**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to initiate a new PASARR (Pre-admission Screening and Resident Review) Level One for one of four residents (Resident (R) 21) reviewed for PASARR to reflect new psychiatric diagnoses out of a total sample of 18 residents. The failure to maintain a PASARR Level One that reflected the new diagnoses of R21 had the potential to delay or limit necessary assistance should R21 experience a psychiatric episode that disrupted her daily life. The facility census is 28. Review of the Census tab in the electronic medical record (EMR) revealed R21 was originally admitted on [DATE]. Review of the Level One Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability, or Related Condition signed by the hospitalist on 11/30/21 prior to R21's admission to the facility and provided by the Administrator revealed the screening form contained the demographics fields to be complete, but the medical/psychiatric questions were unanswered, and the fields were blank. The pre-admission screening did not indicate whether the result was positive or negative for the need of a PASRR Level Two. Review of the Med Diag [Medical Diagnoses] tab of the EMR revealed R21 was diagnosed with major depressive disorder on 10/20/22 and bipolar two disorder on 02/07/23. Review of the Orders tab in the EMR revealed divalproex (anticonvulsant used for manic phase of depressive disorder) 125mg capsule twice a day related to major depressive disorder initiated on 10/18/22 and Cymbalta (antidepressant) 60mg capsules once daily related to major depressive disorder initiated on 12/11/22. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/03/23 under the MDS tab in the EMR revealed R21 had depression (other than bipolar) and bipolar disorder indicated as current diagnoses. Review of the Misc (Miscellaneous) tab in the EMR revealed several psychiatric notes related to R21's diagnoses and behaviors. In an interview on 03/14/25 at 9:20 AM, the Social Services (SSD) staff verified that there was no updated PASRR Level One to reflect R21's current diagnoses of major depressive disorder or bipolar II disorder. She confirmed a new screening should have been completed with each new diagnosis. A PASRR policy was requested for from the Administrator and SSD staff; no policy was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to provide a PASARR (Pre-admission Screening and Resident Review) Level One for one of four residents (Resident (R)21) reviewed for PASARR to reflect a positive or negative screen result out of 18 sample residents. The failure to maintain a PASARR Level One that reflected either a positive or negative screen result had the potential to limit or delay the assistance needed for R21 should R21 experience a psychiatric episode. The facility census is 28. Review of the Census tab in the electronic medical record (EMR) revealed R21 was originally admitted on [DATE]. Review of the Med Diag (Medical Diagnoses) tab of the EMR revealed that R21 was diagnosed with morbid obesity and dysphagia. There was no reference to a psychiatric diagnosis. Review of the Level One Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability, or Related Condition signed by the hospitalist on 11/30/21 prior to R21's admission to the facility on [DATE] and provided by the Administrator revealed the screening form contained the demographics fields to be complete, but the medical/psychiatric questions were unanswered, and the fields were blank. The pre-admission screening did not indicate whether the result was positive or negative for the need for a PASRR Level Two. In an interview on 03/14/25 at 9:20 AM the Social Services (SSD) staff, verified the provided PASRR form from 11/30/21 did not show any psychiatric questions answered nor did the form state if the PASRR screen produced a positive or negative result. The SSD staff stated the point tally indicated on the first page is used for purposes of determining if the person can be admitted to a nursing facility. The SSD staff confirmed the PASRR Level One in R21's chart was incomplete. Review of the facility policy admission Criteria revised March 2019 provided by the Administrator revealed, all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) Process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure showers were provided per resident preference for one of 18 sampled residents (Resident (R)18). This deficient practice had the potential for residents dependent on staff to not maintain personal hygiene and not maintain participation in activities of daily living. The facility census is 28. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting revised March 2018, revealed, Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation l. