**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that menus were posted in advance and followed. This effected three out of 12 sampled residents (Resident #5, #28 and #34). The facility census was 31. Review of the facility's Menu Planning policy, dated 2020, showed:-Meals are planned in advance;-Planned menus take into consideration the food habits of all residents.Review of the Resident Self Determination and Participation policy, dated 2020, showed:-Residents have the right to choose activities, schedules, health care, and providers of health care services consistent with his or her interests, assessments, and plan of care;-Residents have the right to make choices about aspects of his or her life in the facility that are significant to the resident. 1.Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/12/25, showed:-Severe cognitive impairment;-Minimal assistance for transfers, bathing, locomotion, toileting and eating;-Diagnoses included: Alzheimer's Disease, atrial fibrillation (an irregular heart beat) and depression.Review of the resident's updated care plan showed:-Self care deficit related to Alzheimer's Disease;-Impaired decision making.2. Review of Resident #28's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Minimal assistance for transfers, bathing, locomotion, toileting and eating;-Diagnoses included Alzheimer's Disease, cancer and anemia.Review of the resident's updated care plan showed:-Self care deficit related to Alzheimer's Disease;-Impaired decision making.3. Review of Resident #28's annual MDS, dated [DATE], showed:-Severe cognitive impairment;-Minimal assistance for transfers, bathing, toileting and eating;-Diagnoses included dementia and anxiety. Review of the resident's updated care plan showed:-Self care deficit related to dementia;-Impaired decision making.Observation of the memory care unit on 08/18/2025 at 12:23 P.M., showed:-Lunch Menu, breaded pork chop, au gratin potatoes, zucchini and tomatoes, cornbread and frosted poke cake;-No alternates were listed on the menu board.Observation of Lunch on the memory care unit on 08/18/25 at 12:35 P.M., showed:-Residents #5, #28 #34 were served, ham, cauliflower and Jello with fruit.Observation of lunch on the memory care unit on 08/18/25 at 12:35 P.M., showed:-Residents #5, #28 #34 were served, ham, cauliflower and Jello with fruit. During an interview on 08/18/25 at 1:37 P.M., Resident #5's family member said:-He/She is with the resident at the facility daily for meals; -The resident never gets a menu;-No staff have asked the resident if he/she likes what is on the menu;-No staff have asked the resident's family member what the resident's likes and dislikes are.-He/She has told the aides what the resident would like for the meal;-The kitchen did not bring what was ordered for the resident;-The staff said they did not know why the resident did not get what he/she ordered.During an interview on 08/18/2025 at 2:02 P.M. the Dietary Manager (DM) said:-The resident's have a choice of what they eat;-The activity director asks the residents what they would like to eat;-If the residents are unable to tell us what they want staff will contact family.-She was not sure who was in charge of talking to family members about food choices;-The wrong menu was posted in the memory care unit;-The menu should be changed every day;-The dietary department is responsible for changing the menus;-An alternate menu should be posted.During an interview on 08/18/2025 at 2302 P.M. the Activities Director said:-The resident's have a choice of what they eat;-She does not ask the resident's on the memory care unit what they would like to eat for meals;-The kitchen staff were responsible for that.Intake #2586257

Based on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. The facility census was 31.Review of the facility's Sanitation of Dining and Food Service Areas, undated., showed: The dining services manager will be responsible for ensuring the cleaning and sanitation is maintained in the kitchen and dining areas.- All staff will be trained on the frequency of cleaning.- A cleaning schedule will be posted for all cleaning tasks. - Observation of the kitchen on 08/18/25 at 10:46 A.M., showed: - Area under the three compartment sink covered with food debris;-The floor under the prep table covered with dirt and debris;-A metal storage rack above the prep table covered in dirt and dust;-A cake uncovered sat under the dirty and dusty metal storage rack;-The handles of the refrigerator covered with a sticky substance;- A black substance along the drain on the floor in the dish room;-A fan covered with dust and debris blew across a tray with open glasses with ice in them;-The trash can by the prep table with no lid;-A window by the prep table covered in dirt and debris; Dry storage:-A box containing 4 large cans of baked beans sat on the floor; The freezer:-An undated, opened package of sausage patties;-An undated opened package of chicken patties;-An undated opened package of French toast sticks. During an interview on 08/20/25 at 12:45 P.M., [NAME] A said:-Food should be dated and stored in a closed container;-The kitchen should be kept clean;-The kitchen staff try to work together to keep the kitchen clean;-Sometimes things fall through the cracks.During an interview on 08/20/25 at 01:45 P.M., the Dietary Manager said:-Food should be closed and dated;-The kitchen should be clean and sanitary;-The kitchen staff was responsible for cleaning the kitchen.During an interview on 08/20/25 at 02:15 P.M., the Registered Dietitian said:-Food should be stored in a safe and sanitary manner;-Food should be dated and kept in a closed container;-The kitchen should be kept clean and sanitary.During an interview on 08/20/25, at 02:26 P.M., the Administrator said:-She expected the dietary department to keep the kitchen clean;-She expected food to be stored properly;-She expected the dietary staff to take care of needs of the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed protect one sampled residents (Resident #1) right to be free from physical abuse when resident (Resident #2) hit Resident #1 in the head. The facility staff did not place Resident #2 on increased monitoring until the resident was moved to the secured unit six days after the event. The facility census was 37. Review of the facility's abuse policy, titled Abuse, Neglect and Exploitation Policy, dated 1/31/24 showed: -It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. -Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. -The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Increased supervision of the alleged victim and residents, room or staffing changes to protect the resident from the alleged perpetrator. 1. Review of Resident #1's medical record on 6/2/25 showed: - Diagnoses included: Palliative care (specialized medical care that focuses on relieving the symptoms and stress of a serious illness), lung cancer, dementia ( a group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (a progressive, irreversible condition where the kidneys are damaged and lose their ability to filter waste and fluids from the blood), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), cellulitus (a bacterial skin infection affecting the deeper layers of the skin and underlying tissue, often caused by bacteria like Streptococcus or Staphylococcus entering through a break in the skin), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff) showed: -The resident has adequate hearing, clear speech, understands others and is able to make self understood; -He/She scored 8 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates moderately impaired cognitive impairment; -The resident has displayed no behaviors. Review of the resident's comprehensive care plan, dated 5/25/25, showed: - Interventions related to hospice care, activities of daily living, weakness, occasional verbal aggression, cognitive decline, risk for falls, nutrition, incontinence, pain related to lung cancer, and COPD. 2. Review of Resident #2's medical record on 6/2/25 showed: -The resident's diagnoses included: Dementia, age related physical debility, psychosis (a state where a person experiences a loss of contact with reality, often involving hallucinations and delusions, which are false perceptions and beliefs), anemia, pain, malnutrition, heart disease, osteoarthritis (a chronic degenerative joint disease that causes cartilage in the joints to break down over time). Review of the resident's annual MDS, dated [DATE], showed: -The resident has moderate difficulty hearing, clear speech, usually understands others and usually makes self understood; -He/She scored 6 on the BIMS, indicating severely impaired cognitive impairment; -He/She displayed verbal and physical behaviors. Review of the resident's comprehensive care plan, dated 5/25/25, showed: -Interventions related to verbal and physical behaviors toward staff, altercations with another resident; -The resident doesn't like others touching him/her; -When the resident is in the dining room keep other resident's away; -Monitor the resident at meal times to keep from eating and drinking other resident's foods. Review of the facility investigation on 6/2/25 showed: -On 5/23/25 at 3:18 P.M., dietary staff notified nursing staff that Resident #2 had poured milk on and hit resident #1. The dietary aide heard Resident #1 yell out and and turned to see Resident #2 pour milk on Resident #1, and moved to intervene. Before the staff could reach the residents, Resident #2 hit Resident #1 in the head. The dietary staff member separated the residents and notified nursing staff. The charge nurse assessed the residents and no injuries were noted. The physician, administrator, director of nursing and responsible parties were notified of the incident. Resident #2 was moved to the memory care unit on 5/29/25, as it was determined the structured environment would be beneficial for the resident. During an interview on 6/2/25 at 12:56 P.M., the Administrator said: -He/She reviewed the camera footage from the dining room of the incident on 5/23/25. Resident #1 was sitting at the dining table, sleeping in his/her wheelchair. Resident #2 propelled him/herself in his/her wheelchair to the table, and took a drink of the glass of milk in front of Resident #1. Resident #1 awoke, reached out and bumped Resident #2's arm, causing Resident #2 to spill some milk. Resident #2 became upset and poured the milk on Resident #1. Resident #1 then became upset and yelled out. The dietary staff member heard the resident yell and headed to the residents' table. Before the staff member could reach the residents, Resident #2 hit Resident #1 in the head. The dietary staff separated the residents and informed the charge nurse of the incident. -The administrator instructed the staff to keep a close eye on Resident #2. On 5/27/25, the physician reviewed and adjusted Resident #2's medication. The physician also ordered a urine analysis (UA) for resident #2. On 5/28/25, the resident's UA was positive for infection and he/she was started on antibiotics. The charge nurse also spoke with Resident #2's responsible party, who approved the resident's move to the memory care unit, has he/she would benefit from the quiet, structured environment. The resident was moved to the secure unit on 5/29/25. -Staff were not instructed to place Resident #2 on closer supervision, such as 15 minute checks or one on one supervision, as neither resident recalled the incident or were targeting the other. -Resident #2 was not moved to the memory care unit until 5/29/25 as the facility was waiting for approval from the resident's responsible party. MO254735

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facilty staff failed to maintain standard infection control precautions when staff did not perform hand hygiene with glove changes during wound care for two residents (Resident #1 and #2). Additionally, staff did not wear a personal protective gown when assisting with wound care for Resident #2 when the resident was on Enhanced Barrier Precautions (EBP). The facility did not have gowns near or outside of the resident rooms. The facility did not obtain a physicians order to implement EBP when Resident #1 and #2 had wounds. This deficient practice affected two of two sampled residents. The facility census was 33. Review of the facility policy titled, Hand Hygiene, dated 1/1/24 showed: - Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of Practice; - The use of gloves does not replace hand hygiene; - Perform hand hygiene prior to putting on gloves, and immediately after removing gloves. Review of the facility policy titled, Infection Prevention and Control Program, dated 1/124 showed: - Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures; - All staff shall use personal protective equipment (PPE) according to established facility policy. Review of the facility policy titled, Enhanced Barrier Precautions, dated 3/23/24 showed: - EBP refers to an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities; - Make gowns and gloves available immediately near or outside of the resident's room; - High contact resident care activities include wound care; - The facility staff with obtain a physician's order when a resident is placed on EBP precautions. 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 3/12/25 showed: - He/She had a Brief Interview for Mental status score of 10, indicating moderate cognitive impairment; - Diagnoses included: Heart Failure (HF), urinary tract infection (UTI), stroke, and anxiety; - He/She was dependent on the staff to toilet, get dressed and shower; - He/She was at risk for the development of pressure ulcers; - He/She did not have any pressure ulcers. Review of the resident's comprehensive care plan dated 3/8/25 showed the resident's wounds were not addressed. Review of the Physicians Order Sheet (POS) dated 4/2025 showed: - 3/24/25 Left 1st toe, cleanse the area with wound cleanser (WC), apply silver sulfadiazine (a wound treatment to promote healing) and calcium alginate, cover with a non stick pad, wrap in kerlix (a gauze that is wrapped around the area) and an elastic bandage. Change every Monday, Wednesday and Friday; - 3/24/25 Left toes, apply anti-fungal powder in between each toe before wrapping in kerlix and elastic bandage; - 3/24/25 Left and right heels, apply betadine (a liquid that cleans) and foam to both heals, cover with a border gauze dressing one time daily; - The orders did not include an order for EBP. Observation on 4/5/25 at 11:0 A.M. showed: - There was no PPE cart in or near the resident's room; - There was no signage in or near the resident's room indicating staff were to adhere to EBP precautions; - Licensed Practical Nurse (LPN) A and Certified Nurse Aide (CNA) A entered the resident's room; - LPN A pushed the treatment cart into the room; - CNA A did not wash his/her hands prior to putting on gloves; - LPN A washed his/her hands and put on gloves; - LPN A pushed his/her glasses up on his/her face with his/her gloved fingers and the finger of the gloves touched his/her side of nose; - CNA A lifted the resident's leg up and LPN A began cutting the dressing from the resident's right foot; - LPN A removed the dressing and grabbed cleaning gauze pads from the top of the cart with the same gloves on; - LPN A opened the cart and dug through it to get the wound cleanser with the same gloves on; - LPN A cleaned the resident's open wound with the same gloves on; - LPN A removed the used gloved and put on clean ones, he/she did not perform hand hygiene before putting on clean gloves; - LPN A applied the ordered treatment and replaced the dressing to the resident's right foot; - CNA A set the resident's right foot down and lifted the resident's left foot; - LPN A removed the dressing from the resident's left foot, cleaned the wounds with wound cleanser and did not put on clean gloves; - LPN A touched his/her nostril area of his/her nose with his/her gloved right hand; - LPN A placed a clean dressing to the reisdent's wounds and did not change his/her gloves; - LPN A pushed his/her glasses up onto his/her face wearing the same gloves; - LPN A then took off the used gloves and washed his/her hands before exiting the room; - CNA A removed his/her PPE and did not was his/her hands before leaving the resident's room. During an interview on 4/5/25 at 11:17 A.M. CNA A said: - He/She did not know the staff were supposed to adhere to EBP precautions; - He/She had not received educations regarding EBP; - He/She put a protective gown on because LPN A told him/her to; - He/She knew he/she was supposed to wash his/her hands when entering and exiting the resident's room. During an interview on 4/5/25 at 11:27 A.M. LPN A said: - The staff were supposed to adhere to EBP precautions because the resident had a wound; - He/She should have washed his/her hands upon entering and exiting the reisdent's room; - HE/She should have changed his/her gloves and performed hand hygiene before putting on clean gloves prior to cleaning the reisdent's wounds, and prior to completing the wound treatment; - He/She should have changed his/her gloves and performed hand hygiene when he/she touched his/her face and nostrils; - He/She should not have dug in the treatment cart with contaminated gloves on. 2. Review of Resident #2's quarterly MDS dated [DATE] showed: - He/She had a BIMS score of 15, indicating no cognitive impairment; - Diagnoses included: multi-drug resistant organism and anxiety; - The resident was dependent on staff assistance to toilet, get dressed and bathe; - The resident was at risk for the development of pressure ulcers; - The resident had one stage 4 (a pressure ulcer with exposed tendons and bone), and six stage 2 (pressure ulcer characterized by the top layer of skin opened). The reisdent's wound care plan dated 1/30/25 showed: - The staff were supposed to complete wound treatments as ordered by the physician; - Resident was to be monitored for signs and symptoms of infection; - The resident's care plan did not address EBP. Review of the resident's POS dated 4/2025 showed: - 4/4/25 Cleanse the area with Vashe cleanser (wound cleanser), apply betadine to the edges of the wound, calcium alginate with silver to the wound bed, cover with a foam border dressing. Change three times per week on Monday, Wednesday and Friday; - There was no order for EBP. Observation on 4/5/25 at 9:54 A.M. showed: - There was no PPE cart in or near the resident's room; - There was no signage in or near the resident's room indicating EBP precautions; - LPN A placed the resident's treatment items on top of the treatment cart; - LPN A put on a protective gown and entered the resident's room with the treatment cart; - CNA A entered the resident's room and did not put on a protective gown; - LPN A and CNA A did not wash their hands upon entering the residents room; - Both staff put on gloves; - CNA A rolled the resident's to his/her side; - LPN A removed the old dressing from the resident's wound; - LPN A pushed his/her glasses up onto his/her nose with the back of his/her gloved hand; - LPN A did not change his/her gloves after touching his/her glasses; - LPN A cleaned the resident's wound and did not change his/her gloves; - LPN A applied a new wound dressing with his/her contaminated gloves; - LPN A took his/her dirty gloves off and put on clean gloves, LPN A did not perform hand hygiene with the glove change; - LPN A touched his/her face and nostril with his/her gloved fingers; - LPN A dug through his/her pocket and pulled out a pen; - LPN A wrote the date on the resident's wound dressing; - LPN A and CNA A removed his/her gloves and left the residents room with out performing hand hygiene. 3. During an interview on 4/5/25 at 11:52 A.M. the Director of Nursing (DON) said: - She expected all staff to wear protective gowns when they are assisting with wound care; - She expected hand hygiene to be completed between glove changes; - She expected staff to wash their hands when entering a resident's room and exiting; - She expected staff to change their gloves and perform hand hygiene when they have touched their face, nostril, and glasses; - She expected staff to change their gloves and perform hand hygiene when they remove an old wound dressing, again when cleaning the wound, again when applying a new treatment and dressing, and if visibly soiled; - Staff should not dig in their pockets or the treatment cart with gloved hands; she expects staff to have all of the materials needed for the treatment prepared and easily accessible; - There should be a PPE cart in or near the resident's room, so that staff have easy access to PPE; - There should by signage in or near the resident's room to alert staff the resident's was receiving EBP precautions; - She expected EBP to be care planned and a physician's order obtained. MO252238

Based on interviews and record review, the facility failed to complete a discharge summary for one of 12 sampled residents, (Resident #30). The facility census was 29. Review of the facility's policy for discharge summary and plan, revised December 2016, showed, in part: - When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment; - The discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include: current diagnosis medical history (including any history of mental disorders and intellectual disabilities); course of illness, treatment and/or therapy since entering the facility; current laboratory, radiology, consultation, and diagnostic test results; physical and mental functional status; Ability to perform activities of daily living (ADLs) including: bathing, dressing and grooming, transferring and ambulating, toilet use, eating and using speech, language and other communication systems; the need for staff assistance and assistive devices or equipment to maintain or improve functional abilities and the ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in the day- to- day activities of the facility; sensory and physical impairments (neurological, or muscular deficits); nutritional status and requirements: weight and height, nutritional intake, eating habits, preferences and dietary restrictions; special treatments or procedures (treatments and procedures that are not part of basic services provided); metal and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood); discharge potential (the expectation of discharging the resident from the facility within the next three months); dental condition (the condition of the teeth, gums, and other structures of the oral cavity that may affect a resident's national status, communications abilities, quality of life and the need for and use of dentures or other dental appliances); activities potential (the ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being); rehabilitation potential (the ability to improve independence in functional status through restorative care programs); cognitive status (the ability to problem solve, decide, remember , and be aware of and respond to safety hazards); and medication therapy (all prescription and over- the - counter (OTC) medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident); - As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented; - Every resident will be evaluated for his/her discharge needs and will have an individualized post-discharge plan. 1. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/9/24 showed: - Cognitive skills intact; - Independent with eating, toilet hygiene, dressing, toilet use and transfers; - Required set up and clean up with oral hygiene, showers, and personal hygiene; - Always continent of bowel and bladder; - Diagnoses included seizure disorder, anxiety, depression, high blood pressure and post traumatic stress disorder (PTSD, a mental health conditions that's triggered by a terrifying event-either experiencing it or witnessing it). The facility did not provide the resident's care plan. Review of the resident's medical record showed: - 5/8/23- the resident was admitted to the facility; - 4/3/24- the resident was discharged from the facility; - Did not have a discharge summary. During an interview on 530/24 at 3:03 P.M., the Administrator said: - There should be a recapitulation of the resident's stay in their medical record.

Based on observation, interview and record review, the facility failed to employ a qualified activity professional to oversee the activity program for the facility. The facility employees a full time activity director but he/she has not completed an approved activity professional training program. The facility census was 29. The facility did not provide a policy regarding activity professional training and requirements. Review of resident right's policy, dated 1/1/24, showed: -Resident's right to a dignified existence; -Be treated with respect, kindness, and dignity; -Self-determination; -Equal access to quality care. During an interview on 5/29/24 at 6:21 A.M., Activity Director said: -He/She had been the Activity Director since 2017; -He/She had one day of training before becoming activity director; -He/She had attended some training's with administrator, director of nursing, and social services provided by the coalition but no activity specific training certifications; -He/She had no specific dementia activity training. During an interview on 5/30/24 at 3:03 P.M., Corporate Administrator said: -He/She did not know what was required of the activity director certifications; -If regulation guidance indicated Activity Director should be certified, then he/she expected them to be certified. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -He/She did not know what certifications were required of activity directors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received treatment as ordered for one resident (Resident #24) when staff did not float (prevent the resident's heels from resting on the mattress) heels in bed by using pressure off-loading boots, when they did not complete weekly skin assessments, and when they did not visualize the resident's wound dressing on two dates to ensure the dressing was in place. The facility census was 29. The facility did not provide a policy on pressure ulcers. Review of facility policy, Medication and Treatment orders, updated 1/1/24, showed: -Orders for medications and treatments will be consistent with principles of safe and effective order writing; -Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 1. Review of Resident #24's quarterly MDS, dated [DATE], showed: -He/She had severe cognitive impairment; -He/She was dependent on a wheelchair; -He/She was always incontinent of bowel and bladder; -Resident had stage 1 (red area that is caused by continuous pressure) or greater pressure ulcer; -Resident was at risk of pressure ulcers and had unhealed pressure ulcers; -He/She had one stage 3 (a wound that is caused from pressure that is open and exposes the tissue and fat under the skin) pressure ulcers, he/she had zero pressure ulcers upon admission; -He/She had pressure reducing device for chair and for bed; -He/She received pressure ulcer care; -He/She had application of dressings to his/her feet; -Diagnoses included: diabetes (too much sugar in the blood), stage 3 pressure ulcer of left heel, and need for assistance with personal care. Review of care plan, dated 1/27/23, showed: -Resident had pressure ulcers to both heels; -Charge nurse to assess the resident's skin weekly and document on the Treatment Administration Record (TAR); -Follow facility policies/protocols for prevention/treatment of skin breakdown; -Resident to wear offloading boots to both feet. Ensure they are on when he/she is in bed. Review of physician's orders, dated 5/28/24, showed: -Ordered 12/20/23, Float heels in bed, use pressure off-loading boots; -Ordered 1/7/24, weekly skin assessment on Fridays, day shift; -Ordered 5/17/24, visualize area of wound to left heel, ensure dressing in place, and dressing clear of soiling, every day shift. Review of treatment administration record, dated 5/1/24 to 5/27/24, showed: -Visualize area of wound to left heel ensure dressing in place, dressing clear of soiling every day shift, started 5/18/24, no entries on 5/18/24 and 5/19/24; -Weekly skin assessment Fridays, day shift, started 1/12/24, showed no entry on 5/17/24. Review of wound treatment team summaries, dated 3/22/24 to 5/24/24, showed: -On 3/22/24, patient had wounds on his/her left heel, Float heels while in bed; -On 4/5/24, duration greater than 105 days, recommended float heels in bed: Pressure reducing boot preferred; -On 4/10/24, wound duration greater than 110 days, recommended to float heels in bed: Pressure reducing boot preferred; -On 4/17/24, wound duration greater than 117 days, recommended to float heels in bed: Pressure reducing boot preferred; -On 4/24/24, wound duration greater than 124 days, recommended to float heels in bed: Pressure reducing boot preferred; -On 5/1/24, wound duration greater than 131 days, recommended to float heels in bed: Pressure reducing boot preferred; -On 5/8/24, wound duration greater than 138 days, recommended to float heels in bed: Pressure reducing boot preferred; -Dated 5/17, wound duration greater than 147 days, recommended to float heels in bed: Pressure reducing boot preferred; -Dated 5/24, wound duration greater than 154 days, recommended to float heels in bed: Pressure reducing boot preferred. Review of physician notes, dated 3/27/24, showed: -Resident continued with wound doctor for wound care, for left heel wound. Nursing staff reported resident was having quite a bit of pain in his/her left heel, and he/she frequently drew leg into a fetal position for comfort. Observation on 5/29/24 at 2:15 P.M. showed resident was laying down in bed, he/she did not have pressure reducing boots on his/her feet. Boots were laying on the dresser top. Observation on 5/30/24 at 1:28 P.M. showed resident was laying down in bed. He/She did not have heels offloaded and was not wearing boots. During an interview on 5/30/24 at 11:22 A.M., Licensed Practical Nurse (LPN) A said: -All staff are to be offloading resident's heels when he/she is laid down in bed; -Resident's physician's orders to offload heels and apply heel protectors are to be followed; -He/She had issues getting the staff to apply resident's heel protectors. During an interview on 5/30/24 at 12:13 P.M., Certified Nurse Aide (CNA) D said: -He/She did not apply boots yesterday when he/she laid resident down in bed. During an interview on 5/30/24 at 3:03 P.M., Director of Nursing (DON) said: -He/She expected a resident's orders for offloading of their heels while in bed to be followed.

