on 8/12/22 at 3:38 P.M., the DON said he/she would expect dialysis to be addressed on the care plan. During an interview on 8/12/22 at 3:55 P.M., LPN E said he/she would expect for dialysis to be addressed on the resident's care plan. He/She knows how to care for the resident's port by nursing knowledge. This information is also passed on during shift change report. 16. During an interview on 8/12/22 at 3:16 P.M., CNA C said social services is responsible for updating the care plans. He/She said he/she was not sure how often the care plans were updated. During an interview on 8/12/22 at 3:55 P.M., LPN E said nurses can update the care plans, but the MDS coordinator is responsible for updating them monthly and with significant changes. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans are updated by the nursing staff, DON and himself/herself.