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with a. hygiene (bathing, dressing, grooming, and oral care) . Review of R18's admission Record located in the electronic medical record (EMR) under the Profile tab indicated R18 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (stroke) due to embolism of right middle cerebral artery, hemiplegia and hemiparesis of left non-dominant side, and major depression. Review of R18's EMR revealed a quarterly Minimum Data Set (MDS) assessment located under the MDS tab with an Assessment Reference Date (ARD) of 12/13/24 revealed a Basic Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. ADLs were assessed as maximal assistance of two staff. Review of the R18's EMR revealed a revised care plan dated 07/20/23, located under the Care Plan tab that indicated R18 had limited physical mobility and preferred showers. Review of the Daily Shower Schedule updated 02/14/25 located at the nurse's station revealed R18 was scheduled for showers on Tuesdays, Thursdays, and Saturdays. During an interview on 03/11/25 at 1:33 PM, R18 stated he wanted showers three times a week and he had not showered in the last six days. When asked why he had not showered, he stated he did not know. Review of R18's showers sheet provided by the facility revealed in February 2025 no showers were provided on 02/11/25, 02/13/25 and 02/15 25. Review of March 2025 revealed no showers were provided on 03/06/25 and 03/08/25. The facility census is 28 During an interview on 03/12/25 at 2:03 PM, Certified Nursing Aide (CNA) 2 was asked about R18's showers. CNA 2 stated there was a list of when residents received their showers and R18 received them on Tuesday, Thursdays, and Saturdays. CNA 2 was asked how showers were assigned to staff. CNA2 stated usually someone will volunteer to give the showers and the rest of the staff will provide cares and answer lights so there is no set assignment. During an interview on 03/13/25 at 10:06 AM, Registered Nurse (RN)1 was asked about the showers. RN1 stated that a CNA is assigned to the showers and if a resident refuses then the CNA comes and tells the nurse and then the nurse is to talk with the resident and if the shower is still refused chart it. RN 1 was asked if there was documentation that R18 refused. RN 1 stated no. RN1 was asked how she follows up with staff to ensure showers are provided. RN 1 did not answer. During an interview on 03/14/25 at 9:27 AM, the Director of Nursing (DON) was asked about R18 not receiving showers. The DON stated R18 had told her that he had not received a shower in 6 days. The DON stated, I gave him a shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the policy review, record review, and interview, the facility failed to follow the recommendations to obtain weekly weights for one of two residents (Resident (R) 27) reviewed for nutrition out of a total sample of 18 resident which caused inadequate tracking of weight loss or gain. The facility census is 28. Review of the facility's policy titled Weighing and Measuring revised March 2011 revealed .The purpose of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and provide a baseline height in order to determine the ideal weight of the resident . Review of the Face Sheet located in the Profile tab in the electronic medical record (EMR) revealed R27 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure and moderate protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date dated 02/27/25 revealed R27 had a Brief Interview for Mental Status (BIMS) score of 99 indicating R27 could not participate in the assessment. R27 was totally dependent on enteral feeding (tube feeding) from the nurses. Review of R27's Physician orders located in the Orders tab dated 08/15/24 revealed .NPO [nothing by mouth] diet . Review of the Request for Diet Changes dated 11/06/24 revealed .1. Monitor weekly wts [weights] . Review of R27's Physician orders located in the Orders tab dated 01/07/25 revealed .Monitor Weekly Weights . Review of the Request for Diet Changes dated 01/08/25 revealed .1. Obtain January wt. 2. Monitor weekly weights . Most recent weight in PCC [EMR] 8/24 . Review of the Request for Diet Changes dated 02/10/25 revealed .1. Obtain February weight . Review of the R27's weights found located in the vitals tab dated 08/16/24 150 lbs. (pounds), 01/15/25 162 lbs., 02/11/25 163.6 lbs., 02/20/25 160. 