Based on observations, interviews and record review, the facility failed to ensure staff provided catheter care (sterile tube inserted into the bladder to drain urine) care in a manner to prevent a urinary tract infection (UTI, an infection in any part of the urinary system) or the possibility of a UTI when staff failed to clean the catheter tubing, the drainage spout and placed the graduate (a clear plastic container with markings used to collect and measure fluids) directly on the floor which affected one of 12 sampled residents, (Resident #16). The facility census was 29. Review of the facility's policy for urinary catheter care, revised September 2014, showed: - The purpose of this procedure is to prevent catheter - associated urinary tract infections; - Ensure that the catheter remains secures with a leg strap to reduce friction and movement at the insertion site. The catheter tubing should be strapped to the resident's inner thigh; - Use one area of the wash cloth for each downward, cleansing stroke; - Change the position of the wash cloth with each downward stroke; - Next, change the position of the wash cloth and cleanse around the insertion site; - With a clean wash cloth, cleanse the catheter from the insertion site to approximately four inches outward; - Secure the catheter tubing with a leg band. Review of the facility's policy for emptying a urinary drainage bag, revised October 2010, showed, in part: - The purpose of this procedure is to prevent the drainage bag from becoming full and allowing urine to flow back into the bladder, to measure output, and to obtain a sterile specimen; - Place a paper towel on the floor beneath the drainage bag; - Position the measuring container under the drainage bag; - Open the drainage bag and let the urine flow into the measuring container; - After the drainage bag has emptied, close the drain; - Wipe the drain with an alcohol sponge or swab; - Replace the drain tube back in its holder. 1. Review of the resident's care plan, revised on 3/28/24 showed: - The resident was incontinent of bowel and bladder. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/22/24 showed: - Cognitive skills moderately impaired; - Lower extremities impaired on both sides; - Dependent on the assistance of staff for dressing, toilet use, personal hygiene and transfers; - Always continent of urine; - Always incontinent of bowel; - Diagnoses included depression, anxiety, psychotic disorder ( severe mental disorders that cause abnormal thinking and perceptions), diabetes mellitus and urinary tract infection (UTI, an infection in any part of the urinary system). Review of the resident's medical record on 4/27/24 at 9:24 A.M., showed: - admission date - 3/28/24; - The resident's care plan did not address the use of a urinary catheter. Review of the resident's physician order sheet (POS) dated May 2024 showed: - Start date: 5/27/24 - urinary catheter care every shift; - Start date: 5/27/24 - change catheter anchor as needed. Observation on 5/29/24 at 5:27 A.M., showed: - Certified Nurse Aide (CNA) H placed the graduate directly on the floor, removed the spout from the sleeve, unclamped it and emptied 400 milliliters (ml.) of amber colored urine into the graduate. CNA H did not clean the spout before he/she clamped it and place it back in the spout; - The resident did not have a leg strap to secure the catheter tubing; - CNA H unfastened the incontinent brief; - CNA H used a wash cloth and wiped down one side of the groin, folded the wash cloth, wiped down the other side of the groin, folded the wash cloth and wiped down the middle, folded the wash cloth and wiped down the middle; - CNA H did not separate and clean all the skin folds and did not clean the urinary catheter tubing; - Nurse Aide (NA) C and CNA H turned the resident on his/her side; - CNA H removed the soiled incontinent brief; - CNA H used a new wash cloth and wiped up one side of the buttocks with fecal material, folded the wash cloth and wiped up the other side of the buttocks with fecal material, folded the wash cloth and used the same area of the wash cloth to clean fecal material from both sides of the buttocks; - CNA H used a wet paper towel and used the same area of the paper towel to wipe fecal material from the resident's upper thigh; - CNA H and NA C placed a clean incontinent brief under the resident; - CNA H used another wet paper towel and used the same area of the paper towel and removed fecal material from the resident's inner upper thigh. During an interview on 5/29/24 at 4:58 A.M., CNA H said: - He/she was taught to fold the wash cloth four times with peri care; - He/she thought you could use the same area of the wash cloth to clean different areas of the skin; - Should make sure to separate and clean all areas of the skin where urine or feces had touched; - Should not use a paper towel to do peri care; - The resident should have a leg strap to secure the urinary catheter tubing; - He/she should have cleaned the urinary catheter tubing; - He/she usually held the graduate or placed it directly on the floor; - They did not have any alcohol pads to clean the spout. During an interview on 5/29/24 at 5:52 A.M., NA C said: - He/she should not have used a paper towel to do peri care. During an interview on 5/30/24 at 3:03 P.M., the Director of Nursing (DON) said: - The staff should anchor the catheter tubing and clean it; - Staff should place a barrier on the floor then place the graduate on it; - Staff should clean the spout with an alcohol wipe; - Staff should not use the same area of the wash cloth to clean different areas of the skin; - Should not use paper towels to clean resident during peri care; - Staff should separate and clean all areas of the skin where urine or feces had touched.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and respect when staff did not ask each resident before applying clothing protectors to them in North and South dining rooms, stood while assisting four sampled residents with eating (Residents #14, #7, and #29), when staff left a clothing protector on resident before and after meals (Resident #14) and when staff did not provide privacy when was left exposed to hallway while only wearing a brief and T-shirt. (Residents #3). Additionally, the facility failed to ensure staff cared for residents in a dignified manner when they obtained blood sugars and administered insulin in the dining room which affected Resident #12 and #24. The facility census was 29. Review of facility policy, promoting/maintaining resident dignity, updated 1/1/24, showed: -It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality; -All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights; -Groom and dress residents according to resident preference; -Maintain resident privacy; -Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source. Review of facility policy, assistance with meals, updated 1/1/24, showed: -Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity; - Staff will not stand over residents while assisting them with meals; -Avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident. 1. Observation on 5/27/24 at 11:51 A.M. showed housekeeping Aide (HA) A applying clothing protectors to all residents in south dining room. He/She did not ask residents if they wanted clothing protector applied before putting them on residents. Observation on 5/27/24 at 12:10 P.M. showed maintenance supervisor placed clothing protector on residents in south dining room did not ask him/her if he/she wanted one applied. 2. Review of Resident #3's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/14/24, showed: -He/She was severely impaired and never/rarely made decisions; -He/She was dependent on staff for all personal hygiene and dressing; -Diagnoses included cerebral palsy (a disorder that affects movement, muscle tone and posture). Review of care plan, dated 5/4/23, showed: -Resident was dependent on staff for completion of all ADL's; -When resident was in bed, keep a brief on him/her so he/she did not expose self or dirty his/her hands with urine or feces; -Resident was totally depend on two staff for dressing; -Resident had impaired cognitive function, difficulty communication and impaired thought processes; -Resident is dependent on staff with toileting and hygiene. Observation on 5/27/24 10:00 A.M. showed Resident was lying in bed exposed to the hallway wearing only a brief and T-shirt. No privacy curtain pulled. Observation on 5/28/24 at 8:58 A.M. showed resident asleep in bed with no pants on, wearing a brief and T-shirt, exposed to hallway. No privacy curtain pulled. Observation on 5/28/24 at 10:41 A.M. showed resident remained in bed exposed from hallway wearing only a brief and T-shirt, no privacy curtain pulled. Observation on 5/28/24 at 3:28 P.M., showed resident asleep in bed wearing only brief and T-shirt, no privacy curtain pulled. During an interview on 5/30/24 at 12:05 P.M., Activity Director said: -Resident should have his/her privacy curtain pulled when laying in bed with a brief on. During an interview on 5/30/24 at 12:10 P.M., Certified Nurse Aid (CNA) C said: -Privacy curtain should be pulled if a resident is laying in bed wearing a brief and was uncovered. During an interview on 5/30/24 at 12:13 P.M. CNA D said: -He/She should pull resident's privacy curtain or close the door if resident was lying in bed with a brief on and no cover. 3. Review of Resident #14's annual MDS, dated [DATE], showed: -He/She had severely impaired cognition; -He/She exhibited wandering behaviors daily; -He/She required partial/moderate assistance with eating; -He/She was dependent for personal hygiene; -Diagnoses included dementia (condition characterized by impairment of at least two brain functions such as memory loss and judgement), schizophrenia (a disorder that affects a person's ability to think, feel, or behave clearly), need for assistance with personal care, unsteadiness on feet, and generalized muscle weakness. Review of care plan, dated 3/17/23, showed: -He/She was able to feed self after tray is set up. Supervise or encourage and assist him/her with meals as needed; -He/She was assisted by one staff with personal hygiene; -He/She ambulates independently throughout the unit. Supervise/assist him/her as needed. -He/She was at risk for falls due to confusion. Observation on 5/27/24 at 11:05 A.M., showed the resident was laying in bed with a clothing protector tied around his/her neck. Observation on 5/27/24 at 1:57 P.M., showed resident assisted with walking by holding CNA B's hand. Resident was wearing a clothing protector around his/her neck as he/she walked around the facility. Observation on 5/28/24 at 12:16 P.M. showed CNA B standing to assist resident take bites of his/her food. Observation on 5/29/24 at 7:07 A.M., showed CNA D assisted the resident to take a bite of food while leaning over him/her in a standing position. 4. Review of Resident #7's quarterly MDS, dated [DATE], showed: -His/Her cognitive status was untestable; -He/She required touching assistance with eating; -He/She required substantial/maximal assistance with oral care, toileting, upper and lower body dressing, personal hygiene; -Diagnoses included: non-traumatic brain dysfunction; diabetes (a condition resulting into much sugar in the blood), dementia (a group of conditions characterized by impairment of at least two brain functions such as memory loss and judgment that interfered with daily function), anxiety, depression, lack of coordination, and pain. Review of care plan, dated 3/9/23, showed: -Provide verbal encouragement and cueing during meals; -He/She was able to feed self. Sometimes, he/she had a hard time sitting down at the table for whole meal. See if he/she will sit with you and encourage him/her to finish eating. Observation on 5/28/24 at 12:16 P.M., showed CNA C standing and leaning over the resident to assist to with taking bites of his/her food. Observation on 5/28/24 at 12:20 P.M. showed CNA C continued standing to assist the resident to eat his/her food. 5. Review of Resident #29's MDS, dated [DATE], showed: -He/She had severe cognitive impairment; -He/She had impairments to both sides of upper extremities; -He/She was dependent on a walker; -He/She required set up or clean up assistance with eating; -He/She required substantial/maximal assistance with oral hygiene; -He/She was dependent for toileting, putting on shoes, and personal hygiene; -Diagnoses included Alzheimer's Disease (a progressive disease that destroys memory and thinking skills), repeated falls, generalized muscle weakness, need for assistance with personal care, and difficulty in walking. Review of care plan, dated 5/4/24, showed: -Resident was able to eat independently after set up assistance; -Keep resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion; -Resident had impaired cognitive function or impaired thought processes due to dementia. Observation on 5/29/24 at 7:31 A.M. showed CNA C standing next to the resident and offering the resident a bite of breakfast. 6. During an interview on 5/30/24 at 11:58 A.M., Housekeeping Supervisor said: -He/She took feeding course; -He/She thought he/she should stand to feed residents; -He/She should ask residents if they want clothing protectors before applying them; -He/She did not ask residents if they wanted a clothing protector before putting them on residents. During an interview on 5/30/24 at 12:05 P.M., Activity Director said: -Staff should sit beside residents when assisting to feed. During an interview on 5/30/24 at 12:10 P.M., Certified Nurse Aide (CNA) C said: -He/She should sit to assist resident to eat their meals; -It was intimidating when standing next to a resident during meal assistance. During an interview on 5/30/24 at 12:13 P.M., CNA D said: -Staff should not stand to assist residents to eat their meals. During an interview on 5/30/24 at 3:03 P.M., Director of Nursing said: -He/She expected staff to sit when assisting residents to eat during meals; -He/She expected staff to ask resident's if they wanted a clothing protector before one was applied to each resident; -He/She expected staff to pull a privacy curtain when a resident was laying in bed wearing only a brief. 7. Review of Resident #12's admission MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Lower extremities impaired on both sides; - Required assistance with set up and clean up when eating; - Dependent on the assistance of staff for dressing and transfers; - Diagnoses included depression, anxiety, psychotic disorder ( severe mental disorders that cause abnormal thinking and perceptions), diabetes mellitus and urinary tract infection (UTI, an infection in any part of the urinary system). Observation on 5/28/24 at 7:57 A.M., showed: - The resident sat in his/her wheelchair at the dining room table and had finished eating his/her breakfast; - Licensed Practical Nurse (LPN) B obtained the resident's blood sugar after the resident had completed his/her meal and in the presence of two other residents. Observation and interview on 5/28/24 at 12:09 P.M., showed: - The resident sat in his/her wheelchair at the dining room table; - The staff brought the resident his/her meal; - LPN B obtained the resident's blood sugar in the presence of three other residents at the table; -The resident's blood sugar was 128 and LPN B said the resident would not get any insulin. Review of the resident's physician order sheet (POS), dated May 2024 showed: - Start date: 4/17/24 - Humalog (fast acting) insulin per sliding scale, for blood sugar 0 - 150 - no units of insulin. Review of the resident's medication administration record (MAR), dated May 2024 showed: - Humalog insulin per sliding scale, for blood sugar 0 - 150- no units of insulin. 8. Review of Resident #24's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Required assistance with set up and clean up when eating; - Dependent on the assistance of staff for dressing and transfers; - Diagnoses included diabetes mellitus, dementia (inability to think), anxiety, depression and psychotic disorder. Observation on 5/28/24 at 11:49 A.M., showed: - The resident sat in his/her wheelchair at the dining room table; - LPN B obtained the resident's blood sugar in the dining room in the presence of three other residents; - The resident's blood sugar was 292; - LPN B administered the resident's insulin at the dining room table in the presence of three other residents. Review of the resident's POS, dated May 2024 showed: - Start date: 3/1/24 - Novolog (fast acting) insulin, 14 units three times daily related to diabetes mellitus. Review of the resident's MAR, dated May 2024 showed: - Novolog insulin, 14 units three times daily related to diabetes mellitus. During an interview on 5/30/24 at 10:14 A.M., LPN B said: - Part of his/her routine is obtaining blood sugars and administering insulin in the dining room; - He/She should obtain the blood sugars before the resident had their meal; - He/She should not check the blood sugars in the dining room or give the insulin in the dining room, should do it in the residents' rooms. During an interview on 5/30/24 at 3:03 P.M., the Director of Nursing (DON) said: - Staff should not obtain blood sugars in the dining room; - Staff should not administer insulin in the dining room.

Based on interviews and record review, the facility failed to act promptly and resolve resident grievances voiced during the resident council meetings and did not demonstrate a response and rationale for such response. The facility did not maintain documentation of resident concerns, attempts to resolve concerns or follow up actions. The facility census was 29. Review of facility policy, Resident Rights, dated 1/1/24, showed: -Be supported by the facility in exercising his or her rights; -Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility; -To voice grievances to facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; -Have the facility respond to his or her grievances; Review of the grievance policy, updated 1/1/24, showed: -Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance; -Grievances may be voiced in following forums: -Verbal complaint during resident or family council meetings. -Grievance officer will keep residents appropriately apprised of progress towards resolution of the grievances. 1. Review of the resident council meeting notes, dated 3/6/24, showed: -Old business: North residents moved to south end; -New Business: -Residents wanted van ride outing; -Residents wanting different variety for breakfasts like hash browns, shredded wheat cereal, breakfast gravy; -Residents wanted beef gravy on mechanical and pureed meat, not chicken gravy. -The resident council minutes did not indicate how issues were resolved, if it was discussed with the residents, or if resolution was satisfactory with the residents. The notes did not indicate what resident rights were reviewed or how the resident was supposed to report abuse and neglect. 2. Review of the resident council meeting notes, dated 4/9/24, showed: -Old business: nothing documented regarding issues from last meeting and how issues were being resolved. -New Business: -Residents noticed four new staff members and wanted each staff to introduce themselves so residents know who they are; -Residents did not like the chicken florentine, pork loin was always dry with no flavor and could not chew meat due to dryness. -Resident would like breakfast changed weekly to include western omelet, hash browns, breakfast burritos, and rice crispy cereal; -Resident said it was too loud during meal passes and when activities were done; -Residents wanted wooden furniture dusted in foyer, dining rooms, and windows cleaned at entrance daily; -Residents clothes were returning with stains; -Residents wanted to meet the fill in administrator. -The resident council notes did not indicate how the issues were resolved, if it was discussed with residents or if the resolution was satisfactory with the residents. The notes did not indicate what resident rights were reviewed or how the resident was supposed to report abuse and neglect. 3. Review of the resident council meeting notes, dated 5/2/24, showed: -Old business: -Issues from last meetings: Four new corporate team members in facility helping out; -How are issues being resolved: Residents are still getting to know each one of them. -New Business: -Activity director not having resident funds to purchase items they want; -Transportation not showing up to take residents to appointments at times; -Staff continue to be loud laughing and talking during activities in south dining room; -Residents would like window glass cleaned in south dining room; -Residents would like hallways sprayed to cut down on odors; -Residents wanted office door open so they could speak to main person. -The resident council notes did not indicate how the issues were resolved, if it was discussed with residents or if the resolution was satisfactory with the residents. The notes did not indicate what resident rights were reviewed or how the resident was supposed to report abuse and neglect. During resident council meeting on 5/28/24 at 10:54 A.M., Residents said: -Resident council meetings were held out of the blue; -Resident council did not have meetings in January and February; -Meetings were held in south dining room, were not private; -Resident rights were not reviewed during council meetings; -Residents were not notified with a response as a result of the council's recommendations made to the facility. During an interview on 5/28/24 at 6:21 A.M., Activities Director said: -He/She assisted with facilitation of resident council meetings; -He/She did not remember when he/she last educated residents about making grievances; -He/She had educated residents in the past during resident council about voicing grievances; -He/She did not have responses from administration regarding resident concerns voiced during resident council meetings. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -Residents should receive feedback in response to their recommendations and grievances.

Based on interviews the facility staff failed to ensure residents had access to their personal funds after business hours and on the weekend. The facility census was 29. The facility did not provide policy on funds access. Review of facility policy, Resident Rights, revised December 2016 showed: -Manage his or her personal funds, or have the facility manage his or her funds; During a group interview four of four residents said they did not have access to funds on weekends or after hours. During an interview on 5/29/24 at 10:06 A.M., Business Office Manager (BOM) said: -Residents have access to money as long as someone is in the office; -There is no access to money on weekends. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -Residents do not currently have access to funds on weekends or after business hours; -Residents should have access to money after business hours. During an interview on 5/30/24 at 3:03 P.M., Corporate Administrator said: -Residents did not have access to their personal funds after hours; -When residents want funds they make an effort to notify someone in business office about the need prior to the business office being closed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to establish and maintain a system that assured a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf when monthly personal funds reconciliation showed a negative balance and when the facility failed to reimburse residents' and/or their responsible parties after the residents were discharged which affected four of 12 residents (Resident #135, #136, #132, and #131). The facilities census was 29. 1. Review of facility monthly petty reconciliation logs showed: -[DATE] had negative petty cash ending balance of -302.23; -[DATE] had a negative petty cash ending balance of -61.88. Review of Interim Aged Analysis Summary, dated [DATE], showed: -Resident #135 (discharged [DATE]), had a negative balance of -1,190.66 in facility's operating account; -Resident #136 (discharged [DATE]), had a negative balance of -10.00 in facility's operating account; -Resident #132 (discharged [DATE]), had a negative balance of -16.00 in facility's operating account; -Resident #131 (discharged [DATE]), had a negative balance of -11,020.90 in facility's operating account. During an interview on [DATE] at 10:06 A.M., Business Office Manager said: -He/She had been in his/her position since end of [DATE]; -He/She was not working when negative balances were reflected on petty cash logs; -He/She believed balance showed negative when facility ran out of petty cash money; -He/She did not know where funds came from when balance was negative; -He/She notified Medicaid by filling out the form after resident passed away to determine if funds were owed back to Medicaid; -He/She then returned funds to resident's guardian when a resident discharged or passed away; -He/She did not know how long he/she had to return resident funds after discharge; -Resident #135, he/she did not know why resident had a balance; -Resident #136, he/she did not know why resident had a balance; -Resident #132 was deceased , he/she had issued a check to the resident but the Interim Aging report was not updated; -Resident #131 moved to another facility, he/she did not know why the resident had a balance but would check with accounting firm. During an interview on [DATE], Accounting Firm Consultant said: -Resident #131 discharged [DATE]; -Resident #131 did have credit on account from payments received on [DATE] and [DATE]; -Facility needed to check the accounts payable to see if funds were refunded to resident. During an interview on [DATE], Regional Administrator said: -There should be no negative accounting balances; -Funds should be returned within 30 days of discharge from the facility.

Based on observation, record review and interviews, the facility failed to ensure they informed residents of their rights periodically during residents' stay both orally and in writing. The facility census 29. Review of resident right's policy, revised December 2016, showed: -Be informed of his or her rights as a resident of the facility and as a resident or citizen of the United States; - The policy listed out all of the residents' rights; - The policy did not specifically indicate when these rights should be communicated with the residents. During a group interview on 5/28/24 at 10:54 A.M. four of four residents had not received education about their resident rights. Review of resident council meeting minutes showed: -3/6/24, no documentation that resident rights were reviewed; -4/9/24, no documentation that resident rights were reviewed; -5/2/24, no documentation that resident rights were reviewed. During an interview on 5/30/24 at 10:05 P.M., Activity Director said: -He/She facilitated resident council meetings; -He/She had not gone over resident rights during resident council meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to clarify the status of the advanced directives (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury) for one of 12 sampled residents, (Resident #16). The facility census was 29. Review of the facility's policy for advance directives, revised December 2016, showed, in part: - Advance directives will be respected in accordance with state law and facility policy; - Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he/she chooses to do so; - If the resident is incapacitated and unable to receive information about his/her right to formulate an advance directive, the information may be provided to the resident's legal representative; - If the resident becomes able to receive and understand this information later, he/she will be provided with the he same written materials as described above, even if his/her legal representative has already been given the information; - Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his/her legal representative, about the existence of any written advance directives; - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; - If the resident indicates that he/she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident' s decision to accept or decline assistance; - The plan of care for each resident will be consistent with his/her documented treatment preferences and/or advance directive; - The Interdisciplinary Team will conduct ongoing review of the resident's decision making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record; - The Interdisciplinary Team will review annually with the resident, his/her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS, a federally mandated assessment instrument completed by facility staff); - Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan; - The Director of Nursing (DON) or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. 1. Review of Resident #16's care plan, initiated 9/14/23 showed: - Discharge planning - the resident is a Do Not Resuscitate. The resident's father is his/her Durable Power of Attorney (DPOA, a legal document that gives someone the authority to make decisions for another person, even if that person becomes incapacitated); - The resident's father has no plans to discharge him/her from the facility. Review of the resident's Quarterly MDS dated [DATE] showed: - Cognitive skills severely impaired; - Dependent on the staff for oral hygiene, toilet use, showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included non - traumatic spinal cord dysfunction (any damage to the spinal cord that has not been caused by a major trauma) and cerebral palsy (CP, a neurological disorder caused by a non - progressive brain injury or malformation that occurs while the child's brain is under development). Review of the resident's physician order sheet (POS) dated May 2024, showed: - Start date: 9/27/23 - Do Not Resuscitate; - Start dated: 9/14/23- Full code. Review of the resident's face sheet showed the resident was a Do Not Resuscitate. During an interview on 5/30/24 at 3:03 P.M., the Administrator and the DON said: - They fixed the POS today; - The staff should follow the most current order date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN) (the form Centers for Medicare and Medicaid (CMS) - 10055 to each resident. The SNF ABN provides information to residents/beneficiaries so they can decide if they wish to continue receiving the skilled services that may not be paid by Medicare and assume financial responsibilities. The facility used the incorrect form for three of 12 sampled residents, (Resident #27, #28 and #83). The facility census was 29. Review of the facility's policy for advance beneficiary notices, reviewed [DATE], showed, in part: - It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage; - The Business Office Manager (BOM) is the contact person for the information regarding Medicare eligibility, coverage, and applying for benefits. A notice alerting residents/representatives of this contact person shall be posted conspicuously in the facility; - The current CMS - approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form; - For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), form CMS - 10055; - For Part B items and services, the facility shall use the Advance Beneficiary Notice of Non-Coverage (ABN), Form CMS-R-131; - A Notice of Medicare Non-Coverage (NOMNC), Form CMS - 10123, shall be issued tot he resident/representative when Medicare covered services(s) are ending, no matter if resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization (QIO); - When a QIO notifies the facility of a beneficiary request for an expedited determination, a Detailed Explanation of Non-Coverage (DENC) shall be issued to the resident/representative; - To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending; - The Business Office Manager (BOM), or designee, is responsible for issuing notices; - The BOM shall maintain a log of notices that have been provided. 1. Review of Resident #27's medical records showed: - Notice of NOMNC CMS -10123 (expired [DATE]) provided and signed on [DATE]; - Used ABN form CMS - R - 131 (expired 3/2020) dated [DATE]; - No documentation of SNF ABN CMS - 10055 form provided by the facility. 2. Review of Resident #28's medical records showed: - Notice of NOMNC CMS - 10123 (expired [DATE]) provided and signed on [DATE]; - Used ABN form CMS - R - 131 (expired [DATE]) dated [DATE]; - No documentation of SNF ABN CMS - 10055 form provided by the facility. 3. Review of Resident #83's medical records showed: - Used a Notice of Medicare Non - Coverage form which did not have a CMS number. Did not use the correct form for Notice of NOMNC CMS - 10123; - Used a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form and did not use the correct form for SNF ABN CMS - 10055. During an interview on [DATE] at 3:03 P.M., the Administrator said: - She should have used the correct forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to maintain a clean, comfortable, and homelike environment when the facility failed to maintain comfortable temperatures through out the facility, clean floors, replace chipped and broken tiles, replace hand sanitizer dispensers in resident rooms, replace broken or missing blinds, sand and paint drywall patches, repair scraped and missing paint from walls, and did not clean dust and cobwebs in facility. This affected all residents in the facility. The facility census was 29. Review of facility policy, Safe and Homelike Environment, reviewed 1/1/24, showed: -In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. -Comfortable and safe temperature levels means that the ambient temperature should be relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for residents. -Environment refers to any environment in the facility that is frequented by residents, including (but not limited to), the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. -Housekeeping and maintenance service will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. -The facility should strive to keep the temperature in common resident areas between 68 and 81 degrees Fahrenheit. -The facility will maintain comfortable sound levels in the facility. -Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to Housekeeping Department. -Maintain minimal use of alarms, using alternative interventions, unless otherwise indicated by the care plan. -Report any furniture in disrepair to Maintenance promptly. Review of resident council minutes showed: -On 3/6/24 residents said dust in south dining room and front entrance needed cleaned and ice salt needed cleaned from the front and back door, no resolution found on 4/9/24 minutes. -On 4/9/24, residents said wooden furniture in foyer and both dining rooms needed dusted, glass windows needed cleaned, no resolution found on 5/2/24 minutes. -On 5/2/24, residents said widow glass needed cleaned in dining room, hallways needed sprayed to cut down on odors. Observation on 5/27/24 at 8:38 A.M., showed temperature of south dining room [ROOM NUMBER].5 degrees, thermometer reading showed 67 degrees. Multiple residents wearing blankets and coats in dining room. Observation on 5/27/24 at 8:40 A.M. showed sand bags blocking the exit door at end of the hall by the chapel. Observation on 5/27/24 at 8:45 A.M., of chapel room showed cobwebs hanging from window ledges, light fixture, corner of the room, and ceiling. Observation on 5/27/24 at 10:42 A.M. showed room [ROOM NUMBER]'s bathroom fan had dust caked to the fan coils. Observation on 5/27/24 at 10:49 A.M. showed room [ROOM NUMBER]'s bathroom fan had dust caked to the fan coils. Hand sanitizer in room had no hand sanitizer in dispenser. Observation on 5/27/24 at 10:59 A.M., showed room [ROOM NUMBER]'s bathroom fan had dust caked to fan coils. Toilet seat had feces sitting on it. Hand sanitizer in the room was empty with no hand sanitizer in dispenser. Observation on 5/27/24 at 2:49 P.M., showed room [ROOM NUMBER]'s bathroom fan had dust caked to fan coils. Hand sanitizer dispenser in room was empty with no hand sanitizer. Observation on 5/29/24 at 5:21 A.M., showed Licensed Practical Nurse (LPN) C spraying a can of citrus deodorizer spray in hallway by room [ROOM NUMBER]. Observation on 5/29/24 at 3:30 P.M. showed strong odors of feces in hallway between room [ROOM NUMBER]-room [ROOM NUMBER]. Observation on 5/30/24 at 12:50 P.M., showed fabric worn away from headrest of the recliner in room [ROOM NUMBER]. Observation on 5/30/24 at 12:55 P.M. showed on north hall dining room: -Chair rail had missing paint with white shining through brown varnish near the doorway leading to a closed off hall; -Curtain rod in the south window was bent and leaning downwards; -Paint was peeling from window sills in the dining room; -Wood had rotted areas around the window in the dining room; -Blinds were missing on three windows in the dining room; -Floors had brown spilled drink stains. Observation on 5/30/24 at 12:58 P.M., showed north hall resident rooms: -No blind on the window at the end of the hall by resident room [ROOM NUMBER]; -Paint chipping off of the window sill and rust coming through window by exit door near room [ROOM NUMBER]; -Tile was chipped and missing near room [ROOM NUMBER]; -Ceiling air returns were caked with dust. Observation on 5/30/24 at 1:01 P.M., showed dry wall had been patched between rooms #25 and #27 and was not sanded or painted. Observation on 5/30/24 at 1:03 P.M., baseboard heating units along walls throughout the facility were caked with dust. Observation on 5/30/24 at 1:04 P.M., area where dry wall had been patched near the dirty utility room was not sanded or painted. Observation on 5/30/24 at 1:05 P.M., south dining room showed four ceiling vents had dirt caked on units and area on ceilings around units. Observation on 5/30/24 at 1:06 P.M., showed strong odor of feces in hallway by rooms #22-#26. Observation on 5/30/24 at 1:08 P.M., showed floor tile cracked by exit door at room [ROOM NUMBER] and floor tile chipped by room [ROOM NUMBER]. During an interview on 5/27/24 at 8:40 A.M., LPN A said facility had water coming into the building through the door when it rained really heavy. During an interview on 5/30/24 at 11:58 A.M., Housekeeping Supervisor said: -He/She did not have refills for hand sanitizer dispensers that would fit dispensers on wall units. During an interview on 5/30/24 at 1:10 P.M., Housekeeping Aide A said: -Facility had issues getting sanitizer in that fits the dispenser wall units; -The supplier discontinued the proper refills that fit the units on wall in memory care. During an interview on 5/30/24 at 1:32 P.M., Housekeeping Aide C said: -Maintenance was responsible for cleaning vent fans and ceilings. During an interview on 5/30/24 at 1:41 P.M., Maintenance Supervisor said: -He/She was responsible for cleaning fans in the ceilings and vent returns; -He/She checked and cleaned return vents and units once a month with a feather dust; -Blinds should be in proper working order; -He/She did not have blinds on hand to replace broken blinds in facility; -Sandbags were in place to keep the rain from coming in the door from the hay field; -He/She was responsible for replacing broken floor tiles; -He/She became aware of broken items by reviewing maintenance logs at each nurses station; -He/She checked the maintenance logs daily; -He/She cleaned out wall heating units with a vacuum once a year; -Housekeeping was responsible for cleaning wall heating units. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -He/She expected to provide a safe, clean, and homelike environment to residents; -He/She expected broken tiles to be replaced; -He/She expected heating units, vent fans, vent returns, windows to be free of dust and cobwebs; -He/She expected drywall patches to be sanded and painted; -He/She expected missing blinds to be replaced; -He/She expected missing paint spots to be repainted; -He/She expected the facility to be free of odors; -He/She expected curtain rods to be replaced if they were broken or bent; -He/She expected floors to be cleaned and mopped.

Based on observations, interviews, and record review, the facility failed to assure residents have the right to file grievances in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievances, the right to obtain a written decision regarding his or her grievance. This had the ability to affect all residents. The facility census was 29 Review of facility policy, Resident and Family Grievances, reviewed 1/1/24, showed: -Grievances may be voiced in following forums: -Verbal complaint to a staff member or grievance official; -Written complaint to a staff member or grievance official; -Written complaint to an outside party; -Information on how to file a grievance or complaint will be available to the resident. Information may include but is not limited to: a. Contact information of the grievance official with who a grievance can be filed, including his or her name, business address (mailing and email) and business phone number. b. The contact information of independent entities with whom grievances may be filed, that is pertinent to state agency, quality improvement organization, state survey agency, and state long-term care ombudsman program or protection and advocacy system. c. The time frame that a resident may reasonable expect completion of the review of the grievance and a written decision regarding his or her grievance. -Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or grievance official. b. Written complaint to a staff member or grievance official. c. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings. -A grievance may be filed anonymously. During a group interview on 5/28/24 at 10:54 A.M. four of four residents stated they did not know how to complete a grievance, did not have access to grievance forms, could not make anonymous grievances, and did not know who grievance officer for the facility was. Observation on 5/28/24 at 1:30 P.M. showed no grievance forms were available to residents or their families in the facility. During an interview on 5/30/24 at 11:22 A.M., Licensed Practical Nurse (LPN) A said: -There was a form that individuals can fill out regarding grievances; -If anyone makes a complaint staff are to offer them a grievance form and offer to assist the resident or family in filling out the form; -Grievance forms are located in the employee break room; -Residents are not allowed in the employee break room, and could not access the forms. During an interview on 5/30/24 at 12:03 P.M., Administrator said: -Grievance forms are located at the nurses station; -Residents or their families can request a grievance form; -Residents or families could not access a grievance form without asking staff for one. During an interview on 5/30/24 at 12:10 P.M., Certified Nurse Aide (CNA) C said: -Facility had grievance forms that could be filled out; -Grievance forms were located in a file cabinet, but they were not accessible to residents or their families; -He/She did not know who was currently grievance officer of the facility as previous grievance officer was no longer employed at facility; -He/She did not know how residents or families could submit an anonymous grievance; -Staff can fill out the grievance form for the resident or their families and just leave names off of the form. During an interview on 5/30/24 at 12:13 P.M., CNA D said: -There are grievance forms located at the nurses station desk for residents or their families; -The resident or their family members have to go to a nurse or other staff member to request a form; -He/She was not sure of their was a way for residents or their families to make anonymous complaints. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -He/She did not have grievance forms posted and accessible to residents or their families; -Residents and their families should have access to forms to make a facility grievance; -Residents and their families should have a means of reporting grievances anonymously.

Based on record review and interview, the facility staff failed to implement their Abuse and Neglect policy when they failed to complete employee background checks prior to staff working with residents, failed to complete employee disqualification list (EDL) checks, and failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected eight of ten sampled staff (Licensed Pratical Nurse (LPN) C, Housekeeping Aide (HA) B, Nurse Aide (NA) A, Certified Nurse Assistant (CNA) F, HA A, Registered Nurse (RN) A, Dietary Aide C, and CNA B). The facility census was 29. Review of facility Policy, Abuse and Neglect, reviewed 1/31/24, showed: -It was the policty of the facility top provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. -Potential employees will be screen for a hsitory of abuse, neglect, exploitation, or misappropriation of resident property. -Background, reference, and creditial checks shall be completed on potential employees, contracted temporary staff, students afiliated with academic institutions, volunteers, and consultants. -Screenings may be conducted by the facility itself, third-party agency, or academic institution. -The facility will maintain documentation of proof that the screening occurred. Review of facility policy, updated 1/1/24, showed: -Facility conducted employment background screening checks, reference checks, and criminal conviction investigation checks on all applications for positions with direct access to residents. -The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment. -For an individual applying for a position as a Certified Nursing Assistant, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicants file. 1. Review of LPN C employee file, showed: -Employee hired on 5/6/24 -Family Care Registry check was received 5/28/24, after date of hire; -Criminal background check was requested 5/20/24; -EDL was not checked. 2. Review of HA B, showed: -Employee hired on 3/6/24; -Certified Nurse Aide Registry was not checked; 3. Review of NA A employee file, showed: -Employee hired 3/25/24; -Family Care Registry check completed 5/28/24, after date of hire; 4. Review of CNA F's employee file showed: -Employee hired 2/16/23 -His/Her Family Care Registry was completed 5/28/24, three months after hire date; 5. Review of HA A's employee file showed: -Employee hired 3/25/24; -CNA registry had not been checked; -EDL had not been checked; 6. Review of RN A's employee file showed: -Employee hired 5/15/24; -No EDL checked; -No Nurse Aide registry checked; 7. Review of DA C's employee file showed: -Employee hired 2/1/23, -No EDL check; -No nurse aide registry check 8. Review of CNA B's employee file showed: -Employee hired 5/9/24; -No EDL check; -Family care registry check completed 5/28/24; -Criminal background check received 5/14/24, six days after date of hire. During an interview on 5/29/24 at 1:55 P.M., Business Office Manager (BOM) said: -He/She started in BOM position in March; -He/She did not have access to run employee disqualification list checks; -Background checks should be completed prior to hire for employees; -He/She submits back page of employee application for background checks; -He/She did not have access to complete Family Care Registry checks; -He/She checked employee disqualificaiton list checks by running social security numbers; -Nurse aide registry should be checked for all employees; -CNA E never started employment; -LPN A started 5/6/24 and participated in orientation day but did not work the floor; -HA B worked in facility from 3/6/24 to 3/24/24; -NA A worked in facility one shift on 3/29/24; -CNA E never started his/her employment with facility. During an interview on 5/30/24 at 3:03 P.M., Corporate Administrator said: -Background checks should be completed upon hire and prior to staff coming to work at facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure accurate comprehensive assessments were completed accurately on the minimum data set (MDS) for two of 12 sampled residents (Resident #3 and #14 ) when no preferences for customary routine and activities was obtained through resident, family, or staff interviews. The facility census was 29. Facility did not provide a policy on comprehensive assessments. Review of facility policy, activities, updated 4/1/24, showed: -Each resident's interest and needs will be assessed on a routine basis. The assessment shall include, but is not limited to: a. Resident Assessment Instrument (RAI) Process: MDS/Care Area Assessment (CAA)/Care Plan; b. Activity assessment to include resident's interest, preferences, and needed adaptations; c. Social history. Review of facility policy, care plans comprehensive person-centered, updated 1/1/24, showed: -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 1.Review of Resident #3's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/14/24, showed: -He/She was severely impaired and never/rarely made decisions; -No customary activity preferences indicated in MDS, family, significant other, or staff were not interviewed regarding resident's daily and activity preferences; Diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone, or posture which include symptoms of exaggerated reflexes, floppy or rigid limbs, and involuntary motions) diabetes (too much sugar in the blood), seizure disorder, and pain Review of care plan, revised 5/4/23, showed: Resident had no involvement in activities due to cognitive impairment. He/She could make disruptive noises at times; -He/She would have daily one-on-one with activity aide; -He/She participated in aromatherapy; -He/She listened to audio books in his/her room; -He/She seemed to like listening to music; -Document resident's response to interventions as needed; -If he/she is in activity room and a movie is playing, you can turn the lights off so it is dark and quiet like a movie theatre; -If He/She seemed to be overstimulated by surroundings, remove him from the area to a more quiet environment; -Monitor Him/Her for any signs and symptoms of pain or discomfort and report to charge nurse if noted; -Offer fluids or snacks if he/she continued to make noises-check for incontinence as well; -Provide one-on-one visits in a quiet location when he/she was unable to tolerate group activities setting; -Staff to always address him/her by name; -Staff to always introduce themselves to him/her with each contact; -Supervise him/her in all activity areas. Review of daily activity sheets from 1/1/24 to 5/28/24 showed: -Resident was engaged in activities on 3 of 147 days for opportunities; -Resident was involved in only 3 activities including men's trim 2 times and one musical entertainment. -4/3/24, Documented resident did participate in one on one activity but did not say what he/she participated in. -4/8/24, resident included in men's trim. -No activity logs for May were provided. 2. Review of Resident #14's annual MDS, dated [DATE], showed: -He/She had severely impaired cognition; -Preferences for customary routine and activities showed no response, interview was not completed with resident's family, significant other, or staff regarding resident's daily or activity preferences; -Care area triggered included activities -Diagnoses included dementia (group of conditions characterized by impairment of at least two brain functions such as memory, laungauge, problem solving skills), anxiety disorder, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), need for assistance with personal care, unsteadiness on feet, generalized muscle weakness, repeated falls, limitation of activities due to disability Review of care plan, revised 3/16/23, showed: -Resident had little or no activity involvement due to anxiety, depression, disinterest; -Resident will participate in activities of choice at least one time per week through the next 90 days; -Activities to visit with me one-on-one daily; -Assess for changes in mood status as needed; -Assist resident to the activity room throughout the day if he/she is wandering around the unit; -Establish and record resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary; -It is difficult to keep resident sitting down for activities, if staff sit with him/her, he/she will usually be able to complete the activity; -Resident ambulated throughout the unit during the day. He/she often does not like to sit down. He/she gets plenty of exercise each day; -Resident enjoyed coloring, one-on-one visits, listening to music, watching TV and snack time; -Resident enjoyed crafts, listening to music and attending parties/snack time; -Resident has a nervous presence about his/her, this is his/her normal state; -Resident seemed to enjoy attending BINGO, assist him/her to this activity; -Resident's family calls and talks to him/her on the phone. Assist him/her to the phone when they call; -When the weather is nice assist resident outside to sit for a little while if he/she would like to, resident also enjoyed gardening with activity staff. During an interview on 5/29/24 at 6:21 A.M., Activity Director said: -He/She had been activity director since 2017; -He/She did not have any certifications; -He/She develops plan for resident activities by trying to figure out what residents like; -He/She tried to get feedback from residents or their families to find out what activities residents enjoyed doing; -He/She assisted in care planning process by sitting in on meetings; -His/Her role in care planning process was being on care plan team; -Facility had not had care meeting since administration changes in facility; -Facility had no MDS Coordinator. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -He/She expected family, significant others, or staff to be interviewed during the comprehensive assessments regarding a resident's daily preferences and activities when residents was unable to communicate in assessment process.