2 lbs., 03/10/25 162.4 lbs. which indicated a weight gain. Review R27's care plan found in the care plan tab in the EMR dated 02/10/25 revealed R27 was care planned to be NPO except mouth care. Interventions were to weigh R27 monthly and as ordered by the provider and to note any significant changes in R27's weight and to notify the provider. During a telephone interview on 03/13/25 at 12:38 PM, the Registered Dietician (RD) stated the nursing department oversaw making sure the weights were being completed. The RD made a request for the nursing department to monitor weekly weights indefinitely. The RD made this recommendation March 6, 2025, January 8, 2025, December 4, 2024, and November 6, 2024. The RD stated that she writes her recommendations and gives them the Director of Nursing (DON), Dietary Manager, and Administrator and expected the recommendations to be implemented within two weeks. The RD used the admission weight to make sure R27 was getting the correct calories and protein. When there was no weight in the EMR the RD asked the nursing department to obtain weights. The RD stated R27 weights should be obtained weekly. During an interview on 03/13/25 at 12:59 PM, the DON stated the Restorative Aide was responsible for obtaining all the residents' weights. The nurses were responsible for making sure weights were obtained as ordered. The DON stated the lift which was used to weigh R27 was broken, and she was just made aware of it. The DON did not know how long the lift had been broken. During an interview on 03/13/25 at 1:11 PM, the Restorative Aide stated she was responsible for obtaining weights for all residents The Restorative Aide stated she was not told R27 was supposed to be on weekly weights. During an interview on 03/13/25 at 1:23 PM, the Registered Nurse (RN)1 stated whoever was the charge nurse made sure the residents' weights were completed and added to the EMR. During a telephone interview on 03/14/25 at 1:06 PM, the Medical Director stated she did not remember whether she saw the recommendations or not but would have done whatever the Registered Dietician recommended. The RD usually left a form, and the Medical Director would sign off on it. Further interview revealed the Medical Director was not aware the lift used to weigh R27 was not working. The Medical Director stated, If I sign an order, I expect them (nursing staff) to follow the order to weigh the patient. During an interview on 03/14/25 at 1:45 PM, the Administrator stated she did not know there was an issue with the facility getting consistent weights for R27. The Administrator noticed in her report the RD had made recommendations regarding R27 weights. The Administrator's expectations were that if the RD made recommendations, it should be sent to the primary care physicians. The Administrator was made aware of the lift was not working.

Based on observation, interview, record review, and policy review, the facility failed to ensure the oxygen (O2) concentrators had dust free filters on the inlet where the air came into the machine for one of two residents (Resident (R) 25) reviewed for oxygen usage out of a total sample of 18 residents. This deficient practice had the potential for increased chance of infection and unnecessary respiratory treatment. The facility census is 28. Review of the facility's policy titled, Departmental (Respiratory Therapy)- Prevention of Infection revised November 2011, revealed, Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the Procedure Infection control considerations Related to oxygen Administration. 9.Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. 1. Review of R25's undated Face Sheet located in R25's electronic medical record (EMR) under the Profile tab, indicated diagnoses to include solitary pulmonary nodule, chronic respiratory failure with hypercapnia (increased carbon dioxide), and asthma. Review of Physician Orders, dated 01/07/25 and located in R25's EMR under the Orders tab, indicated Oxygen 3LPM [liters per minute] via nasal cannula continuously. During an observation on 03/11/25 at 10:16 AM, R25's oxygen concentrator located in R25's room and was observed to have a black oxygen filter on both sides of the concentrator. Both filters were observed to be full of a buildup of a large amount of white lint and heavy debris and were observed to be very dirty. During an observation on 03/12/25 AM, R25's oxygen concentrator filters were observed to be full of a large buildup of white lint and heavy debris and were observed to be very dirty During observation and interview on 03/13/25 at 9:45 AM, Registered Nurse (RN)1 was shown the filters. RN1 stated no the filters should not look like this. The RN added it should be everyone's responsibility to look at them, but ultimately the nurse was responsible. During an observation and interview on 03/13/25 at 10:25 AM, the Director of Nursing (DON) was shown the filters. The DON stated, They are not clean. The DON was asked who should be cleaning them. The DON stated the night nurse on Sunday nights should be cleaning them weekly.

Based on interview, record review, and policy review, the facility failed to ensure residents were provided the Skilled Nursing Facility Advance Beneficiary Notice, form CMS-10055, or the Notice of Medicare Non-coverage (NOMNC) form CMS-10123 for Medicare Part A Services when they were no longer covered or coverage was ending for two of three residents reviewed (Resident (R) 24, and R32) out of a total sample of 18 residents. This deficient practice had the potential for residents not to be provided the information about what services may not be covered by Medicare for residents to make an informed decision about receiving therapies.The facility census is 28. Review of the facility policy titled, Medicare Advance Beneficiary Notices dated April 2021 revealed, Policy Statement: Residents are informed in advance when changes will occur to their bills. Policy Interpretation and Implementation 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). a. The facility issues the Skilled Nursing Facility Advanced Beneficiary Notice (CMS form 10055) to the resident prior to providing care that Medicare usually covers but may not pay for because the care is considered not medically reasonable and necessary, or custodial. b. The resident (or representative) may choose to continue receiving the skilled services that may not be covered and assume financial responsibility. 2. If the resident's Medicare Part A benefits are terminating for coverage reasons, the director of admissions or benefits coordinator issues the Notice of Medicare Non-Coverage (CMS form 10123) to the resident at least two calendar days before Medicare covered services end (for coverage reasons). a. The Notice of Medicare Non-Coverage informs the resident of the pending termination of coverage and of his/her right to an expedited review of service determination. b. The Notice of Medicare Non-Coverage is not indicated when the resident's Medicare covered days are exhausted; nor is it used to notify the resident of potential liability for payment. 1. Review of an undated document titled, SNF Beneficiary Notification Review for R24 indicated, .Medicare Part A Skilled Services Episode State date was: 10/06/24. The last covered day of Part A Services was 12/18/24. The form indicated, The facility-provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review of the document indicated, Was an SNF/ABN, Form (CMS-10055) provided to the resident? It was marked, No. If no, explain why the form was not provided: The box Other was marked and the explanation was written Oversight. Review of R24's electronic medical record (EMR) revealed no documentation that communication took place between R24 and/or the representative to discuss potential additional costs that the resident might have to pay if they chose to continue to receive services. 2. Review of an undated document titled, SNF Beneficiary Notification Review for R32 indicated, .Medicare Part A Skilled Services Episode State date was: 01/21/25. The last covered day of Part A Services was 01/27/25. The form indicated, Voluntary, i.e., self-initiated in consultation with physician, family, or AMA. Further review of the document indicated, Was an NOMNC, Form (CMS-10123) provided to the resident? It was marked, No. If no, explain why the form was not provided: The box Other was marked and the explanation was written Oversight. Review of R32's EMR revealed no documentation that communication took place between R32 and/or the representative to discuss potential additional costs that the resident might have to pay if they chose to continue to receive services. During an interview on 03/14/25 at 9:24 AM, the Administrator stated the SNF ABN should have been provided for R24, and it was an oversight. The NOMNC was provided for R32, but it could not be located. During an interview on 03/14/25 at 10:14 AM, Social Services (SS) was asked about the forms not being provided to the residents. The SS stated she was not aware that the form had to be provided for R24. The SS was asked about the forms for R32 and the SS stated, They were completed, I can't locate them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to inform the Ombudsman of hospital transfers for two of four residents (Resident (R)8 and R27) reviewed for hospitalization out of a total sample of 18. The failure had the potential to cause the Ombudsman to not be aware of any trends or patterns of hospitalization of residents at the facility. The facility census was 28. 1.Review of the Census tab in the electronic medical record (EMR) revealed R8 was admitted on [DATE]. Review of the Discharge Return Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/25 located under the MDS tab in the EMR revealed R8 was discharged from the facility with an anticipated return from the hospital. Review of a nurse progress note dated 02/25/25 at 2:27 PM located under the Prog Note (Progress Notes) tab of the EMR revealed the nurse went to assess R8 and found him to be showing signs and symptoms of respiratory distress. The physician was in the facility at the time, assessed R8, and advised R8 be sent to the hospital. Review of the Parkdale Manor Health and Rehabilitation [NAME] HealthCare Group transfer form dated 02/25/25 and the Bed Hold Notice dated 02/25/25 provided by the Director of Nursing (DON) revealed all required information for the hospital transfer. An Ombudsman notice was asked for and not received. 