2. Review of Resident #14's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/5/24, showed: -He/She had severely impaired cognition; -He/She was dependent for oral hygiene, toileting, bathing, personal hygiene -Care areas triggered included: Delirium, cognitive loss/dementia, communication, urinary incontinence, psychosocial well-being, behavioral symptoms, activities, falls, nutritional status, pressure ulcer, psychotropic drug use; -He/She took an antipsychotic, antianxiety, and antidepressant medication; -Pre-admisson screening showed resident had not been evaluated by Level II PASRR and determined to have a serious mental illness and /or mental retardation or a related condition -admission occurred 3/3/2020, when he/she admitted from another long term care facility; -Diagnoses included unspecified dementia (loss of memory, langauge, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), anxiety disorder, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly Review of resident's medical record showed: -admission date of 3/3/20; -Payer source -primary-Medicaid, secondary -resident surplus, and third-Medicare B; -No level 1 PASARR was located in the resident's medical record. Review of care plan, revised 5/24/23, showed: -Resident had delirium due to dementia and schizophrenia; -Resident was at risk for falls due to confusion, incontinence, psychoactive drug use, unaware of safety needs; -Resident used psychotropic medications antipsychotic, antianxiety, and antidepressant due to dementia, behavior management, anxiety, depression, and schizophrenia During an interview on 5/30/24 at 9:03 A.M., Central Office Medical Review Unit (COMRU) said: -Resident had a Level 1 PASARR completed 2/11/20 by another facility; -He/She did not trigger for a level 2 PASARR. During an interview on 5/30/24 at 1:34 P.M., Administrator said: -He/She had reached out to COMRU regarding resident's PASARR; -Resident did not have one completed PASARR; -He/She would start a PASARR. Based on interview and record review, the facility failed to ensure staff completed a Level 1 (indicated for any individual who may have an intellectual disability (ID), developmental disability (DD), or mental illness (MI) PASARR (Pre-admission Screening for Mental Illness/Mental Retardation or related condition) prior to admission to the facility. This affected two of 12 sampled residents, (Resident #14 and #26). The facility census was 29. Review of the facility's policy for resident assessment -coordination with PASARR program, dated 2023, showed, in part: - This facility coordinates assessments with the pre-admission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs; - All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening; - PASARR Level 1- initial pre-screening that is completed prior to admission. Negative Level 1 Screen- permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. Positive Level I Screen- necessitates a PASARR Level II evaluation prior to admission; - PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs; - A record of the pre-screening shall be maintained in the resident's medical record; - The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. 1. Review of Resident #26's medical record showed: - Payer source: Hospice (end of life care) Medicaid, resident surplus and medicare; - Diagnosis included unspecified psychosis not due to a substance or known physiological condition; - admission date: 12/16/22. Review of the resident's Level I nursing facility pre-admission screening for mental illness/mental retardation or related conditions, dated 2/2/23 showed: - Section D: Level One Screening Criteria for Serious Mental Illness: staff documented the resident did not show any signs or symptoms of a major metal illness; did not have a current, suspected, or history of a major mental illness as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM); - It was not signed and did not indicate what level of care the resident required. Review of the resident's medical record showed: - Payer source: Hospice (end of life care) Medicaid, resident surplus and medicare; - Diagnosis included unspecified psychosis not due to a substance or known physiological condition; - admission date: 12/16/22. Review of the resident's care plan, revised 1/9/23 showed: - The resident was at risk for adverse reaction related to antipsychotic medication (type of psychiatric medication which are available on prescription to treat psychosis); - Give medication as ordered by the physician; - Monitor for possible sings and symptoms of adverse drug reactions (falls, weight loss, fatigue, incontinence, agitation, lethargy, confusion, depression, poor appetite, constipation and gastric upset as needed); - Review the Pharmacy consult recommendations and follow up as indicated. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/29/24 showed: - Cognitive skills intact; - Required set up and clean up with eating; - Required substantial to maximal assistance from staff for oral hygiene, toilet hygiene, dressing, personal hygiene, and transfers; - Frequently incontinent of bowel and bladder; - The resident took antipsychotic medications on a routine basis; - On 12/5/23 a gradual dose reduction of antipsychotic medications was documented as contraindicated by the physician. Review of the resident's physician order sheet (POS) dated May 2024, showed: - Order date: 2/5/24 - Quetipaine Fumarate 50 milligrams (mgs.) one tablet in the evening related to unspecified psychosis not due to a substance or known physiological condition. During an interview on 5/30/24 at 3:03 P.M., the Director of Nursing (DON) said it was the responsibility of Social Services to correctly fill out the PASARRs. The Administrator is currently filling in as Social Services and they are training another staff member to be the Social Services Designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #25's Annual MDS, dated [DATE], showed: -He/She was severely cognitively impaired; -Diagnoses included: non-traumatic brain dysfunction, dementia, anxiety disorder, depression, psychotic disorder. Review of care plan, dated 1/19/24, showed: -Advance directive was not care planned. Review of physician's orders, dated 5/28/24, showed: -Resident was a full code. Review of electronic medical record showed: -Resident was a full code. During an interview on 5/28/24 at 3:13 P.M., Certified Nurse Aide (CNA) C said: -He/She knew residents code status by looking at sticker on door or electronic medical record. 3. Review of Resident #29's admission MDS, dated [DATE], showed: -He/She admitted [DATE]; -He/She had severe cognitive impairment; -He/She had impairments to both sides of upper extremities; -He/She was dependent on a walker; -He/She was independent with mobility; -Bed rail not used; -Diagnoses included: generalized muscle weakness, difficulty in walking, need for assistance with personal care, and repeated falls. Review of care plan, dated 5/4/24, showed: -Resident was independent with bed mobility; -Side rail or assist bar was not addressed in care plan. Review of physician's orders, dated 5/28/24, showed: -no order for side rail or assist bar. Review of electronic medical record showed: -4/1/24 a bed rail assessment was completed showed that there was no recommendation for side rail placement and a side rail or assist bar was not indicated at that time. Review of monthly device schedule showed resident's room was not included in zone measurements for side rail entrapment. Observation on 5/27/24 at 10:48 A.M. showed resident had a u-shaped rail on left side of bed that was pushed up against the wall. During an interview on 5/28/24 at 3:13 P.M., CNA C said: -Resident's bed was turned a different direction and resident used to use cane rail to get in and out of bed. During an interview on 5/29/24 at 7:53 A.M., CNA D said: -Resident had side rails on his/her bed just because the bed already had them on when he/she moved in; -He/She was not a fall risk. 4. During an interview on 5/29/24 at 5:58 A.M., CNA G said: -He/She looked in residents electronic medical record to know resident specific cares or asks charge nurse; During an interview on 5/29/24 at 6:21 A.M., Activities Director said: -He/She had not participated in care plan meetings since administration changes; -Care plan meetings had not been happening since administration changes; -His/Her role in care planning process was to meet with care plan team and learn more information about the residents. -Facility did not currently have a social services or MDS coordinator. During an interview on 5/29/24 at 7:53 A.M., CNA D said: -He/She did have access to read resident's care plan; -He/She learned resident specific cares from his/her orientation and from reports made during shift change. Based on observations, interviews and record review, the facility failed to ensure they developed and implemented a comprehensive person - centered plan of care which included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for four of 12 sampled residents, (Resident #25, #29 and #81). The facility census was 29. Review of the facility's policy for comprehensive person - centered care plans, revised December 2016, showed, in part: - A comprehensive, person - centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person - centered care plan for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The care planning process will: facilitate resident and /or representative involvement; include an assessment of the resident's strengths and needs; - The person - centered care plan will: include measurable objectives and timeframes; describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well - being; incorporate identified problem areas; incorporate risk factors associated with identified problems; build on on the resident's strengths; - Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan; - The comprehensive, person - centered care plan is developed within seven days of the completion of the required comprehensive assessment; - Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change; - The IDT must review and update the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessment. 1. Review of Resident #81's face sheet showed: - 5/23/24- admission date. - Diagnosis of congestive heart failure. Observation on 5/27/24 at 9:48 A.M., showed: - The resident was in his/her recliner with feet elevated; - Had oxygen on at three liters per nasal cannula (3L/NC). Review of the resident's medical chart on 5/27/24 showed the care plan did not address the use of oxygen. Review of the resident's physician order sheet (POS) dated May 2024 showed: - Start date: 5/23/24 - Oxygen at 2L/NC. May use two to four liters continuously to keep oxygen saturation (amount of oxygen in the blood) greater than 90%. Review of the resident's care plan, revised on 5/28/24 showed: - The resident had congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body); - Oxygen settings: 2L/NC. During an interview on 5/30/24 at 9:29 A.M., the Director of Nursing (DON) said: - She has covered the MDS/Care Plan position since 3/1/24; - Care plans should address the use of oxygen. During an interview on 5/30/24 at 10:14 A.M., Licensed Practical Nurse (LPN) B said: - The care plans should address the use of oxygen. During an interview on 5/30/24 at 3:03 P.M., the Administrator and DON said; - Care plans should be updated quarterly and with significant changes and as needed; - The care plans can be updated by the IDT, Social Services, nurses, MDS and Activity Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #29's admission minimum data set (MDS) dated [DATE], showed: -He/She had a Brief Interview Mental Status (BIMS) score of 2, showed resident had severe cognitive impairment; -He/She had impairments to both sides of upper extremities; -He/She was dependent on a walker; -He/She required set up or clean up assistance with eating; -He/She required substantial/maximal assistance with oral hygiene; -He/She was dependent for toileting, putting on shoes, and personal hygiene; -He/She required partial/moderate assistance with bathing, upper, and lower body dressing; -He/She was independent with mobility; -Bed rail not used; Diagnoses included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior., repeated falls, generalized muscle weakness, need for assistance with personal care, and difficulty in walking. Review of care plan, dated 5/4/24, showed: -Resident was independent with bed mobility. Review of physician's orders, dated 5/28/24, showed: -No order for side rail or assist bar. Observation on 5/27/24 at 10:48 A.M. showed a u-shaped cane rail on left side of bed pushed up against the wall. During an interview on 5/28/24 at 3:13 P.M., Certified Nurse Aide (CNA) C said: -He/She did not know why resident had a side rails; -He/She thought resident's bed had been facing the other direction so resident could utilize his/her side rail. During an interview on 5/29/24 at 7:53 A.M., CNA D said: -Resident had a side rail on his/her bed just because the bed already had a side rail on it; -Resident was not a fall risk. During an interview on 5/30/24 at 3:03 P.M., Director of Nursing (DON) said: -Physician's orders were needed for side rails or assist bars During an interview on 5/30/24 at 3:03 P.M., Administrator said: -Side rail or assist bars should have physician's orders. 5. Review of Resident #24's Quarterly MDS, dated [DATE], showed: -He/She had severe cognitive impairment; -He/She was dependent on a wheelchair; -He/She was always incontinent of bowel and bladder; -Resident had a stage 1 or greater pressure ulcer (observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence; may include changes in skin temperature, tissue consistency and/or sensation); -Resident was at risk of pressure ulcers and had unhealed pressure ulcers; -He/She had one, stage 3 pressure ulcers (full thickness tissue loss), he/she had zero pressure ulcers upon admission; -He/She had pressure reducing device for chair and for bed; -He/She received pressure ulcer care; -He/She had application of dressings to feet -Diagnoses included: diabetes (too much sugar in the blood), pressure ulcer of left heel, stage 3, and need for assistance with personal care. Review of care plan, dated 1/27/23, showed: -He/She required skin inspection daily during cares; -He/She had pressure ulcers to both heels; -Charge nurse to assess skin weekly per Treatment Administration Record (TAR); -Follow facility protocols for the prevention/treatment of skin breakdown; -Resident has potential to be socially inappropriate/disruptive due to dementia; -Monitor and document target behaviors; -Administer medications as ordered. Monitor/document side effects and effectiveness; -Resident used psychotropic medications due to anxiety disorder, psychosis, and depression;; -Monitor/document/report as needed any adverse reactions to psychotropic therapy; -Monitor/record occurrence of target behavior symptoms Review of physician's orders, dated 5/28/24, showed: -Ordered 1/7/24, weekly skin assessment Fridays-day shift, every day shift on Friday; -Ordered 11/16/23, Observe closely for side effects of antipsychotic medication, every shift; -Ordered 1/17/24, Observe closely for side effects of diuretic medication, every shift; -Ordered 11/16/23, Observe closely for significant side effects of anti-anxiety medication, every shift; -Ordered 11/16/23, Observe for significant side effects of anti-depressant medication, every shift; -Ordered 1/17/24, Observe closely for significant side effects of anticoagulant medication, every shift -Ordered 11/2/23, Observe pain monitoring - assess for pain, every shift; -Ordered 11/8/23, Resident did not display anxious behaviors, if behavior observed, document in progress note, every shift; -Ordered 11/8/23, Resident did not display depressive behaviors, if behavior observed, document in progress note, every shift; -Ordered 10/17/23, Resident did not display psychotic behaviors, if behavior observed, document in progress note, every shift; Review of TAR, dated 5/1/24 to 5/28/24, showed: -Order started 1/12/24 at 6:00 A.M., weekly skin assessment Fridays, showed no entry on 5/17; Review of Licensed Nurse Record, dated 5/1/24 to 5/28/24, showed: -Observe closely for significant side effects of anti-anxiety medication showed no entry on day shift on 5/1, 5/6, 5/11, 5/17, 5/18, and 5/27; -Observe closely for significant side effects of anticoagulant medication, showed no entry on day shift on 5/1, 5/6, 5/11, 5/17, 5/18, and 5/27; -Observe closely for significant side effects of anti-depressant, showed no entry on day shift on 5/1, 5/6, 5/11, 5/17, 5/18, and 5/27; -Pain monitoring - assess for pain every shift, showed no entry on say shift on 5/1, 5/6, 5/11, 5/17, 5/18, and 5/27; -Resident did not display anxious behaviors, showed no entry on day shift on 5/1, 5/6, 5/11, 5/17, 5/18, and 5/27; -Resident did not display depressive behaviors, showed no entry on day shift on 5/1, 5/6, 5/11, 5/17, 5/18, and 5/27; -Resident did not display psychotic behaviors, showed no entry on day shift on 5/1, 5/6, 5/11, 5/17, 5/18, and 5/27. During an interview on 5/30/24 at 11:22 A.M., Licensed Practical Nurse (LPN) A said: -There should not be any blanks on the Medication Administration Record or TARS; -There had been several days there was no Internet service for hours so the medication administration system went down; -He/She could not get medications; -He/She was aware of two days where TARS were not completed because he/she did not have access to get online to complete entries into electronic medical record. During an interview on 5/30/24 at 3:03 P.M., Director of Nursing (DON) said: -There should be no blanks in the MARS or TARS; -A blank entry indicates the medication or treatment was not done. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -There should be no blanks in the MARS or TARS' -If there is no entry on the MAR or TAR it indicates the treatment or medication was not given. Based on observations, interviews and record review, the facility failed to ensure staff followed professional standards when staff failed to obtain a order to check blood sugars for two of 12 sampled residents, (Resident #12 and #24), failed to ensure the low air loss mattress (medical mattress designed to prevent and treat pressure ulcers (PU, an area of localized damage to skin and underlying tissue caused by pressure, shear, friction and/or a combination of these) settings were correct for Resident #16. and additionally failed to obtain a physician's order for a side rail ( assistive device used to assist resident to reposition in bed) for Resident #29. The staff failed to ensure documentation was completed for medications and treatments for Resident #24. The facility census was 29. Review of the facility's policy for medication and treatment orders, revised July 2016, showed, in part: - Orders for medications and treatments will be consistent with principles of safe and effective order writing; - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications; - Drug and biological orders must be recorded on the physician's order sheet (POS) in the resident's chart; - Orders for medications must include: name and strength of the drug; number of doses, start and stop date, and/or specific duration of therapy; dosage and frequency of administration; and clinical condition or symptoms for which the medication is prescribed; - Orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders. Review of the undated manufacturer's guidelines for the drive low air loss mattress showed: - It is recommended that the pressure - selector knob set to firm or press auto firm on the touch panel each time the mattress is first inflated; - Users can then easily adjust the air mattress to a desired firmness according to the resident's weight. 1. Review of Resident #16's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/22/24 showed: - Cognitive skills severely impaired; - Dependent on the staff for oral hygiene, toilet use, showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included non - traumatic spinal cord dysfunction (any damage to the spinal cord that has not been caused by a major trauma), cerebral palsy (CP, a neurological disorder caused by a non - progressive brain injury or malformation that occurs while the child's brain is under development), anxiety and depression. Observation on 5/27/24 at 8:52 A.M., showed: - The resident was in bed laying on a a low air loss mattress (medical mattress designed to prevent and treat pressure ulcers (PU, an area of localized damage to skin and underlying tissue caused by pressure, shear, friction and/or a combination of these) on the skin); - The Drive brand of low air loss mattress showed the setting for the resident's weight was 300 pounds. Review of the resident's medical chart on 5/27/24 at 3:08 P.M., showed the following weights for the resident: - 5/8/2024 10:41 74.0 Lbs Wheelchair (Manual) - 5/4/2024 15:31 76.0 Lbs Wheelchair (Manual) - 4/2/2024 12:31 76.0 Lbs Wheelchair (Manual) - 3/4/2024 10:56 76.0 Lbs Wheelchair (Manual) - 2/5/2024 09:32 74.0 Lbs Wheelchair (Manual) - 1/26/2024 14:08 76.0 Lbs Wheelchair (Manual) - 1/3/2024 11:11 76.0 Lbs Wheelchair (Manual) - 12/4/2023 12:16 74.0 Lbs Wheelchair (Manual) Review of the resident's physician order sheets (POS), dated May 2024, showed he/she did not have an order for a low air loss mattress or what the settings should be. Observation on 5/29/24 at 5:16 A.M., showed: - The resident laid on the low air loss mattress and the setting for the resident's weight was 300 pounds. During an interview on 5/29/24 at 4:58 A.M., Certified Nurse Aide (CNA) H said: - The charge nurses take care of the settings on the low air loss mattress; - He/she did not adjust it or change the settings. During an interview on 5/30/24 at 9:29 A.M., CNA I said: - He/she did not know who checked or adjusted the settings on the low air loss mattress; - He/she had never done anything with them. During an interview on 5/30/24 at 10:14 A.M., Licensed Practical Nurse (LPN) B said: - He/she was not for sure who was supposed to check the settings on the low air loss mattress. During an interview on 5/30/24 at 11:01 A.M., LPN A said: - He/she did not know who was supposed to check the settings on the low air loss mattress; - If the setting for the resident's weight was 300 pounds and the resident weighed around 70 pounds, then that would not be the correct setting. During an interview on 5/30/24 at 3:03 P.M., the Director of Nursing (DON) said: - The nurses are responsible to check the settings on the low air loss mattress and it should be documented on the resident's treatment administration record (TAR); - If the resident weighted around 70 pounds and the low air loss mattress was set on 300 pounds, that would not be the correct setting. 2. Review of Resident #24's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Required assistance with set up and clean up when eating; - Dependent on the assistance of staff for dressing and transfers; - Diagnoses included diabetes mellitus, dementia (inability to think), anxiety, depression and psychotic disorder ( severe mental disorders that cause abnormal thinking and perceptions), Review of the resident's POS, dated May 2024, showed: - Start date: 2/15/24 - Basaglar (Lantus, long acting) insulin, 35 units at bedtime for diabetes mellitus; - Did not have a physician's order for the staff to obtain blood sugars or how often they should be obtained, 3. Review of Resident #12's admission MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Lower extremities impaired on both sides; - Required assistance with set up and clean up when eating; - Dependent on the assistance of staff for dressing and transfers; - Diagnoses included depression, anxiety, psychotic disorder, and diabetes mellitus. Review of the resident's POS, dated May 2024 showed: - Start date: 4/17/24 - Humalog (fast acting) insulin before meals and at bedtime per sliding scale, for blood sugar 0 - 150 - no units of insulin; - Did not have a physician's order for the staff to obtain blood sugars or how often they should be obtained. During an interview on 5/30/24 at 10:14 A.M., LPN B said: - There should be a physician's order to check blood sugars and how often. During an interview on 5/30/24 at 11:01 A.M., LPN A said; - The residents should have a physician's order to check blood sugars. During an interview on 5/30/24 at 3:03 P.M., the DON said there should be a physician's order to check the blood sugars.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff did not provide appropriate perineal care which affected one of 12 sampled residents (Resident #16) failed to provide oral care to two of the 12 sampled residents (Resident #12 and #16), failed to wash the face and hands of one of the 12 sampled residents (Resident #12), and failed to ensure staff provided shaving care to one of the 12 sampled residents (Resident #24). This affected three of the 12 sampled residents. The facility census was 29. Review of facility policy, ADL's, reviewed 1/1/24, showed: -Facility will, based on the resident's comprehensive assessment and consistent with resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for the following activities of daily living: -Bathing, dressing, grooming, and oral care; -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal, and oral hygiene. Review of facility policy, Resident Rights, dated 1/1/24, showed: -Resident's have the right to a dignified existence. 1. Review of Resident #24's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/3/24, showed: -He/She had a Brief Interview Mental Status (BIMS) score of 3, showed resident had severe cognitive impairment; -He/She had no behaviors; -He/She was dependent for personal hygiene; -No customary activity preferences; -He/She was dependent on a wheelchair; -He/She was always incontinent of bowel and bladder; -Diagnoses included: brain injury, dementia (a disease that affects the brain that impairs memory and reasoning), need for assistance with personal care. Review of care plan, dated 1/27/23, showed: - Activities of daily living self-care performance deficit due to dementia and impaired balance . -Requires assist by one staff with personal hygiene. During an interview on 5/27/24 at 9:50 A.M. Resident was found laying in bed. Resident said he/she liked to be shaved daily. He/She had not been shaved since last week. Observation on 5/27/24 at 9:50 A.M. showed the resident had hair growth observed on face of quarter inch in length. Observation on 5/27/24 at 11:18 A.M., showed resident had not been shaved. During an interview on 5/28/24 at 2:49 P.M., Certified Nurse Aide (CNA) B said: -He/She had no issues completing resident's morning cares; -Shaving was completed during shower days or as resident requested. During an interview on 5/30/24 at 3:03 P.M., the Director of Nursing said: -He/She expected staff to brush resident's teeth, use restroom, wash resident's face and brush their hair as part of morning cares. -He/She expected shaving to be offered during shower days and per resident's preference. 2. Review of the facility's policy for perineal care, revised February 2018, showed, in part: - The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; - Wash the perineal area, wiping from front to back; - Separate the skin folds and wash area downward from front to back; - If the resident has a urinary catheter (sterile tube inserted into the bladder to drain urine), gently wash the juncture of the tubing from the insertion site down the catheter tubing about three inches; - Continue to wash the perineum moving from inside outward to the thighs; - Turn the resident on his/her side; - Wash the rectal area thoroughly, wiping from the base of the skin fold towards and extending over the buttocks. 3. Review of Resident #12's care plan, revised 3/28/24 showed: - The resident had an activities of daily living (ADL) self - care performance deficit related to left above the knee amputation and generalized weakness; - The resident required extensive assistance of staff with personal hygiene and oral care. Review of the resident's admission MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Lower extremities impaired on both sides; - Required assistance with set up and clean up when eating; - Dependent on the assistance of staff for dressing and transfers; - Always continent of urine; - Always incontinent of bowel; - Diagnoses included depression, anxiety, psychotic disorder ( severe mental disorders that cause abnormal thinking and perceptions), diabetes mellitus and urinary tract infection (UTI, an infection in any part of the urinary system). Observation on 5/29/24 at 6:39 A.M., showed: - CNA H and CNA I provided incontinent care, dressed the resident for the day and used the mechanical lift and transferred the resident from the bed to his/her wheelchair; - CNA I brushed the resident's hair; - CNA H and CNA I did not offer or provide oral care or wash the resident's face and hands. During an interview on 5/29/24 at 4:58 A.M., CNA H said: - He/She should have offered oral care to the resident and washed the resident's face and hands. During an interview on 5/30/24 at 9:54 A.M., CNA I said: - When they get the residents up in the morning, they should provide or offer oral care, brush or comb the resident's hair and wash their face and hands or at least offer them a wet wash cloth. 4. Review of Resident #16's care plan, revised 9/28/23 showed: - The resident had no teeth or dentures. The resident was dependent on staff for oral care in the morning and in the evening. The resident required mouth inspections daily during oral care; - The resident was dependent on staff for all ADL's. The resident is totally dependent on the assistance of one or two staff for personal hygiene and oral care; - The resident is always incontinent of bowel and bladder related to cognitive impairment. Check and change the resident every two hours and as needed. Clean the peri area with each incontinent episode. Review of the resident's Quarterly MDS dated [DATE] showed: - Cognitive skills severely impaired; - Dependent on the staff for oral hygiene, toilet use, showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included non - traumatic spinal cord dysfunction (any damage to the spinal cord that has not been caused by a major trauma) and cerebral palsy (CP, a neurological disorder caused by a non - progressive brain injury or malformation that occurs while the child's brain is under development). Observation on 5/29/24 at 5:16 A.M., showed Nurse Aide (NA) C and CNA H provided incontinent care in the following manner: - CNA H unfastened the resident's wet and soiled incontinent brief; - CNA H wiped down one side of the resident's groin, folded the wash cloth and wiped down the other side of the resident's groin, folded the wash cloth and wiped once down the middle; - NA C turned the resident onto his/her side; - CNA H used a new wash cloth and wiped from front to back with fecal material noted on the wash cloth, folded the wash cloth and wiped from front to back again with fecal material on the wash cloth then used the same area of the wash cloth and wiped both sided of the buttocks; - CNA H used a new wash cloth, wiped from front to back with fecal material on the wash cloth, folded the wash cloth and used the same area of the wash cloth and wiped both sides of the buttocks; - CNA H and NA C placed a clean incontinent brief on the resident. During an interview on 5/29/24 at 4:58 A.M., CNA H said: - He/She was taught to fold the wash cloth four times with peri care; - He/She thought you could use the same area of the wash cloth to clean different areas of the skin; - Should make sure to separate and clean all areas of the skin where urine or feces had touched. Observation on 5/29/24 at 8:23 A.M., showed: - CNA I and CNA J provided incontinent care, dressed the resident for the day and used the mechanical lift to transfer the resident from his/her bed to his/her wheelchair; - CNA I brushed the resident's hair and washed the resident's face; - CNA I and CNA J did not offer or provide oral care. During an interview on 5/30/24 at 10:47 A.M., CNA J said: - Morning cares would include brushing the resident's hair, make sure their clothes are clean and look nice, wash the resident's face and hands and provide oral care. During an interview on 5/30/24 at 3:03 P.M., the DON said: - Staff should not use the same area of the wash cloth to clean different areas of the skin; - Staff should separate and clean all areas of the skin where urine or feces had touched; - When staff get the residents up in the morning, they should brush the resident's teeth, brush their hair and wash the resident's face and hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being of each resident for five of 12 sampled residents (Residents #3, #14, #22, #24, and #25). The facility census was 29. Review of facility policy, activities, updated 4/1/24, showed: -It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, psychosocial well-being. Activities will encourage both independence and interaction within the community. -Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Create opportunities for each resident to have a meaningful life. c. Promote and enhance physical activity. d. Promote and enhance cognition. e. Promote and enhance emotional health. f. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success, and independence. g. Reflect resident's interest and age. h. Reflect cultural and religious interests of the residents. i. Reflect choice of the residents. -ADL-related activities, such as manicures/pedicures, hair styling, and makeovers may be considered part of the activities program. -Activities may be conducted in different ways: a. One to one programs. b. Person appropriate - activities relevant to the specific needs, interests, culture, background, etc. for resident they are developed for. c. Program of Activities - to include a combination of large and small groups, one to one, and self-directed as the resident desires to attend. -Activities will include individual, small, and large group activities as well as: a. Indoor and Outdoor activities. b. Activities away from the facility. c. Religious programs. d. Exercise Programs. e. Community activities. f. Social activities. g. In-Room Activities. h. Individualized activities. i. Educational Programs. -Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. 1. Review of Resident #3's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/14/24, showed: -He/She was severely impaired and never/rarely made decisions; -No customary activity preferences indicated in MDS; -He/She was dependent on a wheelchair for mobility; -Care area triggered included activities; Diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone, or posture which include symptoms of exaggerated reflexes, floppy or rigid limbs, and involuntary motions) diabetes (too much sugar in the blood), seizure disorder, and pain. Review of care plan, revised 5/4/23, showed: Resident had no involvement in activities due to cognitive impairment. He/She could make disruptive noises at times; -He/She would have daily one-on-one with activity aide through the next 90 days; -He/She participated in aromatherapy; -He/She listened to audio books in his/her room; -He/She seemed to like listening to music; -Document resident's response to interventions as needed; -If he/she is in activity room and a movie is playing, you can turn the lights off so it is dark and quiet like a movie theatre; -If He/She seemed to be overstimulated by surroundings, remove him from the area to a more quiet environment; -Monitor him/her for any signs and symptoms of pain or discomfort and report to charge nurse if noted; -Offer fluids or snacks if he/she continued to make noises-check for incontinence as well; -Provide one-on-one visits in a quiet location when he/she was unable to tolerate group activities setting; -Staff to always address him/her by name; -Staff to always introduce themselves to him/her with each contact; -Supervise him/her in all activity areas. Review of daily activity sheets from 1/1/24 to 5/28/24 showed: -Resident was engaged in activities on 3 of 147 days for opportunities; -Resident was involved in only 3 activities including men's trim twice and one musical entertainment; -4/3/24, Documented resident participated in one on one activity but did not say what he/she participated in; -4/8/24, resident included in men's trim (shaved). -No activity logs for May were provided. During an interview on 5/29/24 at 6:21 A.M., Activity Director said: -He/She liked music, lotion therapy, going outside; -He/She talked to resident about weather was like. 2. Review of Resident #14's annual MDS, dated [DATE], showed: -He/She had severely impaired cognition; -Wandering behavior exhibited daily; -Preferences for customary routine and activities showed no response, interview was not completed with resident's family, staff did not complete activity preferences; -He/She required partial/moderate assistance with eating; -Care area triggered included activities; -Diagnoses included dementia (a disease of the brain that causes memory loss and loss of reasoning), anxiety disorder, schizophrenia (a mental illness that affects a person's thoughts, feelings and behaviors). Review of care plan, revised 3/16/23, showed: -Resident had little or no activity involvement due to anxiety, depression, disinterest; -Resident will participate in activities of choice at least one time per week through the next 90 days; -Activities to visit with the resident one-on-one daily; -Assess for changes in mood status as needed; -Assist resident to the activity room throughout the day if he/she is wandering around the unit; -It is difficult to keep resident sitting down for activities, if staff sit with him/her, he/she will usually be able to complete the activity; -Resident ambulated throughout the unit during the day. He/She often does not like to sit down; -Resident enjoyed coloring, one-on-one visits, listening to music, watching TV and snack time; -Resident enjoyed crafts, listening to music and attending parties/snack time; -Resident has a nervous presence about his/her, this is his/her normal state; -Resident seemed to enjoy attending bingo; -Resident's family calls and talks to him/her on the phone. Assist him/her to the phone when they call; -When the weather is nice assist resident outside to sit for a little while if he/she would like to. Resident also enjoys gardening with activity staff. Review of daily activity sheets from 1/1/24 to 5/27/24, showed: -Resident was engaged in activities on 5 of 147 days for opportunities; -Resident was involved in only 3 activities including men's trim twice and one musical entertainment; -1/1/24 - Resident was involved in snack and coloring; -3/13/24, resident involved in sorted button, watching television, and went outside and folded towels; -3/25/24, resident involved in walking and listening to piano; -3/26/24 -Resident played with baby doll, walked halls, listened to music, snacks, and television; -4/8/24, resident included in adult coloring; -No activity logs for May provided. Continuous observation on 5/27/24 at 1:44-3:36 P.M. on the memory care unit showed: -1:44 P.M., Nurse Aide (NA) B sitting in chair in front of nurses station, not engaged with resident; -2:35 P.M., Housekeeping Supervisor came to unit so NA B could go on break, observed Housekeeping supervisor telling resident to sit down, did not offer activities; -2:43 P.M. showed resident sitting in blue chair by television; -2:57 P.M. showed resident walking halls and edges of dining room on unit holding onto CNA B's hand. -3:30 P.M. Resident pacing halls and dining room; -3:36 P.M., Resident sitting in blue chair Continuous observation on 5/28/24 at 9:02 A.M. to 10:35 A.M. on the memory care unit showed: -9:18 A.M., CNA B took resident to shower room via a shower chair; -9:32 A.M., resident walks out of shower room dressed; -10:32 A.M., resident sitting at table. -10:35 A.M., no activities have occurred or been offered since observation start. Continuous observation on 5/28/24 at 11:44 A.M. to 12:38 P.M. on memory care unit showed: -11:47 A.M., resident is pacing around halls and dining room; -11:54 A.M., resident walking around with a baby doll. Continuous observation on 5/28/24 from 1:58 P.M. to 3:27 P.M. -1:58 P.M., resident in room having visit from family members; -2:39 P.M., resident pacing after visit with family then sat down at table in dining room -2:45 P.M., resident holding hands with another resident walking, CNA C intervened and advised other resident that this resident was not steady on his/her feet and he/she could not walk with them. CNA B intervened and took resident to sit down in a chair. During an interview on 5/29/24 at 6:21 A.M., Activity Director said: -Resident did not stay on task; -He/She got emotional a lot and got upset; -He/She used to sit and participate in adult coloring, but no longer has the attention span; -He/She could put a game show on for resident and he/she may fall asleep; -He/she acted like he/she did not want to do anything; -He/She would rather be walking around. 3. Review of Resident #22's annual MDS, dated [DATE], showed: -He/She was unable to be tested on cognition levels; -Review of daily preferences showed it was somewhat important to choose what clothes to wear, take care of his/her personal belongings, to have snacks available between meals, choose own bedtime, have family or close friend involved in discussions about care, place to lock up things and keep safe -He/She found it somewhat important to have books, newspapers, or magazines to read, and to do things with groups of people, -He/She was dependent on a walker; -Diagnoses included: Dementia, anxiety, major depressive disorder, weakness. Review of care plan, revised 2/3/23, showed: -Resident had little or no activity involvement due to resident wished not to participate; -Resident enjoyed sitting outside when the weather was nice; -Resident enjoyed watching television in his/her room. Assist him/her with turning on television on and changing channels as needed; -Resident liked chocolate and coffee at times; -Resident liked getting a manicure. Allow him/her to choose his/her own nail color; -Resident liked to sit in another resident's room and conversate. They seem to enjoy each other's company; -Provide an environment that respects his/her privacy; -Remind resident when activities are scheduled. Review of activity attendance log from 1/1/24 to 5/27/24, showed: -Resident was engaged in activities on 7 of 147 days for opportunities; -On 1/1/24 resident did not participate in manicure, trivia, bingo, adult coloring; -On 3/11/24 resident participated in manicures, and name that tune; -On 3/12/24 resident participated in drink cart and trivia game; -On 3/14/24 resident participated in who's line and bible study; -On 3/19/24 resident participated in music entertainment; -On 3/27/24 resident participated in coffee and today in history and board games; -On 4/3/24, resident participated in coffee and conversation, one on one - unknown activity not documented, and bingo; -No activity logs available for May 2024. Observation on 5/27/24 at 10:25 A.M. showed resident sitting at end of table with two other residents, no drinks or items on the table. CNA B also sitting at table with resident. During an interview on 5/27/24 at 10:25 A.M., CNA B said resident liked to sit and visit. Continuous observation on 5/28/24 at 9:02 A.M. to 10:35 A.M. on the memory care unit showed: -9:02 A.M. Resident sitting at table in dining room with head down asleep in front of nurses station. Two other residents also sitting at table, no activities out. CNA C looking at computer and CNA B sitting in dining room chair along wall with other resident; -9:20 A.M. Resident walking with walker and leaning against doorway at end of hall; -10:32 A.M., Resident sitting at same spot at table in dining room dozing on and off from sleep; -10:34 A.M., Resident asked by CNA B if he/she wanted to take a shower and resident did not respond; -10:35 A.M., no activities have occurred or been offered since observation start. Continuous observation on 5/28/24 at 11:44 A.M. to 12:38 P.M. on memory care unit showed: -11:55 A.M., resident seated at the end of the table in the dining room, no engagement from staff; Continuous observation on 5/28/24 from 1:58 P.M. to 3:27 P.M. -2:02 P.M. showed resident wanted snacks, given snacks by activity director; -2:24 P.M., showed resident sitting in same chair in dining room, no staff engagement with him/her. Resident is dozing in and out of sleep. He/She had no magazine or book available, music was playing in day room; -3:03 P.M., Resident remains seated in same spot in dining room, no engagement has occurred by staff. Continuous observation on 5/29/24 at 5:22 to 7:53 A.M. -5:22 A.M., showed resident was awake, dressed, and seated at the same spot in dining room wearing clothing protector. Resident was eating cookies and drinking juice served by CNA G; -7:32 A.M., resident remained seated at the same spot at the end of the table, had fallen asleep with eyes closed while seated; -7:36 A.M., resident got up from table and headed to room. During an interview on 5/29/24 at 6:21 A.M., Activity Director said: -Resident would rather bite his/her fingernails than do anything; -He/She used to attend bible study on Thursdays on South hall but now he/she states he/she wanted to stay on memory care unit; -He/She asked resident if he/she wanted to color yesterday but he/she refused ; -Resident's son said he/she used to have a sewing basket; -When he/she first arrive he/she would carry a sewing basket around and would state that was his/her tote; -He/She used to embroidery, he/she did not have any sewing activities for resident; -He/She enjoyed music group that comes out to sing every three weeks; He/she liked music. 4. Review of Resident #24's quarterly MDS, dated [DATE], showed: -He/She had a Brief Interview Mental Status (BIMS) score of 3, showed resident had severe cognitive impairment; -He/She had no behaviors; -No customary activity preferences; -He/She was dependent on a wheelchair; -Diagnoses included: brain injury, diabetes dementia, anxiety, depression, psychotic disorder. Review of annual MDS, dated [DATE], showed: -No customary preferences on activities -Interview was not completed by resident or family; -Staff assessment of resident activities showed resident preferred choosing clothes to wear, caring for personal belongings, receiving shower, snacks between meals, family or significant other involvement in care, reading books, newspapers, or magazines, listening to music, doing things with groups of people, participation in favorite activities; Review of resident's care plan, dated 3/29/24, showed: -Resident had little or no activity involvement due to disinterest or dementia; -Encourage social conversations and allow resident to verbalize feelings; -Establish and record resident's prior level of activity involvement and interests by talking with the resident, caregiver, and family on admission and as necessary; -Resident liked cola soda. Offer him/her a soda every now and then; -Resident's family visits often. Allow him/her privacy when they are visiting; -One on one visits daily; -Ongoing assessment for change in mood status; -Provide opportunities for increased socialization; -Provide privacy for family and friend visitors; -Visit and discuss past social patterns in the community. Resident was a farmer and worked with cattle. Review of daily activity sheets from 1/1/24 to 5/27/24, showed: -Resident was engaged in activities on 3 of 147 days for opportunities; -1/1/24, resident was involved in a men's trim; -3/19/24, resident participated in music entertainment; -4/8/24, resident included in men's trim, -No activity logs for May provided. During an interview on 5/29/24 at 6:21 A.M., Activity Director said: -He/She did lotion therapy with the resident; -He/She would talk to resident about livestock and cattle, sometimes resident will tell him/her to get out of his room and did not want to be bothered; -When resident was agitated he/she left them alone. 5. Review of Resident #25's annual MDS, dated [DATE], showed: -He/She was severely cognitively impaired; -He/She behavioral symptoms not directed toward others 1-3 days; -He/She exhibited wandering behavior occurred daily -He/She had trouble concentrating on things 12-14 days nearly every day -Diagnoses included: non-traumatic brain dysfunction, dementia, anxiety disorder, depression, psychotic disorder, insomnia, psychosis. Review of care plan, revised 1/19/24, showed: -Resident had little or no activity involvement due to depression; -Establish and record resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary; -Resident enjoys listening to music. Assist him/her with turning on music in his/her room. -The resident's preferred activities are: watching TV in her room, getting a manicure and snacks between meals. Review of daily activity attendance sheets, dated 1/1/24 to 5/27/24, showed: -Resident was engaged in activities on 7 of 147 days for opportunities; -3/11/24, Resident participated with going outside; -3/12/24, Resident participated with bird watching; -3/13/24, Resident participated in watching TV, playing cards, and sorted buttons, and outside; -3/25/24, Resident participated in snack and walking; -3/26/24, Resident played with baby doll, listened to music, walked halls, snacks, TV, and games; -4/2/24, Resident participated in sensory and puzzles; -4/3/24, Resident participated in one on one unknown activity; Observation on 5/27/24 at 2:35 P.M. showed CNA B got a puzzle out and sat with resident at table to work on puzzle. 6. Review of training records showed no dementia training offered to staff in last year. During an interview on 5/28/24 at 2:49 P.M., CNA B said: -Activity director conducted activities with the residents; -He/She had not had dementia training since he/she worked at facility; During an interview on 5/28/24 at 3:13 P.M., CNA C said: -He/She used to be able to take residents outside but with current staffing it was not safe to take memory care residents outside currently; -Activities were led by activity director and not staff on the floor; -Facility used to have an aide that also did activities but no longer did; -Activity Director had not gotten money for supplies for activities; -If staff has ability to help they can assist with activities; -Activity Director ensured every Monday through Friday there were activities. During an interview on 5/29/24 at 5:58 A.M., CNA G said: -He/She had not had any dementia training. During an interview on 5/29/24 at 6:21 A.M., Activity Director said: -He/She had been activity director since 2017; -He/She did not have any activity certifications; -He/She had done a few in person training's and online training's; -He/She developed plans for resident activities by trying to figure out what residents liked; -He/She did an activity called helping hands where residents folded towels and talk amongst themselves; -He/She organized bingo on Monday, Wednesday, and Fridays for the residents on South hall; -Residents liked trivia, coffee and conversation where we talk about things coming up or their family visits; -He/She tried to get feedback from residents or their families to find out what activities residents enjoyed doing; -He/She did activities like lotion therapy with non-verbal residents; -He/She would like more training on how to be more interactive and what he/she can do to keep residents focused; -There were times he/she did not have resources to complete activities; -He/She has had no training for the Activity Director position; -Thursdays was his/her shopping day. He/She shopped for some of the residents on South hall; - At times when he/she needed money the office would not get money so he/she had to use his/her own funds; -He/She had a monthly budget of $225.00, it used to be $480.00; -Fridays is donuts and muffins and last Thursday nobody was in office to get me money so he/she had to use own money; -He/She obtained money from business office manager; -He/She had moved offices during last 30 days and could not locate any activity May logs; -He/She did not complete activity logs during nursing home week, but planned a theme day each day of the week; -He/She did not do logs during nursing home week, each day was a different theme; -Facility staff had access to stuff like puzzles, coloring books, crosswords when he/she was off work; -He/She did not plan activities on weekends or holidays; -Staff could take residents outside as long as they let the charge nurse know and wore a walkie talkie; -He/She took residents outside if weather temperature was 78 degrees or warmer; -He/She used to have an activity aide but currently facility did not have high enough census for facility to hire an activity aide to assist him/her; -He/She has not had dementia specific training since he/she has worked at facility; -He/She had training specific to planning and engaging residents in activities with dementia. During an interview on 5/29/24 at 7:32 A.M., CNA D said: -The activity director did the activities with residents; -He/She did not take residents outside; -He/She would give resident baskets of towels they can fold; -He/She did puzzles or coloring books with residents when activity director was not in building. During an interview on 5/30/24 at 11:22 A.M., Licensed Practical Nurse (LPN) A said: -No activities were planned for residents on holidays or weekends. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -He/She would expect activities planned to engage cognitively impaired residents; -He/She expected all staff to engage residents in activities; -Activities should be offered to residents frequently; -Activities were not currently offered to residents after hours or on weekends for residents; -Dementia care training and interventions should be offered to staff upon hire, annually, and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #24's Quarterly minimum data set (MDS), dated [DATE], showed: -He/She had a Brief Interview Mental Status (BIMS) score of 3, showed resident had severe cognitive impairment; -He/She was dependent on staff for personal hygiene; -He/She was dependent on a wheelchair for mobility; -Diagnoses included: brain injury, diabetes (too much sugar in the blood), dementia, anxiety, depression, psychotic disorder, pressure ulcer of left heel, stage 3, need for assistance with personal care; Review of care plan, dated 10/17/23, showed: -Resident was transferred using mechanical lift as needed. At times he/she can transfer with an assist of two staff. Observation on 5/29/24 at 9:21 A.M. of CNA J and CNA D who completed a hoyer lift transfer using invacare hydraulic lift 9805P when transfering resident from wheelchair to his/her bed showed staff did not lock the wheelchair brakes before lifting the patient and transferring him/her to bed. 3. Review of Resident #3's Annual MDS, dated [DATE], showed: -He/She was dependent on a wheelchair for mobility; -He/She was dependent on staff for all personal hygiene, eating, mobility, dressing, and oral care; Diagnoses included cerebral palsy, diabetes, seizure disorder, and pain. Review of care plan, dated 3/23/23, showed: -Resident required hoyer lift with two staff assistance for transfers. Observation on 5/29/24 at 9:28 A.M. showed CNA J and CNA D who completed hoyer lift transfer using invacare hydraulic lift 9805P while transferring resident from his/her wheelchair to their bed showed staff did not lock wheelchair brakes. During an interview on 5/30/24 at 3:03 P.M., the Director of Nursing (DON) said the wheelchairs should be locked during the mechanical lift transfers. Based on observations, interviews and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when staff failed to lock residents' wheelchairs during transfers which affected three of 12 sampled residents, (Resident #3, #16 and #24). The facility census was 29. Review of invacare hydraulic 9805 portable patient lift and sling manual, revised 5/23/06, showed: -Wheelchair wheels locks must be in a locked position when lifting the person. Review of the facility's policy for using a mechanical lifting machine, revises July 2017, showed, in part: - The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device; - The policy did not address if the wheelchairs should be locked during the transfer. 1. Review of Resident #16's care plan, revised 9/28/23 showed: - The resident was dependent on staff for all ADLs; - The resident is totally dependent on the assistance of two staff for transfers with the mechanical lift. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 3/22/24 showed: - Cognitive skills severely impaired; - Dependent on the staff for oral hygiene, toilet use, showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included non - traumatic spinal cord dysfunction (any damage to the spinal cord that has not been caused by a major trauma) and cerebral palsy (CP, a neurological disorder caused by a non - progressive brain injury or malformation that occurs while the child's brain is under development) and anxiety. Observation on 5/29/24 at 8:23 A.M., showed: - Certified Nurse Aide (CNA) I and CNA J provided incontinent care to the resident, dressed the resident for the day and used invacare hydraulic lift 9805P mechanical lift to transfer the resident from his/her bed to the wheelchair; -The brakes on the wheelchair were not locked during the transfer. During an interview on 5/30/24 at 9:54 A.M., CNA I said: - He/she did not know what the policy was for transfers, if the wheelchair was supposed to be locked or unlocked; - He/she started in May and the facility did not give him/her any training. He/she went directly to the floor and started working with the residents. During an interview on 5/30/24 at 10:47 A.M., CNA J said: - The wheelchairs should be locked during transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assure staff provide proper respiratory care when staff failed to ensure the oxygen concentrator had humidified sterile water, which affected one of 12 sampled residents, (Resident #16), failed to date the oxygen tubing for Resident #12 and Resident #81. The facility census was 29. Review of the facility's policy for oxygen administration, reviewed 1/1/24 showed: - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person - centered acre plans, and the resident's goals and preferences; - Oxygen is administered under orders of a physician; - Change oxygen tubing and cannula weekly and as needed if it becomes soiled or contaminated; - Change humidifier bottle when empty, every 72 hours or per facility policy. Use only sterile water for humidification; - Keep delivery devices covered in plastic bag when not in use. 1. Review of Resident #16's care plan, revised 11/20/23 showed: - The resident had oxygen therapy; - Change tubing per protocol; - Oxygen settings: Oxygen at two liters via nasal cannula (2L/NC) at bedtime; - Provide with humidification. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 3/22/24 showed: - Cognitive skills severely impaired; - Dependent on the staff for oral hygiene, toilet use, showers, dressing, personal hygiene and transfers; - Diagnoses included non - traumatic spinal cord dysfunction (any damage to the spinal cord that has not been caused by a major trauma) and cerebral palsy (CP, a neurological disorder caused by a non - progressive brain injury or malformation that occurs while the child's brain is under development) and anxiety. Review of the resident's physician order sheet (POS), dated May 2024 showed: - Start date: 11/16/23 - change oxygen tubing weekly on Thursday nights and as needed; - Start dated: 11/08/23 - Check humidified bottle water level every shift and as needed. Observation on 5/27/24 at 8:59 A.M., showed: - The resident was in bed; - The oxygen concentrator was set on three liters; - The oxygen tubing was on the floor and did not have a date on it; - The humidified water bottle was empty. 2. Review of Resident #81's care plan, revised on 5/28/24 showed: - The resident had congestive heart failure (CHF, an accumulation of fluid in the lungs and other areas of the body); - Oxygen settings: 2L/NC. Review of the resident's POS, dated May 2024 showed; - Start date: 5/23/24 - Oxygen at 2L/NC. May use 1 - 4 liters continuously to keep oxygen saturation (amount of oxygen in the blood) greater than 90%; - Start date: 5/23/24 - Change tubing and humidified water bottle weekly on Thursday nights. Review of the resident's medical records showed the resident was admitted on [DATE]. Observation on 5/27/24 at 9:48 A.M., showed: - The resident sat in his/her recliner with his/her feet elevated; - The resident had oxygen on at 3L/NC and the oxygen tubing was not dated. During an interview on 5/30/24 at 9:54 A.M., Certified Nurse Aide (CNA) I said: - He/she did not know who or when the oxygen tubing was changed or who was supposed to fill the humidified water bottle. During an interview on 5/30/24 at 10:14 A.M., Licensed Practical Nurse (LPN) B said: - The day or night shift charge nurse changed the oxygen tubing; - The oxygen tubing should be dated and initialed when it was changed; - There should be sterile water in the humidified water bottle and it should be dated and initialed when it is changed; - The oxygen tubing and cannula should not be on the floor. During an interview on 5/30/24 at 11:01 A.M., LPN A said: - The oxygen tubing and cannula should not be on the floor; - The oxygen tubing and the humidified water bottle should be dated when changed; - There should be water in the humidified water bottle. During an interview on 5/30/24 at 3:03 P.M., the Administrator ad the Director of Nursing (DON) said: - The oxygen tubing should be changed weekly on Thursday nights; - The oxygen tubing should not be on the floor; - There should be sterile water in the humidified water bottle.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess residents for risk of entrapment from bed rails prior to installation when they failed to complete a side rail assessment (Resident #29), failed assess for an alternative to side rails (Resident #14 and #29), failed to obtain a physician's order (Resident #29) failed to measure entrapment zones for installed side rails (Resident #29) for two of 12 sampled residents (Resident #14, and #29). The facility census was 29. Review of facility policy, bed safety, dated 1/1/24, showed: -To prevent deaths/injuries from the beds and related equipment the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established; c. Ensure that when the bed system components are worn and need to be replaced, components meet manufacturer specifications; d. Ensure that bed side rails are properly installed using the manufacturer's instructions; e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment. -The maintenance department shall provide a copy of inspections to the Administrator; -If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative. -The staff shall obtain consent for the use of side rails from the resident or resident's legal representative prior to use; -Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternative can be identified. 1. Review of Resident #14's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/5/24, showed: -He/She had severely impaired cognition; -He/She was dependent for oral hygiene, toileting, bathing, personal hygiene; -He/She required substantial/maximal assistance with upper and lower body dressing; -He/She had 2 or more falls with no injury since last assessment on 12/4/23, and no falls with injury - No bed rail; -Diagnoses included need for assistance with personal care, unsteadiness on feet, generalized muscle weakness, falls. Review of care plan, revised 1/27/23, showed: -He/She was at risk for injury due to cane rail; -He/She will have no injury due to transfer handle through next 90 days; - He/She was able to reposition self in bed; -He/She was able to transfer self. Review of physician's orders, dated 5/28/24, showed: -Ordered 11/2/23, cane rail x 1 for bed mobility, repositioning, and generalized weakness. Review of electronic medical record showed no side rail assessment completed. Review of monthly device schedule showed resident's room number had 1 bed rail: -Measurements taken 5/28/24, showed: 1 bed rail, zone 1 - 16 inches, zone 2 not applicable, zone 3 and 1/2 inches, zone 4 and 5 not applicable, zone 6 2 inches, zone 7, 18 inches -Measurements taken 4/12/24 showed: 1 bed rail, zone 1 16 inches Zone 2 - NA, Zone 3, 3 and 1/2 inches, zone 4 and zone 5, not applicable, zone 6 2 inches, zone 7 18 inches; -Measurements taken 3/13/24, showed: 1 bed rail, zone 1 11 and 3/4 inches, zone 2 - NA, zone 3 - 3 inches, zone 4 and zone 5 Not applicable, zone 6 3 inches, zone 7 14 and 1/4 inches; -Measurements taken 2/1/24, showed: 1 bed rail, zone 1 - 12 inches, zone 2 not applicable, zone 3 - e inches, zone 4 and 5 not applicable, zone 6, 1 inch, zone 7 15 inches; -Measurements taken 1/24/24, showed: 1 bed rail, zone 1 12 inches, zone 2 - NA, zone 3 - 3 inches, zone 4 - and zone 5 NA, zone 6 -1 inch, zone 7 - 15 inches Observation on 5/27/24 at 11:05 A.M. showed resident had a cane rail on right side of his/her bed near head of the bed. 2. Review of Resident #29's admission MDS, dated [DATE], showed: -He/She admitted [DATE]; -He/She had severe cognitive impairment; -He/She had impairments to both sides of upper extremities; -He/She was dependent on a walker; -He/She was independent with mobility; -Bed rail not used; -Diagnoses included: weakness, difficulty in walking, need for assistance with personal care, falls. Review of care plan, dated 5/4/24, showed: -Resident was independent with bed mobility; -Side rail or assist bar was not addressed in care plan. Review of physician's orders, dated 5/28/24, showed: -No order for side rail or assist bar. Review of electronic medical record showed: -4/1/24 a bed rail assessment was completed showed that there was no recommendation for side rail placement and a side rail or assist bar was not indicated at that time. Review of monthly device schedule showed resident's room was not included in zone measurements for side rail entrapment. Observation on 5/27/24 at 10:48 A.M. showed resident had a U-shaped rail on left side of bed that was pushed up against the wall. During an interview on 5/28/24 at 3:13 P.M., Certified Nurse Aide (CNA) C said: -Resident's bed was turned a different direction and resident used to use cane rail to get in and out of bed. During an interview on 5/29/24 at 7:53 A.M., CNA D said: -Resident had side rails on his/her bed just because the bed already had them on when he/she moved in; -He/She was not a fall risk. During an interview on 5/29/24 at 5:53 A.M., Maintenance Supervisor said: -Once a month he/she went around and did safety checks and measured side rails to mattresses from head of bed, foot of bed, and measured gaps; -He/She recorded measurements in a book in the front office; -He/She received orders to install side rails from the front office; -Facility used nothing but cane rails. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -A physician's orders should be obtained for side rails/assist bars; -Side rails or transfer handle should be care planned; -Side rail assessments should be completed prior to installation; -Measurements should be completed on bed frames and mattresses monthly or if there is a change in mattresses.