2.Review of the Census tab in the EMR revealed R16 was admitted on [DATE]. Review of the Discharge Return Anticipated MDS with an ARD of 01/03/25 located under the MDS tab of the EMR revealed R16 was discharged from the facility with an anticipated return from the hospital. Review of a nurse progress note dated 01/03/25 at 6:35 PM located under the Prog Note tab of the EMR revealed R16 was assessed to have profuse bleeding from her vaginal area. Due to her history of a bladder tumor, the physician opted to have R16 sent to the hospital for treatment. The facility census is 28. Review of the Parkdale Manor Health and Rehabilitation [NAME] HealthCare Group transfer form dated 01/03/25 and the Bed Hold Notice dated 01/03/25 provided by the DON revealed all required information for the hospital transfer. An Ombudsman notice was asked for and not received. Review of the facility policy Transfer or Discharge Notice revised March 2021 revealed, a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. In an interview on 03/12/25 at 2:40 PM, the Administrator stated the Social Services (SS) staff did not realize the Ombudsman was to be notified when a resident was sent out. The Administrator stated the SS had a tracking system for monitoring hospital transfers but had not been sending the log monthly to the Ombudsman. In an interview on 03/14/25 at 10:15 AM, the SSD stated she was unaware the Ombudsman was to receive notice of resident transfers to the hospital. She stated she kept track of all transfers but had not sent a copy of the transfer list to the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observations, and interviews, the facility failed to label and date enteral feedings for two of two residents (Residents (R) 27 and R29) who required enteral feedings out of a total sample of 18 residents. This failure increased the risk of nurses not knowing if the correct formula and rate was being provided and what date the formula was hung. The facility census is 28. Review of the policy titled Enteral Feeding via Continuous Pump revised November 2018 revealed . On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order . 1.Review of R27's Face Sheet located in the Profile tab in the electronic medical record (EMR) revealed R27 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure and moderate protein-calorie malnutrition. Review of R27's Physician orders located in the Order tab in the EMR dated 08/15/24, revealed .NPO [nothing by mouth] diet . Review of R27's Physician orders located in the Order tab dated 12/11/24, revealed enteral feed every day and night shift for enternal feed of Jevity (protein and calorie liquid food) 1.5 at 65 ml (milliliter)/hour. Enteral feeding is provided through a tube that is surgically inserted through the abdomen into the stomach. Review of R27's care plan located in the Care Plan tab in the EMR dated 01/13/25, revealed R27 required tube feeding of Jevity 1.5. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/25, revealed R27 had a Brief Interview for Mental Status (BIMS) score of 99 indicating R27 could not participate in the assessment. R27 was totally dependent on enteral feeding from the nurses. Observation in R27's room on 03/11/25 at 11:04 AM, revealed the enteral feeding bag had formula and was running. The bag was unlabeled without the type of formula, the rate to run, the time it was hung, and which nurse hung the formula. Observation and interview in R27's room on 03/11/25 at 3:04 PM, revealed the enteral feeding bag had formula and was running. The bag was unlabeled without the type of formula, the rate to run, the time it was hung, and which nurse hung the formula. Licensed Practical Nurse (LPN) 4 confirmed R27's enteral feeding bag was not labeled. LPN 4 stated the night nurse were the ones to hang the bag and usually wrote the name of the formula, date time it was hung, and initials of who hung it. 2.Review of R29's Face Sheet located in the Profile tab in the electronic medical record (EMR) revealed R29 admitted to the facility on [DATE], with diagnoses which included gastrostomy (tube surgically placed through the abdomen and into the stomach for fluids, nutrition, and medications) status and dysphagia. Review of R29's physician orders located in the Orders tab and dated 03/07/25, revealed an enteral feed order every shift Jevity 1.5 at 45 ml continuous. Review of R29's care plan located in the Care Pla tab in the EMR dated 02/12/25, revealed .The resident has dehydration or potential fluid deficit r/t [related to] being NPO and receiving all nutrition enterally through J-tube. [named R29] also has a G-tube for gastric draining . Review of R29's admission MDS with an ARD of dated 02/17/25, revealed R29 had a BIMS score of 99 indicating R29 could not participate in the assessment. R29 was totally dependent on enteral feeding from the nurses. Observation in R29's room on 03/11/25 at 11:22 AM, revealed R29's enteral feeding bag had formula and was running. The bag was unlabeled without the type of formula, the rate to run, the time it was hung, and which nurse hung the formula. Observation and interview in R27's room on 03/11/25 at 3:01 PM, revealed the enteral feeding bag had formula and was running. The bag was unlabeled without the type of formula, the rate to run, the time it was hung, and which nurse hung the formula. LPN 4 confirmed R27's enteral feeding bag was not labeled. LPN 4 confirmed the nurses were supposed to label the enteral feeding bags with the date, time, name of formula, and who hung it. During an interview on 03/14/25 at 1:55 PM, the Director of Nursing stated the night nurses were responsible for hanging the enteral feeding for R27 and R29 and labeling the bags.

Based on interview and policy review, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program to identify, maintain, and evaluate concerns for effective resident care. This deficient practice had the potential to not identify issues and/or capture the efforts made in measuring the care and services for 28 residents.The facility census is 28. Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program revised April 2014 revealed, Policy Statement The facility shall develop, implement, and maintain an ongoing, facility- wide Quality Assurance and performance Improvement (QAPI) program to actively pursue quality of care and quality of life goals. During an interview on 03/14/25 at 12:12 PM, the Administrator was asked about the QAPI Program, and an example of a Performance Improvement Projects (PIP) that was in progress. The Administrator stated they were not currently working on a PIP due to not having the staffing in place to perform QAPI activity. The Administrator was asked how the facility identified issues and worked on improvements. The Administrator stated there were several different meetings such as risk, infection control or clinical in which topics were discussed and reviewed but there had not been the staff for QAPI.

Based on interview and policy review, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program committee met on a quarterly basis to work on performance improvement projects (PIP) and track the performance of the PIP. This deficient practice had the potential to not identify or improve the care and services for 28 residents.The facility census is 28. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan revised April 2014 revealed, Policy Statement This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Policy Interpretation and Implementation The objectives of the QAPI Plan are to: 1. provide a means to identify and resolve present and potential negative outcomes related to resident care and services; 2. Provide structure and processes to correct identified quarterly and/or safety deficiencies; 3. Establish and implement plans to measure performance and set goals 4. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome; 5. Establish practices to systematically analyze underlying causes of deficiencies 6. Establish systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program. Committee Membership 1. The Administrator shall appoint both committee members as designated below and shall appoint individuals to fill any vacancies occurring on the committee. 2. The following individuals will serve on the committee: a. Administrator; b. Director of Nursing Services; c. Medical Director; d. Dietary Representative; e. Social Services Representative; f. Activities Representative; g. Environmental Services Representative; h. Rehabilitative Services Representative; i. Business office. During an entrance conference on 03/11/25 at 9:34 AM, the Administrator was asked for a list of the QAPI committee members. A list was provided that included the Administrator, Director of Nursing (DON), the Medical Director, business office Manager (BOM), Minimum Data Set (MDS) Coordinator, Social Services, Activities, housekeeping, maintenance, therapy, dietician, pharmacy, Regional Nurse and the Director of Operations. During an interview on 03/14/25 at 12:12 PM, the Administrator was asked about the QAPI Program, and an example of a Performance Improvement Projects (PIP)that was in progress. The Administrator stated QA was not currently working on a PIP due to not having the staffing in place to perform QAPI activity. The Administrator stated that staff had been meeting but there was no documentation or evidence that a QAPI program was in place. The Administrator was asked how the facility identified issues and worked on improvements. The Administrator stated there were several different meetings such as risk, infection control or clinical in which topics were discussed and reviewed but there just had not been the staff for QAPI. The Administrator was asked about the list of committee members that had been provided when asked for. The Administrator stated that list is who the facility wants to have on the committee. The Administrator was asked to verify if the committee had met to discuss QAPI. The Administrator stated there had been a meeting on January 31 in which it was discussed about getting QAPI started. During an interview on 03/14/25 at 1:14 PM, the Medical Director was asked if she had participated in QAPI meetings since becoming the Medical Director. The Medical Director stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to assure staff followed acceptable standards of practice for one (1) of the five (5) sampled residents, (Resident #1), when staff failed to follow provider orders, remove a resident's surgical staples in a timely manner, and charted that the surgical staples had been removed per provider orders and were not actually removed. The facility census was 24. The facility did not provide policies and procedures relating to physician orders and weekly skin assessments. Review of the facility's policy for Wound Care, revised October, 2010, showed: - The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; - Verify that there is a physician's order for this procedure; - Review the resident's care plan to assess for any special needs of the resident; - The following information should be recorded in the resident's medical record: - (1.) The type of wound care given. - (2.) The date and time the wound care was given. - (4.) The name and title of the individual performing the wound care. - (6.) All assessment data obtained when inspecting