Based on interviews and record review, the facility failed to ensure they employed a Registered Nurse (RN) for eight consecutive hours per day, seven days per week. The facility census was 29. Review of the facility's policy for nursing services - Registered Nurse (RN), reviewed 1/1/24 showed, in part: - It is the intent of the facility to comply with Registered Nurse staffing requirements; - The facility will utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week. Review of the staffing sheets for October 2023 showed: - No RN scheduled for eight consecutive hours 10/27, 10/28. and 10/29. Review of the staffing sheets for March 2024 showed: - No RN scheduled for eight consecutive hours 3/10 and 3/11. Review of the staffing sheets for April 2024 showed: - No RN scheduled for eight consecutive hours 4/27 and 4/28. Review of the staffing sheets for May 2024 showed: - No RN scheduled for eight consecutive hours 5/4, 5/5, 5/11, 5/12, 5/18, 5/19, and 5/26. During an interview on 5/30/24 at 3:03 P.M., the Administrator and the Director of Nursing (DON) said: - They should have an RN coverage eight hours a day, seven days a week.

Based on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made eight medication errors out of 25 opportunities for error, resulting in a medication error rate of 32%. This affected four of 12 sampled residents, (Resident #12, #16, #21, and #24). The facility census was 29. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed. Review of the facility's policy for nasal spray administration, updated 4/15/24, showed, in part: - Nasal spray medications are administered by qualified staff as ordered by the physician and in accordance with professional standards of practice; - Verify orders and labeling prior to administration; - Compare the label with the order to verify correct medication, dose, route, and time of administration; - Agitate the contents in accordance with the manufacturer's instructions; - Occlude opposite nostril with your finger, and insert tip of medication container into the desired nostril; - Spray medication into nostril while instructing resident to inhale with mouth closed. Instruct resident to exhale through the mouth; - If ordered, spray the nostril again, repeating the procedure in the other nostril as ordered; - Instruct the resident to tilt head back for several minutes, breathing through his/her nose. Instruct to not blow nose for about 15 minutes; - Rinse the tip of the medication container in lukewarm water, and allow to dry. Replace cap. Review of the package leaflet for Flonase nasal spray, revised March 2016, showed, in part: - Shake the bottle gently; - Blow your nose to clear the nostrils; - Close one side of the nostril. Tilt your head forward slightly and carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose, and while breathing in press firmly and quickly down one time on the applicator to release the spray; - Repeat in the other nostril; - Wipe the nasal applicator with a clean tissue and replace the cap. Review of the website https://www.webmd.com for multivitamin with minerals showed: - Swallow the tablets whole. Do not crush or chew the tablets. Review of the website https://www.drugs,com for senna tablets showed: - Tablets should be swallowed whole with water and without breaking, chewing, or crushing. 1. Review of Resident #16's physician order sheet, (POS), dated May 2024 showed: - Start date: 9/15/23 - Fluticasone Propionate nasal suspension, 50 micrograms (mcg.) two sprays in both nostrils daily for nasal congestion; - Start date: 9/15/23 - Senna (Sennosides) tablets 8.6 milligrams (mg.), two tabs twice daily via peg tube ( a tube inserted through the wall of the abdomen directly into the stomach) for constipation; - Start date: 9/15/23 - Thera-tabs M oral tablet (multiple vitamins with minerals), give one tablet via pet tube daily for supplement. Review of the resident's medication administration record (MAR), dated May 2024 showed: - Fluticasone Propionate nasal suspension, 50 mcg. two sprays in both nostrils daily for nasal congestion; - Senna (Sennosides) tablets 8.6 mg, two tabs twice daily via peg tube for constipation; - Thera-tabs M oral tablet (multiple vitamins with minerals), give one tablet via peg tube daily for supplement. Observation on 5/27/24 at 10:18 A.M., showed: - Licensed Practical Nurse (LPN) A crushed the Senna tabs and the Thera tabs M oral tablet, mixed then with water and administered through the peg tube. - LPN A shook the bottle of Flonase, did not close either side of the resident's nostril and gave one spray in each nostril. During an interview on 5/30/24 at 10:14 A.M., LPN B said: - Senna tabs should not be crushed; - The Thera M oral tablet (multiple vitamins with minerals) should not be crushed. During an interview on 5/30/24 at 11:01 A.M., LPN A said: - If the physician ordered two sprays of Flonase, then that's what should have been administered; - He/she should have followed the manufacturer's guidelines for the administration of the Flonase (had the resident blow his/her nose, shake the bottle close one side of the nostril); - He/she said the Senna tabs could be crushed; - He/she said the Thera M oral tablet (multiple vitamins with minerals) could be crushed. During an interview on 5/30/24 at 3:03 P.M., the Director of Nursing (DON) said: - She would expect the staff to follow the manufacturer's guidelines when Flonase is administered; - If the physician had ordered two sprays, then that is what the staff should administer; - If Senna is enteric coated, you cannot crush it; - As long as the multiple vitamins with minerals is not enteric coated, it can be crushed. 2. Review of Resident #21's POS, dated May 2024, showed: - Start date: 5/21/24 - Please call the pharmacy to reorder Seroquel Cream every 20 days for refill for medication; - Start date: 3/1/24 - Seroquel rub 50 mg. per milliliter (ml.) one ml. topically to skin four times daily for unspecified psychosis ( when an individual has a psychotic episode, but does not meet any other criteria for a more specific diagnosis). Review of the resident's MAR, dated May 2024 showed: - Seroquel Rub 50 mg./ml., apply one ml. topically to skin four times daily for unspecified psychosis; - Staff documented a nine which indicated the medication was not administered. There were 64 opportunities in which the medication was not administered. Observation on 5/28/24 at 11:14 A.M., showed: - The Seroquel Rub came in from the pharmacy; - LPN B said they have been out of the Seroquel Rub for a while; - Registered Nurse (RN) B sanitized, gloved and squirted one ml. from the syringe onto his/her gloved finger, pulled up the resident's right sleeve and rubbed the medication in his/her arm, pulled the resident's sleeve down, removed gloves and sanitized. During an interview on 5/30/24 at 10:14 A.M., LPN B said: - Resident #21 has not had the Seroquel Rub at all until it came in on 5/28/24. During an interview on 5/30/24 at 11:01 A.M., LPN A said: - The Seroquel Rub was ordered on 3/1/24 and the resident has never had it until it came in this week. The Administrator and the DON said they would notify the physician. During an interview on 5/30/24 at 3:03 P.M., the Administrator and the DON said; - They did not know how long the resident had been without the Seroquel Rub; - The resident has had it since it was ordered on 3/1/24. 3. Review of the facility's policy for insulin pen, updated 1/1/24, showed, in part: - It is the policy of the facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge; - Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir; - Remove the pen cap from the insulin pen; - Wipe the rubber seal with an alcohol pad; - Screw the pen needle onto the insulin pen; - Dial two units by turning the dose selector clockwise; - With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears; - Turn the dose selector to the ordered dose. 4. Review of Resident #24's POS, dated May 2024 showed: - Start date: 3/1/24 - Novolog (fast acting) insulin, 14 units three times a day for diabetes mellitus. Review of the resident's MAR, dated May 2024 showed: - Novolog insulin, 14 units three times a day for diabetes mellitus. Observation on 5/28/24 at 11:49 A.M., showed: - LPN B removed the cap from the Novolog insulin pen, did not clean the port and attached the needle; - LPN B dialed the dose selector to 14 units and administered the insulin to the resident; - LPN B did not prime the insulin pen. 5. Review of Resident #12's POS, dated May 2024 showed: - Start date: 4/17/24 - Humalog (fast acting) insulin before meals and at bedtime per sliding scale- for blood sugar 150-175- two units of insulin. Review of the resident's MAR, dated May 2024 showed: - Humalog insulin before meals and at bedtime per sliding scale- for blood sugar 150-175- two units of insulin. Observation on 5/29/24 at 7:31 A.M., showed: - LPN B obtained the resident's blood sugar - 154; - LPN B removed the cap from the Humalog insulin pen, did not clean the port and attached the needle; - LPN B dialed the dose selector to two units and administered the insulin to the resident; - LPN B did not prime the insulin pen. During an interview on 5/30/24 at 10:14 A.M., LPN B said: - He/she should have cleaned the port with an alcohol wipe then attached the needle; - He/she should have primed the insulin pens with two units of insulin before administering the insulin. During an interview on 5/30/24 at 3:03 P.M., the DON said: - The staff should clean the insulin port with an alcohol wipe before the needle was attached; - The insulin pens should be primed with two units before the insulin is administered.

Based on observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective medication administration system that was free of significant medication errors when staff failed to prime insulin pens prior to administering insulin which affected two of 12 sampled residents, (Resident #12 and Resident #24). The facility census was 29. Review of the facility's policy for insulin pen, updated 1/1/24, showed, in part: - It is the policy of the facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge; - Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir; - Remove the pen cap from the insulin pen; - Wipe the rubber seal with an alcohol pad; - Screw the pen needle onto the insulin pen; - Dial two units by turning the dose selector clockwise; - With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears; - Turn the dose selector to the ordered dose. 1. Review of Resident #24's physician order sheet (POS), dated May 2024 showed: - Start date: 3/1/24 - Novolog (fast acting) insulin, 14 units three times a day for diabetes mellitus. Review of the resident's medication administration record (MAR), dated May 2024 showed: - Novolog insulin, 14 units three times a day for diabetes mellitus. Observation on 5/28/24 at 11:49 A.M., showed: - Licensed Practical Nurse (LPN) B removed the cap from the Novolog insulin pen, did not clean the port and attached the needle; - LPN B dialed the dose selector to 14 units and administered the insulin to the resident; - LPN B did not prime the insulin pen. 5. Review of Resident #12's POS, dated May 2024 showed: - Start date: 4/17/24 - Humalog (fast acting) insulin before meals and at bedtime per sliding scale- for blood sugar 150-175- two units of insulin. Review of the resident's MAR, dated May 2024 showed: - Humalog insulin before meals and at bedtime per sliding scale- for blood sugar 150-175- two units of insulin. Observation on 5/29/24 at 7:31 A.M., showed: - LPN B obtained the resident's blood sugar - 154; - LPN B removed the cap from the Humalog insulin pen, did not clean the port and attached the needle; - LPN B dialed the dose selector to two units and administered the insulin to the resident; - LPN B did not prime the insulin pen. During an interview on 5/30/24 at 10:14 A.M., LPN B said: - He/she should have cleaned the port with an alcohol wipe then attached the needle; - He/she should have primed the insulin pens with two units of insulin before administering the insulin. During an interview on 5/30/24 at 3:03 P.M., the Director of Nursing (DON) said: - The staff should clean the insulin port with an alcohol wipe before the needle was attached; - The insulin pens should be primed with two units before the insulin is administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #24's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/3/24, showed: -He/She had a Brief Interview Mental Status (BIMS) score of 3, showed resident had severe cognitive impairment; -He/She was dependent for personal hygiene; -He/She was dependent on a wheelchair; -Diagnoses included: brain injury, diabetes (too much sugar in the blood), dementia (loss of memory, language, problem-solving and other thinking abilitites that are severe enough to interfere with daily life), anxiety, depression, psychotic disorder (a condition characterized with disconnection from reality), need for assistance with personal care. Review of physician's orders, dated 5/1/24 to 5/27/24, showed: -Resident had no orders for antifungal powder with miconazone nitrate 2%; -Resident had no orders to self-administer medications. Review of care plan, dated 3/29/23, showed -Observe skin for irritation and redness during incontinent care and notify charge nurse of any skin issues; -He/She required skin inspection daily during cares. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. -Administer medications as ordered; -Resident had impaired cognitive function and impaired communication at times due to dementia; -Check all body for breaks in skin and treat promptly as ordered by doctor. Observation on 5/27/24 at 9:47 A.M. showed antifungal powder with miconazole nitrate 2% on sink in resident's room with no label. During an interview on 5/30/24 at 11:22 A.M., Licensed Practical Nurse (LPN) A said: -Medications should not be left at bedside in a resident's room; -Antifungal powder should not be left in resident's room; -Resident did not self-administer his/her own medications. During an interview on 5/30/24 at 12:05 P.M., Activities Director said: -Medications should not be left at bedside. During an interview on 5/30/24 at 3:03 P.M., Director of Nursing said: -Medications should not be left at bedside. Based on observations, interviews, and record review, the facility failed to ensure medications had a pharmacy label on them to indicate who they belonged to for one of 12 sampled residents, (Resident #11), failed to ensure staff did not leave medication at bedside which affected Resident #16 and #24. Additionally, the staff failed to ensure the drawers of the medication cart were clean without any debris. The facility census was 29. Review of the facility's policy for storage of medications, revised November 2020 showed, in part: - The facility stores al drugs and biologicals in a safe, secure and orderly manner; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; - Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. 1. Observation and interview on 5/28/24 at 3:38 P.M., showed the following in the South medication cart: - Resident #11 had a bottle of Flonase nasal spray which did not have a pharmacy label on it to indicate who it belonged to. The staff had hand written the resident's name on the bottle but most of the name had been wiped off; - Two of the medication drawers had a lot of sticky powdery substance in them; - Registered Nurse (RN) B said he/she did not know who was responsible to clean the medication carts and the Flonase should have a pharmacy label to indicate who it belonged to. 2. Review of Resident #16's Quarterly Minimum Data Set (MDS) dated [DATE] showed: - Cognitive skills severely impaired; - Dependent on the staff for oral hygiene, toilet use, showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included non - traumatic spinal cord dysfunction (any damage to the spinal cord that has not been caused by a major trauma) and anxiety and cerebral palsy (CP, a neurological disorder caused by a non - progressive brain injury or malformation that occurs while the child's brain is under development). Observation and interview on 5/27/24 at 8:52 A.M., showed: - There was a clear medication cup on the resident's bedside table with approximately 15 milliliters (ml.) of clear liquid and what appeared to be crushed medication settled in the bottom; - Licensed Practical Nurse (LPN) A said it looked like medication to him/her but it was not from his/her shift. LPN A dumped it out and threw the medication cup in the trash. During an interview on 5/30/24 at 3:03 P.M. the Administrator and Director of Nursing (DON) said: - Medications should not be left at bedside; - Medication should have a pharmacy label on them.