the wound. - Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #1's medical record showed: - The resident was admitted to the facility on [DATE] following surgery to correct broken bones in both legs; - The resident's surgical incisions on both legs had been closed using surgical staples; - Provider orders for staple removal read: Start Date: 10/22/2024 Remove staples one time only for staple removal for one day; - The resident's treatment record shows staple removal charted as completed on 10/22/2024; - A mobile x-ray of the resident's legs was ordered by the provider on 10/24/2024. The facility failed to include any indication the x-ray was completed or resulted in the resident's medical record; - Weekly skin assessments were charted in the resident's treatment record as complete on 10/27/2024, 11/03/2024, and 11/10/2024; - Neither of the two users who documented performing a complete skin assessment on the resident recognized, reported, or intervened to ensure the resident's healing was not delayed by staples still in the resident's skin; - The resident was scheduled for a follow-up appointment on 11/06/2024 which was missed and had to be rescheduled for 11/11/2024; - The resident's surgical staples were removed on 11/13/2024, five weeks after surgery; - The resident was alert and oriented and capable of making decisions and verbalizing needs with a Brief Interview for Mental Status (BIMS)score of 15, indicating the resident was cognitively intact. During an interview on 12/04/2024 at 10:15 A.M., Resident #1 said: - He/She was incredibly upset about how long it took the facility to remove his/her surgical staples and he/she was so fed up with the situation. During an interview on 12/04/2024 at 2:23 P.M., the facility administrator said: - Resident #1's original follow-up appointment had been scheduled by the hospital prior to the resident's admission to the facility. The follow-up appointment had been titled virtual and did not contain any provider contact information, which led facility staff to believe this was not an in-person appointment and this is the reason the first appointment was missed; - He/She had attempted to call the hospital that had made the appointment for clarification but did not receive a call back for two (2) days and by the time the return call was received, the resident had already missed the appointment; - The x-ray the provider ordered on 10/24/24 was a mobile x-ray and the result summary was sent directly to the resident's orthopedic (bone doctor) provider. The provider required the resulting x-ray to be sent to him on a disc which the mobile x-ray company was unable to accomplish so a second x-ray was ordered out of the facility. The results of this x-ray were sent directly to the orthopedic provider and were never seen by facility nursing staff. - Facility administration was not aware that the resident's surgical staples had not been removed until 11/10/2024. When administration became aware of the staples still being in place, it was discovered the facility did not have any staple removal kits. The kits were ordered but the resident's family presented to the facility with kits they had purchased themselves. The facility nursing staff used these kits to remove the resident's staples on 11/13/24. - Usually, the facility social services director would schedule and confirm follow-up appointments are scheduled for residents, but that at the time he/she was serving as both the facility administrator and the social services director due to staffing complications. - Nursing staff is expected to chart tasks as completed only after they are finished. MO245146

Based on observations, interviews and record review the facility failed to provide appropriate treatment and services to maintain the ability to communicate for one of 12 sampled residents, (Resident #9). The facility census was 22. The facility did not provide a policy related to scheduling appointments for residents. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/5/23 showed: - Cognitive skills intact; - Minimal difficulty with hearing; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers; - Upper and lower extremity impaired on both sides; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing), dementia and anxiety. Review of the resident's care plan, revised 7/20/23 showed it did not address the resident's hearing issues. Observation and interview on 8/1/23 at 12:48 P.M. showed: - The resident sat in his/her wheelchair; - The surveyor frequently had to repeat questions because the resident was unable to hear properly; - He/she asked about how to get hearing aides because he/she needed some and wanted to know if the state would help pay for them; - The resident said staff had taken him/her to get a hearing test and to see about hearing aides but that was over two years ago and he/she still did not have any and really needed them; - The resident said it's very hard for him/her to hear the staff when they interact with him/her. It's very difficult to understand any questions anyone asks him/her because of his/her hearing issues. It limits his/her ability to attend activities because he/she cannot hear what is being said. During an interview on 8/3/23 at 8:25 A.M., Social Services said: - He/she she had taken the resident to get a hearing test and see about hearing aides about a year ago; - The resident had medicare and medicaid and the company did not take the resident's insurance and it was going to cost $3000; - The resident's son wanted to take the resident somewhere so he/she could get two hearing aides instead of one; - He/she had not heard anything from the resident's