Based on observations, interviews, and record reviews, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The facility census was 29. 1. Review of the facility job description for DM, dated 2020, showed: - Minimum requirements include one of the following: -Certification as a dietary manager. -Certification as a food service manager. -Has similar national certification for food service management and safety from a national certifying body. -Has an associate's or higher degree in food service management or in hospitality, if the course of study includes food service or restaurant management, for an accredited institution of higher learning. -Must also meet state requirements for food service managers or dietary managers. -Two years experience in food service management. Prior experience in healthcare foodservice preferred. Record review showed DM had enrolled in a course on 8/7/2023, and was not scheduled to complete the course until 11/14/24 November 14, 2024. During an interview on 5/29/24 at 11:35 A.M., DM said: -He/She had been DM since April of 2021; -He/She did not have dietary certification; -He/She was enrolled in a 15 month program and currently completing schooling but had not finished the program; -He/She had three months left of the program. During an interview on 5/30/24 at 12:10 P.M., Corporate Administrator said: -DM moved into Dietary Manager position in April 2021; -DM should be certified. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -DM should be certified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections when the failed to ensure all employees completed a Mantoux test screening for tuberculosis (TB) screening prior to hire. Review of six of 10 sampled employees (Nurse Aide (NA) A, Certified Nurse Aide (CNA) E, CNA F, NA B, Registered Nurse (RN) A, and CNA B) showed the facility was not in compliance. The facility also failed to provide alcohol-based hand rub (ABHR) on the memory care unit when hand sanitizer dispensers were left empty. The facility census was 29. 1. Review of facility policy, Infection Prevention and Control Manual Employee Health, dated 2019, showed: -All healthcare workers be tested for tuberculosis upon hire and yearly thereafter; -Initial testing will be two-step procedure with the first dose given before beginning work and the second booster dose given 7-21 days after the first dose is negative along with an employee risk screening tool; -New employees will not be allowed to work until the Tuberculin Skin Test or chest x-ray results are known; -Employees who will be receiving the two-step Tuberculin Skin Test (TST) may begin work after the first step results are negative; -Documentation of the TB assessment will be kept in the employee's medical file. A. Review of NA A employee file, showed: -Employee hired 3/25/24; -No TB testing completed; B. Review of CNA E's employee file showed: -Employee hired 5/7/24; -No TB testing completed. C. Review of CNA F's employee file showed: -Employee hired 2/16/23 -No TB testing completed. D. Review of NA B's employee file showed: -Employee hired 5/15/24; -No TB testing completed. E. Review of RN A's employee file showed: -Employee hired 5/15/24; -No TB testing completed. F. Review of CNA B's employee file showed: -Employee hired 5/9/24; -No TB testing completed. During an interview on 5/29/24 at 1:55 P.M., Business Office Manager (BOM) said: -First round TB tests should be completed and read after forty-eight hours and prior to staff working with residents; -He/She did not know how often TB tests should be completed. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -TB tests should be completed upon hire and annually. 2. Review of facility policy, hand hygiene, dated 2023, showed: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. -Alcohol-based hand rub with 60-95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and whatever whenever they are visibly dirty, before eating, and after using the restroom. Observation on 5/27/24 at 10:38 A.M., showed no hand sanitizer in dispenser in room [ROOM NUMBER] on Memory Care Unit. Observation on 5/27/24 at 10:42 A.M. showed no hand sanitizer in dispenser in room [ROOM NUMBER] on Memory Care Unit. Observation on 5/27/24 at 10:48 A.M. showed no hand sanitizer in dispenser in room [ROOM NUMBER] on Memory Care Unit. Observation on 5/27/24 at 10:55 A.M. showed no hand sanitizer in dispenser in room [ROOM NUMBER] on Memory Care Unit. Observation 5/28/24 at 12:11 P.M., showed no hand sanitizer available in North dining room; During an interview on 5/28/24 at 12:15 P.M., CNA B said: -He/She did not know if there was hand sanitizer anywhere on the Memory Care Unit; -Memory care unit needed to get hand sanitizer. Observation on 5/28/24 at 2:59 P.M. showed housekeeping supervisor attempted to place hand sanitizer in wall dispenser but hand sanitizer did not fit in the wall unit. CNA B said that Housekeeping staff are going to find different dispensers to hang on the wall. During an interview on 5/28/24 at 3:13 P.M., CNA C said: -There was no hand sanitizer on the Memory Care Unit currently. Observation on 5/29/24 at 5:52 A.M. showed CNA B asked Maintenance Supervisor about hand sanitizer for dispenser in North dining room. Maintenance Supervisor told CNA B that there was no hand sanitizer for that dispenser. During an interview on 5/29/24 at 5:58 A.M., CNA G said: -There had been no hand sanitizer on the Memory Care Unit since March; -The staff person who orders the hand sanitizer received different dispensers but did not have the right hand sanitizer refills to go in the dispensers; -He/She carried their own hand sanitizer while working. During an interview on 5/29/24 at 7:53 A.M., CNA D said: -There has been no hand sanitizer in dispensers in resident rooms or hallways; -There is usually one small bottle of hand sanitizer on nurses medication cart. During an interview on 5/30/24 at 11:57 A.M., HA C said: -Facility had been out of hand sanitizer on Memory Care Unit because supplier kept sending facility the wrong stuff; -Facility could not ship back the wrong hand sanitizer dispenser refills. During an interview on 5/30/24 at 11:58 A.M., Housekeeping Supervisor said: -He/She just put hand sanitizer on north hall today; -He/She did not have refills that fit dispensers on north hall; -He/She had Maintenance Supervisor take a dispenser from the closed north hall and put it up in north dining room. Observation on 5/30/24 at 12:18 P.M. showed a new hand sanitizer until was hanging in dining room. During an interview on 5/30/24 at 1:06 P.M., Maintenance Supervisor said: -He/She installed a new hand sanitizer unit in dining room of memory care unit today; -He/She removed a hand sanitizer dispenser from the closed off north hallway and moved to dining room. During an interview on 5/30/24 at 1:10 P.M., HA B said: -Facility had issues getting hand sanitizer in that fit the wall dispenser units; -The supplier discontinued refills and will send different refills that did not fit the dispensers. During an interview on 5/30/24 at 3:03 P.M., Director of Nursing said: -Hand sanitizer should be available on Memory Care Unit; -He/She was not aware of any issues with hand sanitizer being available on Memory Care Unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the call light system was accessible for residents in their rooms when call lights were out of reach for two of twelve sampled resident(Resident #24 and #2), draped over the top of the over the bed light fixtures for two of twelve sampled residents (Resident #29 and #6) and when call lights had no strings attached to the wall units for two (Resident #14 and #21) of twelve sampled residents. The facility census was 29. Review of facility policy, call lights accessibility and timely response, updated [DATE], showed: -Purpose of the facility policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, adn bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. -Each resident will be evaluated ofr unique needs and preference to determine any special accommodations that may be needed in order for the resident to utilize the call system. -Staff will ensure the call light is within reach of resident and secured, as needed. -The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. -Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. 1. Review of Resident #14's Annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed: -He/She had severely impaired cognition; -He/She was dependent for oral hygiene, toileting, bathing, personal hygiene -He/She required substantial/maximal assistance with upper and lower body dressing; -Diagnoses included dementia (condition causing the impairment of two or more brain functions such as memory loss and judgement), anxiety disorder, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), need for assistance with personal care, unsteadiness on feet, generalized muscle weakness, and repeated falls. Review of care plan, dated [DATE], showed: -Staff are to ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Resident needed prompting response to all requests for assistance. Observation on [DATE] at 11:05 A.M. showed resident did not have a call light with in reach. Call light unit on wall had no cord attached to it. 2. Review of Resident #21's Quarterly MDS, dated [DATE], showed: -He/She cognitive status was untestable. -He/She required substantial to maximal assistance with personal hygiene, dressing, toileting, and bathing; -He/She was independent with rolling left and right, sit to lying, lying to sitting, sit to stand, chair to bed transfers, and toilet transfers; -Diagnoses included dementia (a condition characterized by impairment of at least two brain functions such as memory loss and judgement), pain, anxiety disorder, and major depressive disorder. Review of care plan, dated [DATE], showed: -Staff are to ensure/provide a safe environment: Call light with in each, adequate low glare light, keep bed in lowest position and wheels locked, avoid isolation. Observation on [DATE] at 11:05 A.M. showed resident did not have a call light in reach. Call light unit on wall had no cord attached to it. 3. Review of Resident #24's quarterly MDS, dated [DATE], showed: -Resident had severe cognitive impairment; -He/She was dependent for personal hygiene; -He/She was dependent on a wheelchair; -He/She was incontinent of bowel and bladder; -Diagnoses included: brain injury, diabetes (too much sugar in the blood), dementia, anxiety, depression, psychotic disorder, pressure ulcer of left heel, stage 3, need for assistance with personal care; Review of care plan, dated [DATE], showed: -Be sure resident's call light is within reach and encourage the resident to use it for assistance, as needed. He/She needed prompting response to all requests for assistance. Observation on [DATE] at 1:08 PM showed resident had was taken to his/her to room by Registered Nurse A. At 1:12 P.M., Resident said he/she needed to go to bathroom and no staff present. Resident's call light was observed laying on the resident's bed and out of the resident's reach. 4. Review of Resident #29's admission MDS, dated [DATE], showed: -He/She had severe cognitive impairment; -He/She had impairments to both sides of upper extremities; -He/She was dependent on a walker; -He/She was dependent for toileting, putting on shoes, and personal hygiene; -He/She required partial/moderate assistance with bathing, upper, and lower body dressing; -He/She was dependent with mobility; -Diagnoses included alzheimer's disease (a progressive disease that destroys memory and other important mental functions), repeated falls, rheumatoid arthritis (a chronic inflammatory disorder affecting small joints in the hands and feet), generalized muscle weakness. Review of care plan, [DATE], showed: -Resident had an ADL self-care performance deficit due to dementia; -Resident was at moderate risk for falls due to confusion; -Observation on [DATE] at 10:48 A.M., showed resident's call light was draped over the light and hanging above his/her bed. The call light was not in reach. -Observation on [DATE] at 11:50 A.M., showed resident asleep in bed, resident's call light draped over the light hanging above the bed and was not in reach. 5. Review of Resident #6's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -He/She was independent with personal hygiene, dressing, toileting, and mobility; -Diagnosis included Alzheimer's disease a type of dementia that affects memory, thinking, and behavior), and overactive bladder. Observation on [DATE] at 10:38 A.M. showed resident's call light was draped over the over the bed light at the head of the bed, and out of resident's reach. During an interview on [DATE] at 7:53 A.M., CNA D said: -Call lights should be within reach; -Call lights on the unit work; -Resident #14 did not understand call light concept; -Resident #21 did not understand call light concept; -Resident #25 used call light one time During an interview on [DATE] at 12:10 P.M., CNA B said: -Call lights should be laid across a resident's chest; -All rooms got a call light put in them yesterday, the maintenance supervisor went around and checked all the call lights in resident rooms; -There was some residents who did not have a call light string in their room. During an interview on [DATE] at 1:06 P.M., Maintenance Supervisor said: -He/She installed call lights in rooms yesterday and added tubing to the call light strings; -He/She checked all rooms; -room [ROOM NUMBER] did not have any strings attached to the call lights as the strings had broken; -There was other rooms that did not have strings attached to the wall unit but he/she did not remember what rooms he all added strings to. 6. Review of Resident #2's care plan, revised [DATE] showed: - The resident had a communication problem related to dementia (inability to think); - Ensure or provide a safe environment: call light in reach. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Required partial to moderate assistance with oral hygiene, toilet use and showers; - Supervision and touch assistance for transfers; - Always incontinent of bowel and bladder; - Diagnoses included dementia, psychotic disorder ( severe mental disorders that cause abnormal thinking and perceptions) and arthritis. Observation on [DATE] at 9:43 A.M., showed the resident was in bed and the resident's call light was on the floor at the head of the bed and not within the resident's reach. 7. Review of Resident #16's care plan, revised [DATE] showed it did not address the use of the call light. Review of the resident's Quarterly MDS dated [DATE] showed: - Cognitive skills severely impaired; - Dependent on the staff for oral hygiene, toilet use, showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included non - traumatic spinal cord dysfunction (any damage to the spinal cord that has not been caused by a major trauma) and cerebral palsy (CP, a neurological disorder caused by a non - progressive brain injury or malformation that occurs while the child's brain is under development). Observation on [DATE] at 8:52 A.M., showed: - The resident was in bed laying on a a low air loss mattress (medical mattress designed to prevent and treat pressure ulcers (PU, an area of localized damage to skin and underlying tissue caused by pressure, shear, friction and/or a combination of these) on the skin); - The resident's call light was laying on the floor and not within the resident's reach. During an interview on [DATE] at 9:54 A.M., CNA I said: - The call lights should be in reach of the resident's at all times. During an interview on [DATE] at 10:14 A.M., Licensed Practical Nurse (LPN) B said: - The call lights should be in reach of the resident at all times; - If the resident can't use a call light, they can use the flat call lights where they can press on them to make them work. During an interview on [DATE] at 11:01 A.M., LPN A said: - The call lights should not be draped over chairs or bed or be on the floor; - The call lights should be in the resident's reach. During an interview on [DATE] at 3:03 P.M., the Administrator said - The call lights should be in reach of the residents.

Based on observation, record review, and interview the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to use sanitary practice of washing hands and turning off faucet handle with same towel, failed to date food items, failed to check and record temperatures of the refrigerator and freezer units daily, failed to check the dishwasher twice daily prior to washing dishes, failed to temperature check all foods being served to residents, failed to store personal items away from food, and failed to complete daily food temperature log prior to meal service. The facility census was 29. 1. Review of facility policy, proper hand washing and glove use, dated 2020, showed: -All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines. -Proper procedure for washing hands is as following: a. Turn on water as hot as comfortable. b. Wet hands and apply soap. c. Scrub 15 to 20 seconds or more: getting under nails, between fingers, and all exposed areas, such as back of hands and forearms. d. Rinse hands thoroughly. e. Dry hands with paper towel or air dryer. f. Turn off faucet with paper towel. -All employees will wash hands upon entering the kitchen from any other location, after all breaks (including bathroom and smoking breaks), and between all tasks. Hand washing should occur at a minimum of every hour. -Employees will wash hands before and after handling food, after touching any part of the uniform, face, or hair, and before and after working with an individual resident. -Gloves are to be used whenever direct food contact is required. -Hands are washed before donning gloves and after removing gloves. Continuous observation on 5/29/24 starting at 11:15 A.M., showed: -11:38 A.M., Dietary manager washed hands, turned faucet off with paper towel, then used same paper towel to dry his/her hands; -11:43 A.M., Dietary manager washed hands, used paper towel to turn off faucet handle, then used same paper towel to dry his/her hands; -11:59 A.M., Dietary manager washed hands, used paper towel to turn off faucet handle, then used same paper towel to dry his/her hands; -12:00 P.M., Dietary Aide B washed hands, used paper towel to turn off faucet handle, then used same paper towel to dry his/her hands; -12:03 P.M., Dietary Manager washed hands, turned off faucet handle with paper towel and then dried hands with same paper towel; -12:14 P.M., Dietary Manager washed hands, turned off faucet handle with paper towel and then dried hands with same paper towel; -12:27 P.M., Dietary Manager washed hands, turned off faucet handle with paper towel and used same paper towel to dry his/her hands. During an interview on 5/29/24 at 12:20 P.M., Dietary Aide B said: -He/She should wash his/her hands every time he/she opened and closed doors, every time he leaves and re-enters kitchen, anytime he/she touched his/her face; -He/She had training on hand washing; -It was not sanitary to turn off faucet handle with paper towel and use the same paper towel to dry his/her hands; -He/She did use the same paper towel to dry his/her hands with that he/she used to turn off faucet. During an interview on 5/29/24 at 12:33 P.M., Dietary Manager said: -It was not sanitary to use a paper towel to turn off faucet handle and then use same paper towel to dry his/her hands. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -The same towel should not be used to turn off faucet handle and then dry staff's hands, he/she expected staff to use different towel. 2. Review of facility policy, monitoring food temperatures for meal service, dated 2020, showed: -Food temperatures will be monitored to prevent food borne illness and ensure foods are served at a palatable temperature. -Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below. -The temperature of each food item will be recorded on the food temperature log. Observation on 5/27/24 at 8:48 A.M., showed weekly food temperature log dated 5/26/24 to 6/1/24, showed: -No temperatures recorded for breakfast on 5/27/24, breakfast had already been served for the day. Observation on 5/29/24 at 11:45 A.M., in the kitchen of [NAME] A showed he/she temperature checked foods on the steam table and drinks on drink cart. The chicken temperature was 202.1 Fahrenheit (F), mechanical soft chicken 200.0 degrees F, peas showed 190.4 degrees F, pureed pees 180.9 degrees F, gravy 188.0 degrees F, penee pasta 166.6 degrees F, puree pasta 191.8 degrees F. He/She did not temperature check the hamburger patties and carrots which were located on the steam table. He/She did not temperature check the peach crisp which was located on a food cart. [NAME] A recorded temperatures immediately on Food Temperature log. Observation on 5/29/24 at 12:01 P.M. showed [NAME] A added tomato soup to the microwave and turned on two minutes. Observation on 5/29/24 at 12:02 P.M. showed [NAME] A stirred tomato soup with a plastic spoon. Observation on 5/29/24 at 12:04 P.M. showed [NAME] A added a cooked hamburger patty to residents plate to be served. Hamburger patty was not temperature checked before being served. Observation on 5/29/24 at 12:07 P.M., showed [NAME] A obtained tomato soup from microwave, was not temperature checked, and was served to a resident. Observation on 5/29/24 at 12:17 P.M., showed [NAME] A added second bowl of tomato soup to microwave, tomato soup pulled out of microwave and was not temperature checked and served to a resident in the dining room. During an interview on 5/29/24 at 12:28 P.M., Dietary Manager said: -All foods should be temperature checked; -Tomato soup should be temperature checked when removed from the microwave. During an interview on 5/29/24 at 12:34 P.M., [NAME] A said: -He/She did not temperature check the hamburger patties and carrots; -He/She did not think to temperature check the tomato soup coming from the microwave. During an interview on 5/30/24 at 3:03 P.M., Corporate Administrator said: -Food temperatures should be tested before meal service to ensure appropriate temperature. 3. Facility did not provide a policy on sanitation buckets. Observation on 5/27/24 at 9:31 A.M. of Dietary Aide A completing sanitizer bucket test strip showed bucket was at 200 parts per million. Review of sanitizing bucket chemical log, dated April 2024, showed: -The log had no recorded entries for breakfast on 4/20, 4/23, 4/24, and 4/30; -The log had no recorded entries for lunch for entire month; -The log had no recorded entries for dinner on 4/20, 4/27, 4/29, and 4/30. Review of sanitizing bucket chemical log, dated May 2024, showed: -The log had no recorded entries for breakfast on 5/4, 5/5, 5/10, 5/15, 5/22, and 5/27; -The log had no recorded entries for lunch for the entire month; -The log had no recorded entries for dinner on 5/2, 5/12, 5/16, 5/25, 5/26. During an interview on 5/30/24 at 12:58 P.M., Dietary Manager said: -He/She expected logs to be completed daily; -Sanitizer bucket solution should be tested every two hours. 4. Review of facility policy, food storage (dry, refrigerated, and frozen, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. -All food items will be labeled. The label must include the name of the food and the date by which it should be consumed or discarded. -Keep potentially hazardous foods out of the temperature danger zone (41 degrees F to 135 degrees F, or per state specific regulations). -Set refrigerators to the proper temperature. The setting must ensure the internal temperature of the food is 41 degrees F or lower. Place a thermometer in the warmest part of the refrigerator to monitor the air temperature in the refrigerator. -Conduct random temperature checks of food items. -Check freezer temperatures regularly. Review of facility policy, labeling and dating foods, dated 2020, showed: -Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. Observation on 5/27/24 at 8:44 A.M. showed: -Single door refrigerator had: -Two Opened and undated one gallon containers of milk; -Opened and undated 5 pound (lb) container of sour cream; -Opened and undated chocolate syrup; -Dry storage room: -Ear buds in a case was sitting on dry storage rack next to the food; -Cell phone and charger was laying on top of a box of pudding on the dry storage rack and plugged into the outlet behind the dry storage food rack; -Styrofoam cup filled with ice sitting on wire dry storage food rack; -Spice rack: -Opened onion powder dated 2/9, no year; -Opened parsley, tape showed refilled 2/2, no year; -Opened 10 oz oregano, showed received 1/12, no opened date; -Unclear labeling when a container labeled with masking tape had salt written on it, red marker writing showed 10/25, black marker writing was written over top of red marker showed 3/11/24; -Opened black pepper dated 2/13, do not have year; -Opened chopped onion, 3 lb, dated 4/9 did not have year. Review of Refrigerator/Freezer temperature log, dated April and May 2024 ,showed: Upstairs Freezer: -No temperature recorded for morning readings on 4/3, 4/8, 4/14, 4/20, 4/23, 4/24, 4/30, 5/5, 5/22, 5/27; -No temperature recorded for evening readings on 4/6, 4/7, 4/13, 4/20, 4/26, 4/27, 4/29, 4/30, 5/2, 5/6, 5/11, 5/12, 5/16, 5/21, 5/25, and 5/26; Reach in refrigerator: -No temperature recorded for morning readings on 4/3, 4/8, 4/11, 4/14, 4/20, 4/23, 4/24, 4/30, 5/4, 5/5, 5/10, 5/15, 5/22, 5/27; -No temperature recorded for evening readings on 4/3, 4/6, 4/7, 4/13, 4/20, 4/26, 4/27, 4/29, 4/30, 5/2, 5/6, 5/11, 5/12, 5/16, 5/20, 5/21, 5/25, and 5/26; Milk Refrigerate: -No temperature recorded for morning readings on 4/3, 4/8, 4/11, 4/14, 4/20, 4/23, 4/24, 4/30, 5/4, 5/5, 5/10, 5/22, and 5/27; -No temperature recorded for evening readings on 4/3, 4/6, 4/7, 4/10, 4/13, 4/20, 4/26, 4/27, 4/29, 4/30, 5/2, 5/6, 5/11, 5/12, 5/20, 5/21, 5/25, and 5/26; Downstairs Freezer: -No temperature recorded for morning readings on 4/3, 4/8, 4/11, 4/14, 4/20, 4/23, 4/24, 4/30, 5/15, and 5/27; No temperature recorded for evening readings on 4/3, 4/6, 4/7, 4/10, 4/13, 4/20, 4/21, 4/27, 4/29, 4/30, 5/2, 5/6, 5/11, 5/12, 5/16, 5/20, 5/21, 5/25, and 5/26; During an interview on 5/30/24 at 12:58 P.M., Dietary Manager said: -Logs should be completed daily; -Food should be dated when opened; -Opened milk should have an opened date written on it; -Spices should be dated when opened; -Spices should include a year on the date it was opened; -He/She expected packages to have two dates, one date written when item was received in kitchen and a second date written when item package was opened; -Employee personal items should not be stored in dry storage room. During an interview on 5/30/24 at 3:03 P.M., Corporate Administrator said: -Expected food to be dated when it was opened; -Spices should be labeled with the years; -Temperatures of refrigerators and freezers should be tested every day; -Personal items should not be stored near food; -Phone resting on food on dry storage rack is not appropriate storage. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -He/She expected spices to be dated with year; -Food should be dated when opened. 5. Review of facility policy, Dishwashing: Machine Operation, dated 2020, showed: -Check the dishwashing machine before first use. If the dishwashing machine has not been used for several hours, it is recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper functions. -Record log documents twice daily for either final rinse temperature or sanitizer concentration (low-temperature dishwashing machine with chemical sanitizer) Observation on 5/27/24 at 8:44 A.M. showed Dietary Aide A was running dishes through the low temperature dishwasher. Wash cycle observed showed temperature was at 120 degrees. Dietary Aide A ran a test strip which showed 100 parts per million (PPM) which was appropriate sanitation. Dietary Aide A then wrote test strip down on dishwasher machine log. Several cycles of dishes had already been washed and no test had been recorded in log book for 5/27/24 until requested observation was completed. During an interview on 5/27/24 at 8:48 A.M., Dietary Aide A said: -He/She recorded tests of dishwasher once per shift; -There were two shifts daily that recorded temperatures of low temperature dish washer; -He/She ran test strip any time during his/her shift. Review of dishwasher machine log, dated May 2024, showed: -No reading 5/2/24, 5/12/24, 5/16/24, 5/25/24, 5/26/24, 5/27/24 for P.M. shift; -No reading on 5/4/24, 5/5/24, 5/10/24, 5/15/24 for day shift. During an interview on 5/30/24 at 12:58 P.M., Dietary Manager said: -Logs needed to be completed daily; -Dishwasher should be tested twice daily; -Testing should be done when staff arrive in the morning before 7:00 A.M. and around 3:00 P.M.; -The dishwasher should have run a couple of cycles before it was first tested to ensure the unit was heated up to proper sanitation temperatures; -He/She expected to complete log book right after testing was completed. During an interview on 5/30/24 at 3:03 P.M., Corporate Administrator said: -Dishwasher sanitizer should be tested weekly to monthly, whatever the policy read.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to report allegations of resident to resident sexual abuse to the Department of Health and Senior Services (DHSS) in the required time frame for three residents (Residents #1, #2, and #3). The facility census was 29. Review of the facility's Abuse and Neglect Policy, dated 2/21/17, included: - Any and all types of allegations will be investigated. - The Administrator and the Director of Nursing (DON) will be responsible for conducting, investigating and reporting the results to the proper authorities. The Administrator or DON will ensure allegations are investigated by conducting staff and resident interviews, conducting and completing assessments, making observations, and reporting allegations to the Missouri Department of Health and Senior Services. 1. Review of Resident #1's Annual Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 11/8/23, showed staff assessed the resident as: - Moderate cognitive impairment; - Independent with mobility, transfers, walking, and eating; - Required 1 person for oversight with bathing, dressing, personal hygiene, and wandering; - Diagnoses of dementia and depression. Review of the resident's care plan, dated 11/17/23, showed: - One person physical assistance for personal hygiene, showers, and dressing; - Independent with walking, transfers, and mobility; - Takes medication for depression and administered by facility staff; - At risk for elopement, requires a secured unit. - No behaviors or staff interventions were care planned. Review of the resident's Nursing Progress/Behavioral Notes for the month of January 2024, showed: - On 1/9/24, resident wandered into three different resident rooms, staff redirected each time and resident was verbally abusive with the staff. Resident also displayed sexual inappropriateness towards residents. Physician was notified and a urine culture was ordered; - On 1/20/24, resident displaying sexual behaviors towards another resident, was re-directed away from the residents. Physician and family notified. 2. Review of Resident #2's Annual MDS, dated [DATE], showed staff assessed the resident as: - Cognitively impaired; - Independent with ambulation and eating; - Required staff assistance for all personal hygiene, grooming, dressing, and decision-making; - Diagnoses of dementia, anxiety, depression, and wandering. Review of the resident's Care Plan, dated 12/20/23, showed: - Required assist of one nursing staff for personal hygiene, grooming, and decision-making related to impaired cognition; - An elopement risk and often wanders; - No behaviors or staff interventions were care planned. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as: - Severe cognitive impairment; - Required one person physical assist for all personal hygiene, grooming, dressing, and decision-making; - Independent of mobility, ambulation, transfers, walking, and eating; - Diagnoses of dementia, depression, and elopement risk. Review of the resident's care plan, dated 12/6/23, showed: - Resident required supervision on the secured unit; - Anticipate and meet all needs of the resident; - No information regarding behaviors or the interventions for the resident residing on the secured unit; - No behaviors were care planed. 4. During an interview on 2/2/24 at 10:05 A.M., the facility transportation aide said: - On 1/19/24, he/she and Licensed Practical Nurse (LPN) B were searching for Resident #3, as the resident had a doctor's appointment that day. After searching every room on the hall, the transportation aide and LPN B saw a bathroom door open going into a non-occupied resident room. - Upon entry through the bathroom into the empty room, both the transport aide and LPN B saw Resident #1 completely naked, sitting on the bed with Resident #3 who was clothed. Resident #1 guided Resident #3's hand onto Resident #1's genitalia and encouraged Resident #3 to manually stimulate Resident #1. - He/she did not report it to anyone because LPN B was in the room and witnessed the activity as well. - It wasn't until a week later when he/she overheard staff talking about Resident #1 with another resident that it triggered him/her to report what he/she witnessed to the Administrator. During an interview on 2/2/23 at 2:15 P.M., LPN B said: - On 1/19/24, he/she witnessed Resident #1 naked and alone sitting on the bed with Resident #3, who was clothed. Resident #1 had his/her hand on Resident #3's hand on top of Resident #1's genitals. - He/She and transportation aid immediately separated them. - He/She stated reported the inappropriate behavior and resident to resident interaction to the charge nurse on duty, who was LPN A. - He/She did not report it the Administrator and did not know that he/she needed to. During an interview on 2/2/23 at 11:45 A.M., the Administrator said: -She was unaware of any incident between Resident #1 and Resident #3 until it was reported to her by the transportation aide on 2/1/24 and then a facility self-report was completed and an investigation started. - She would expect any staff member concerned with abuse or who has witnessed abuse or inappropriate behavior between residents to report immediately to the Administrator and/or DON in addition to the charge nurse on duty. During an interview on 2/22/24 at 4:05 P.M., LPN A said: - He/She did not realize initially that there had been physical sexual touching between Resident #1 and Resident #3 during the incident on 1/19/24. - He/She did not remember who reported it to the DON but was made aware by Administration that all concerns of possible inappropriate behavior between residents need to be fully investigated and followed up on by administration and nursing staff. -He/She should have reported it to administration, and started 15 minute checks on Resident #1. 5. During an interview on 1/25/24 at 1:31 P.M., Certified Medication Technician (CMT) A, said: - On 1/20/24, he/she saw Resident #1 take Resident #2 by the hand and walk into an empty room together at the end of the hall. - The door was closed and CMT A opened the door and saw Resident #1 with his/her pants down to his/her ankles and observed Resident #2 standing in front of Resident #1 with Resident #1's genitalia in the hands of Resident #2. - He/She immediately separated both Residents #1 and #2, and Resident #1 pulled up his/her pants and rushed out of the room quickly to separate his/herself from the situation. -He/She immediately reported the interaction between the two residents to the nurse on duty, LPN A. During an interview on 1/25/24 at 2:02 P.M., LPN A, said: - He/She was unaware that Resident #1 and Resident #2 had physical contact with each other. - He/She recalled the two being found together, but could not remember who reported it to him/her. - He/She was not certain it was reported to the DON or DHSS. - He/She notified Resident #1's family, and did not notify Resident #2's family but should have. - He/She said anyone could file a complaint with the adult abuse hotline at any time. During an interview on 1/25/24 at 2:20 P.M., the DON said: - He/She was not aware of the sexual physical interaction between Resident #1 and Resident #2 on 1/20/24. - It should have been reported to him/her, the family of both, the Administrator, and DHSS. - He/She understood that she could self-report any concerns or allegations of abuse at any time to DHSS. - Anyone could report allegations or observations of abuse to DHSS at any time. During an interview on 1/25/24 at 3:05 P.M., the Administrator said: - The observed interaction between Resident #1 and Resident #2, should have been self-reported to the state survey agency. - She was not aware that physical contact had occurred between Resident #1 and Resident #2. - She would expect that all responsible family or guardian would be notified of this type of sexual behaviors. - She would also expect any allegation of abuse to be reported to DHSS. - All allegations of abuse should be self-reported to DHSS within 2 hours of knowing about the allegations of abuse. - The allegations regarding Resident #1's behavior with Residents #2 and #3 should have been self-reported to DHSS. During an interview on 1/26/24 at 9:30 A.M., the family/guardian of Resident #2, said: - Resident #2 had a history of sexually inappropriate behavior at the current facility and other facilities. - He/She was notified of the most recent encounter between Resident #2 and Resident #1 on the morning of 1/26/24, approximately 6 days after the event occurred. During an interview on 2/2/23 at 1:35 P.M., the DON said: - All witnessed and reported concerns with abuse or residents behaviors should be reported immediately to her, the Administrator, and the charge nurse. - All events surrounding such events are to be documented in the clinical record, and physician and guardian/family notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow facility policy and thoroughly investigate allegations of resident to resident sexual abuse for three residents (Residents #1, #2, and #3). The facility census was 29. Review of the facility's Abuse and Neglect Policy, dated 2/21/17, included: -The facility staff will help identify risk factors for abuse in the facility, for residents with unmanaged problematic behaviors, and staff training that is lacking in knowledge of management in behaviors. -The facility management team will institute measures to address the needs of residents to minimize the possibility of resident abuse. -Any and all types of allegations will be investigated. The Administrator and the Director of Nursing (DON) will be responsible for conducting, investigating and reporting the results to the proper authorities. The Administrator or DON will ensure allegations are investigated by conducting staff and resident interviews, conducting, and completing assessments, making observations, and reporting allegations to the Missouri Department of Health and Senior Services. 1. Review of Resident #1's Annual Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 11/8/23, showed staff assessed the resident as: - Moderate cognitive impairment; - Independent with mobility, transfers, walking, and eating; - Required 1 person for oversight with bathing, dressing, personal hygiene, and wandering; - Diagnoses of dementia and depression. Review of the resident's care plan, dated 11/17/23, showed: - One person physical assistance for personal hygiene, showers, and dressing; - Independent with walking, transfers, and mobility; - Takes medication for depression and administered by facility staff; - At risk for elopement, requires a secured unit. - No behaviors or staff interventions were care planned. Review of the resident's Nursing Progress/Behavioral Notes for the month of January 2024, showed: - On 1/6/24, resident was observed walking into another resident's room and became verbally abusive with staff when they attempted to redirect the resident; - On 1/9/24, resident wandered into three different resident rooms, staff redirected each time and resident was verbally abusive with the staff. Resident also displayed sexual inappropriateness towards residents. Physician was notified and a urine culture was ordered; - On 1/20/24, resident displaying sexual behaviors towards another resident, was re-directed away from the residents. Physician and family notified. 2. Review of Resident #2's Annual MDS, dated [DATE], showed staff assessed the resident as: - Cognitively impaired; - Independent with ambulation and eating; - Required staff assistance for all personal hygiene, grooming, dressing, and decision-making; - Diagnoses of dementia, anxiety, depression, and wandering. Review of the resident's Care Plan, dated 12/20/23, showed: - Required assist of one nursing staff for personal hygiene, grooming, and decision-making related to impaired cognition; - An elopement risk and often wanders; - No behaviors or staff interventions were care planned. Review of Resident #2's Nursing Progress/Behavioral notes for the month of January 2024, showed no documentation regarding sexual inappropriate behaviors or that resident had a history of sexual behaviors with other residents. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as: - Severe cognitive impairment; - Required one person physical assist for all personal hygiene, grooming, dressing, and decision-making; - Independent of mobility, ambulation, transfers, walking, and eating; - Diagnoses of dementia, depression, and elopement risk. Review of the resident's care plan, dated 12/6/23, showed: - Resident required supervision on the secured unit; - Anticipate and meet all needs of the resident; - No information regarding behaviors or the interventions for the resident residing on the secured unit; - No behaviors were care planed. 4. During an interview on 2/2/24 at 10:05 A.M., the facility transportation aide said: - On 1/19/24, he/she and Licensed Practical Nurse (LPN) B were searching for Resident #3, as the resident had a doctor's appointment that day. After searching every room on the hall, the transportation aide and LPN B saw a bathroom door open going into a non-occupied resident room. - Upon entry through the bathroom into the empty room, both the transport aide and LPN B saw Resident #1 completely naked, sitting on the bed with Resident #3 who was clothed. Resident #1 guided Resident #3's hand onto Resident #1's genitalia and encouraged Resident #3 to manually stimulate Resident #1. - He/she did not report it to anyone because LPN B was in the room and witnessed the activity as well. - It wasn't until a week later when he/she overheard staff talking about Resident #1 with another resident that it triggered him/her to report what he/she witnessed to the Administrator. During an interview on 2/2/23 at 2:15 P.M., LPN B said: - On 1/19/24, he/she witnessed Resident #1 naked and alone sitting on the bed with Resident #3, who was clothed. Resident #1 had his/her hand on Resident #3's hand on top of Resident #1's genitals. - He/She reported the inappropriate behavior and resident to resident interaction to the charge nurse on duty, who was LPN A. - He/She did not report it the Administrator. During an interview on 2/2/23 at 11:45 A.M., the Administrator said: -She was unaware of any incident between Resident #1 and Resident #3 until it was reported to her by the transportation aide on 2/1/24 and then a facility self-report was completed and an investigation started. - She would expect any staff member concerned with abuse or who has witnessed abuse or inappropriate behavior between residents to report immediately to the Administrator and/or DON in addition to the charge nurse on duty. During an interview on 2/22/24 at 4:05 P.M., LPN A said: - He/She did not realize initially that on the incident of 1/19/24 there had been physical sexual touching between Resident #1 and Resident #3. - He/She did not remember who had reported it to the DON but was made aware by Administration that all concerns of possible inappropriate behavior between residents need to be fully investigated and followed up on by administration and nursing staff. -He/She should have completed a full investigation, reported it to administration, and started 15 minute checks on Resident #1. 5. During an interview on 1/25/24 at 1:31 P.M., Certified Medication Technician (CMT) A, said: - On 1/20/24, he/she saw Resident #1 take Resident #2 by the hand and walk into an empty room together at the end of the hall. - The door was closed and CMT A opened the door and saw Resident #1 with his/her pants down to his/her ankles and observed Resident #2 standing in front of Resident #1 with Resident #1's genitalia in the hands of Resident #2. -He/She immediately reported the interaction between the two residents to the nurse on duty, LPN A. During an interview on 1/25/24 at 2:02 P.M., LPN A, said: - He/She was unaware that Resident #1 and Resident #2 had physical contact with each other. - He/She recalled the two being found together but could not remember who reported it to him/her. - He/She did not write up an investigation or investigate and could not remember the date of the occurrence between Resident #1 and Resident #2. - He/She wasn't sure if Resident #2 was charted on when the two residents were found together, but it should have been in the chart. - He/She was not certain it was reported to the DON. During an interview on 1/25/24 at 2:20 P.M., the DON said: - He/She was not aware of the sexual physical touching between Resident #1 and Resident #2 on 1/20/24. - It should have been reported to him/her, the family of both, and the Administrator and DHSS. - He/She did not complete an investigation but should have. During an interview on 1/25/24 at 3:05 P.M., the Administrator said: - The observed interaction between Resident #1 and Resident #2, should have been investigated and documented. - She was not aware that physical contact occurred between Resident #1 and Resident #2.

Based on record review and interviews, the facility failed to ensure they maintained a surety bond in an amount to cover any loss of theft to residents' money held in the facility's Resident Trust Fund (RTF) account which affected all residents who had money held in their RTF account. The facility census was 39. Review of facility policy Resident Funds/Trust - Surety Bond, not dated, showed: -It is the policy of facility to ensure that the facility maintains a surety bond for the safety of resident trust. -A surety bond is to be 1.5% of the total of the current balance. -If the required surety bond total is larger than the current bond it must be increased. -The facility insurance agent will be contacted to increase the surety bond. Review of the facility's surety bond letter, approved on 08/28/20, showed a amount of $40,000. Review of the RTF worksheet, completed on 10/05/2022, showed: -The average monthly balance for the facility's interest bearing account of $29,755.83; -The approved bond amount for this average monthly balance (Grand Total rounded to the nearest thousand x 1.5 = required bond amount) should be at least $45,000.00. During an interview on 10/05/22 at 11:36 A.M. the Administrator said: -He/she was in charge of all funds right now, since the last Business Office Manager (BOM) left; -The bond amount should be reviewed at least yearly. -The bond review had not been done due to COVID.

Based on observations, record review, and interviews, the facility failed to ensure staff prepared foods in a form designed to meet the needs of individual residents when they did not ensure the puree (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency. This affected three residents identified by the facility as having orders for a pureed diet (Residents #8, #9, and #37). The facility census was 39. Review of the facility's Therapeutic Diets Policy, revised October 2017, showed: - Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes; - A therapeutic diet is considered a part of treatment for a clinical condition, to modify nutrition or to alter the texture of the a diet for example: Altered consistency diet. Review of the facility's Puree Food Preparation Policy, revised November 2017, showed: - Pureed Diet: o Puree foods should be prepared in such a manner to prevent lumps or chunks; o The goal is a smooth, soft homogenous consistency similar to mashed potatoes. Observation of meal preparation for lunch on 10/5/22 at 11:05 A.M., showed: - The dietary manager began preparing the pureed lunch meal; - He/she placed two cups of cooked pulled pork into the food processor; - He/she then turned on the food processor and began adding pork broth and blended until it was the desired consistency; - The mixture was thick with visible pea sized chunks in it. Observation of meal preparation for lunch on 10/5/22 at 11:15 A.M., showed: - The dietary manager placed two cups of baked sweet potatoes fries into the food processor; - He/she added warm milk and blended until it was the desired consistency; - The mixture was thick and hard to stir. Observation of lunch service on 10/5/22 at 11:55 A.M., showed: -Residents #8, #9, and #37 being served their pureed meals that were thick and had chunks in it. Observation of pureed lunch meal on 10/5/22 at 12:12 P.M., showed: - Pureed pulled pork: was very thick and allowed a spoon to remain standing. The mixture had particles of pork, similar to the consistency of rice, that required chewing; - Pureed sweet potatoes fries were very thick and allowed a spoon to remain standing with pieces of sweet potatoes the size of a pea that required chewing; - Pureed beans were very thick and allowed a spoon to remain standing and hard to swallow. During an interview on 10/5/22 at 1:36 P.M., the Dietary Manager said: - Pureed food should be a smooth, pudding-like consistency with no chunks or particles; - He/she did not feel the pureed food was the wrong consistency; - He/she did not realize the pureed food was chunky. During an interview on 10/5/2022 at 2:26 P.M., the Administrator said: - There should be no chunks of food in the pureed food; - Pureed food should not be lumpy; - Pureed food should not be hard to swallow. During an interview on 10/6/22 at 9:48 A.M., the Registered Dietitian said: - Pureed food should be a pudding-like consistency; - There should be no particles in the pureed food; - The pureed food should not be thick and hard to swallow.

Based on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 39. The facility did not provide a policy addressing kitchen sanitation or storage of toxic materials. Review of the manufacturer's instructions for the Low Temp Sanitizer Solution, dated 3/16/16, showed: - Directions for use: o Use a chlorine test kit and increase dosage as necessary to obtain the desired level of available chlorine; o Solutions containing an initial concentration of 100 parts per million (ppm) available chlorine must be tested and adjusted to insure that the available chlorine does not drop below 50 ppm. Review of the manufacturer's instructions for the sanitizer test strips, dated 8/5/22, showed: - Dip the strip into the sanitizing solution for 10 seconds; - Instantly compare the resulting color with color chart on label; - Chart on label showed: o 100 ppm - olive green, 200 ppm - aqua green, and 400 ppm - dark turquoise. 1. Review of the chemical sanitation log for the dishwasher showed there were no entries indicating the sanitation level had been checked on the following days: - 7/4/22 and 7/7/2022 through 7/20/22; - 8/1/22, 8/2/22, 8/8/22, 8/13/22 through 8/15/22, and 8/25/22; - 9/5/22, 9/6/22, and 9/8/22. 2. Observation and interview on 10/5/22 at 9:10 A.M., showed: - Dietary Aide A washed dishes in the two compartment sink then ran them through dishwasher; - Dietary Aide A did not check the chemical sanitizer in the dishwasher. - He/she was not sure how to check the level of chemical sanitizer in the dishwasher; - He/she had not checked the level of the chemical sanitizer in the dishwasher; - Dietary Aide A said the dishwasher should have the proper amount sanitizer in it since that was how he/she sanitizes dishes because the facility does not have a three compartment sink; - He/she would find out how to check the sanitizer in the dishwasher. Observation and interview on 10/5/22 at 9:35 A.M., showed: - Dietary Aide A checked the sanitizer in the dishwasher by dripping a white sanitizer testing strip in the dishwasher for 10 seconds; - The strip remained white; - Dietary Aide A used another sanitizer testing strip to test the sanitizer in the dishwasher and strip did not change color. - He/she thought the strip should change color if there was sanitizer chemical in the dishwasher; he/she would have to talk to the dietary manager. 3. Observation of the kitchen on 10/5/22 at 9:55 A.M., showed: - Eight cracked tiles along the wall under dishwasher; - A large piece of cardboard laying on the floor under the two compartment sink that was wet and had soaps suds on it; - A large square piece of linoleum curled up on four sides with missing pieces, coming off of the floor under the two compartment sink; - The baseboard broken in pieces and coming away from the wall under the two compartment sink; - Two chipped floor tiles by the door that goes to the dining room from the kitchen; - Black substance and debris on the wall under the dishwasher; - Paint peeling from the ceiling above a shelf with a basket with silverware in it; - The lining on the shelf under the steamtable with pots and pans on it peeling off; - A black substance on the seal of the upright freezer containing vegetables in the basement; - The chest freezer in the basement containing bread had a coating of ice three to four inches thick on the bottom and sides of the inside of the freezer and no thermometer was found; - Five metal bowls stored face up under the prep table; - Two loaf pans and two muffin pans stored face up on the shelf under the steam table. Observation of the dry goods storage on 10/5/22 at 10:07 A.M., showed: - The door of the dry goods storage room was open; - A can of industrial strength oven cleaner sat on the floor next to the shelf containing five bags of pasta. 4. During an interview on 10/5/22 at 2:19 P.M., the dietary manager said: - The chemical sanitizer in the dishwasher should be checked daily; - The sanitizing strip should change color to indicate the sanitizer level in the dishwasher; - If the strip remains white that means there is no measurable amount of sanitizer in the dishwater; - The level of the sanitizer should be 50 - 100 ppm; - The level of sanitizer should be recorded in the log at least daily; - An outside company is responsible for coming out to change the sanitizing solution every two weeks; - The sanitizing chemical ran out this morning; - Dishes should be sanitized after washing in the two compartment sink; - Bowls and cups should be stored in a manner that will prevent contamination; - All refrigerators and freezers should be clean and free of excess ice build up; - All refrigerators and freezers should have thermometers; - The kitchen staff is responsible for keeping the kitchen, freezers and refrigerators clean; - Toxic materials should be stored away from food; - Repairs to the kitchen reported to the maintenance department and written in the maintenance log. During an interview on 10/5/22 at 2:28 P.M., the Maintenance Director said: - He/she knew the floor under the sink in the kitchen needed repaired; - Repairs needed in the kitchen are written in the maintenance log behind the nurses' desk; - He/she was waiting on a good time to get in the kitchen to fix the floor. During an interview on 10/5/22 at 3:16 P.M. the Administrator said: - The kitchen should be clean and in good repair; - The dishwasher sanitizer should be checked daily to ensue the dishes are being sanitized correctly; - The kitchen staff is responsible checking and recording the chemical sanitation level in the dishwasher; - Toxic chemicals should not be stored in the dry goods storage area with food; - Bowls and kitchen utensils should be stored in way to prevent contamination; - The maintenance department is responsible for repairs to the kitchen; - The maintenance log should be utilized for maintenance requests; - She was not aware the floor was damaged under the two compartment sink.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician sign the Out of Hospital Do Not Resuscitate form (OHDNR, it instructs health care providers not to begin cardiopulmonary resuscitation, or CPR, if the resident's breathing stops or if a resident's heart stops beating) which affected one of 12 sampled residents (Resident #29). The facility census was 40. 1. Review of the facility's Do Not Resuscitate (DNR) order policy, revised [DATE], showed, in part: - The facility will not use CPR and related emergency measures to maintain life functions on a resident when there is a DNR Order in effect; - The DNR order form must be completed and signed by the attending physician and the resident (or the resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record. 2. Review of Resident #29's face sheet, showed: - The resident's admission date was [DATE]; - The resident had a guardian; - The resident was a DNR. Review of the resident's purple OHDNR order, dated [DATE], showed: - The form was signed the resident's guardian; - The form had not been signed by the physician. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: - Cognitive skills moderately impaired; - Had verbal behaviors toward others; - Required extensive assistance of one staff for bed mobility, transfers, dressing and toilet use; - Upper and lower extremities impaired on one side; - Diagnoses included cancer, dementia and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). Review of the resident's physician order sheet (POS), dated [DATE], showed: - The resident was a DNR. Review of the resident's undated care plan, showed: - Discharge planning: the resident had a guardian, did not have a plan to move the resident from the facility and the resident was a DNR. During an interview on [DATE], at 11:17 A.M., the Social Services Designee (SSD) said: - The physician should have already signed it; - He/she had missed getting the physician to sign it. During an interview on [DATE], at 3:22 P.M., the Director of Nursing (DON) said: - Social Services was responsible to make sure the OHDNR forms were signed and placed in the resident's chart; - It should take about a week from admission for the physician to sign the OHDNR and place it in the resident's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided written notices of transfer or discharge to residents or their responsible parties and the reasons for the transfer in writing in a language they understood. This affected two of 12 sampled residents (Residents #8 and #36). The facility census was 40. 1. The facility did not provide a policy related to transfer and discharge of a resident. 2. Review of Resident #8's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility and dressing; - Dependent on two staff for transfers and toilet use; - Lower extremity impaired on both sides; - Had a Foley catheter (a sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - Diagnoses included urinary tract infections (UTI) in the last 30 days, diabetes mellitus and paraplegia (characterized by motor or sensory loss in the lower limbs and trunk). Review of the resident's hospital bed hold policy letter, dated [DATE], at 4:15 P.M., showed: - The charge nurse (CN) documented the resident's name on the letter and signed the letter. Review of the resident's long term care handoff communication form, dated [DATE], at 4:20 P.M., showed: - Form is used when the resident is transferred to the local hospital; - The reason for the transfer was an elevated temperature; - The resident was a full code; - The resident was transported by ambulance to the local hospital and report was given to the hospital staff. Review of the resident's notes, showed: - [DATE], at 4:21 P.M.: Had a temperature of 103 degrees and 600 milligrams (mg) of ibuprofen (used to treat pain and reduce pain or inflammation). Resident's temperature was rechecked at 4:00 P.M., and was 102.7 degrees. Vital signs obtained; the physician was notified with order to send the resident to the local hospital for evaluation and treatment. The resident called his/her mother prior to discharge; - [DATE] at 6:58 P.M.: the resident returned to the facility by ambulance at 5:45 P.M.; - The resident's medical record did not show a letter of reason for the transfer/discharge to the hospital or sent to the responsible party. During an interview on [DATE], at 9:53 A.M., the resident said: - He/she was in the hospital last week for a UTI; - He/she gets UTIs all the time. 3. Review of Resident #36's quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Limited assistance of two staff for bed mobility and transfers; - Required extensive assistance of two staff for dressing; - Required extensive assistance on one staff for toilet use; - Frequently incontinent of urine; - Diagnoses included congestive heart failure (CHF, a decrease in the ability of the heart to pump blood, resulting in an accumulation of fluid in the lungs and other areas of the body) and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing and anxiety). Review of the resident's hospital bed hold policy letter, dated [DATE], at 9:21 P.M., showed: - The CN documented the resident's name on the letter and signed the letter. Review of the resident's long term care handoff communication form, dated [DATE], at 9:25 P.M., showed: - The reason for the transfer was because the resident had a slow heart rate; - The resident was a Do Not Resuscitate (DNR, it instructs health care providers not to begin cardiopulmonary resuscitation, or CPR, if the resident's breathing stops or if a resident's heart stops beating); - The resident was transported by ambulance to the local hospital and report was given to the hospital staff. Review of the resident's transfer summary, dated [DATE], at 9:35 P.M., showed: - The resident was transferred to the emergency room for evaluation and treatment related to a slow heart rate ranging from 35 - 44 beats per minute and shortness of air. Review of the resident's notes, showed: - [DATE], at 10:23 A.M.: The resident was sent to the local hospital. The local hospital sent the resident to another hospital for further treatment. Return is anticipated; - [DATE], at 8:45 P.M.: The resident returned from the hospital at 6:05 P.M.; - The resident's medical record did not show a letter of reason for the transfer/discharge to the hospital or sent to the responsible party. During an interview on [DATE], at 4:10 P.M., the Social Services Designee (SSD) said: - When a resident was transferred out, the facility sent a transfer sheet to the physician, the family would be notified by phone and the nurses would do a bed hold letter; - He/she sends the Ombudsman a monthly report of discharges and transfers; - He/she was not aware a written letter had to be sent to the resident or the responsible party. During an interview on [DATE], at 3:22 P.M., the Director of Nursing (DON) said: - She was not aware they had to provide written notification when the resident was transferred or discharged .