son. During an interview on 8/3/23 at 9:02 A.M., Social Services said: - He/she had a clarification. He/she said the resident was taken to get a hearing test on 4/6/21 and the resident had insurance that the company did not take; - The resident did not have medicare or medicaid when he/she took the resident but a different type of insurance that the company would not take; - The resident now has medicare and medicaid so he/she was going to talk to the son and see if he wanted to take the resident somewhere else or have him/her take the resident. During an interview on 8/3/23 at 9:30 A.M., the business office manager (BOM) said: - The resident has had medicare since 2013 and has had medicaid since before 5/15/20. During an interview on 8/2/23 at 11:30 A.M., Social Services said he/she had called the resident's son and discussed what to do and the son said he/she said it was fine to set up an appointment. During a telephone interview on 8/3/23 at 9:58 A.M., Family Member A (FM A) said: - He/she was aware the facility had taken the resident for a hearing test but it was a long time ago. The staff said it was going to cost $3000 and evidently the facility decided it was too much money because the resident did not get any hearing aides; - There have been a couple of times since then when Social Services said the resident wanted hearing aides and FM A said that was fine but never heard anything after that; - Social Services texted FM A and said he/she had scheduled a hearing appointment for 8/11/23; - FM A was happy that the resident was going to get at least one hearing aide. One would be better than none!; - FM A did not understand why it had taken so long for the resident to get a hearing aide; - If the resident needed anything, all the staff had to do was call and ask him/her. During an interview on 8/4/23 at 7:53 A.M., Social Services said: - Two years was a long time to wait to get a hearing aide but it goes back to the resident's insurance; - The facility did not have anyone who came in to check the resident's hearing. During an interview on 8/4/23 at 12:23 P.M., the Director of Nursing (DON) said: - If the insurance did not pay for the hearing aides in 2021, there should have been some type of follow up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed assess one resident (Resident #24) for a history of trauma and provide trauma informed care for a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event). The facility census was 22. Review of the facility's Trauma Informed Care policy, revised March 2019, showed: -The purpose of this policy is to guide staff in appropriate and compassionate care specify to individuals that have experienced trauma; -All staff are provided in-service training about trauma and its impact on health and Post Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event); -Nursing staff are trained on trauma assessment and how to identify triggers associated with re-traumatizing the resident; -Caregivers are taught strategies to help eliminate or mitigate a resident's triggers; -The comphrensive assessment should be used as a screening tool to identify a history of trauma.1. Review of Resident #24's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - No behaviors; - Independent with bed mobility, transfers, and dressing; - Diagnoses included stroke, depression, psychotic disorder ( a mental disorder characterized by a disconnection from reality), PTSD and prolonged grief. Review of the resident's care plan, revised 7/20/23 showed the care plan did not address the resident's diagnosis of PTSD. During an interview on 8/3/23 at 10:01 A.M., the SSD said since the new company had taken over, he/she did not know where the trauma informed care assessments were located in the electronic medical records and he/she was unable to print them. During an interview on 8/3/23 at 3:41 P.M., the MDS/CP Coordinator said: - He/she was not aware of any resident with a diagnosis of PTSD; - The care plans should address the diagnosis of PTSD, the triggers and the interventions. During an interview on 8/4/23 at 7:45 A.M., the resident said: - He/she lived at home and got up in the middle of the night to go to the bathroom and got dizzy and lost his/her balance; - He/she hit her head on the door frame which caused a scar across his/her forehead and down across his/her face. He/she had 27 stitches in his/her head and spent a year in the hospital; - The physicians said he/she is lucky to be alive. During an interview on 8/4/23 at 7:53 A.M., the SSD said: - To his/her knowledge, they did not have any residents with a diagnosis of PTSD; - He/she would find that information by looking at the resident's face sheet at the diagnoses. During an interview on 8/4/23 at 11:33 A.M., Family Member B (FM B) said: - He/she did not know the resident had a diagnosis of PTSD; - He/she thought it had something to do with when the resident fell. Afterwards the resident started hallucinating (experience an apparent sensory perception of something that is not actually present), seeing things that were not there and talking to people who were not there; - He/she did not think the resident had any triggers; - The facility was aware of the resident's fall and how bad it was. During an interview on 8/3/23, at 10:18 A.M., the Social Services Director (SSD) said: -He/she was not sure what the policy was on trauma informed care because they have changed owners. -All residents should be assessed for a history of trauma when they are admitted ; -He/he does the trauma informed care assessments on all new residents and if there is trauma it is care planned; -Trauma should be identified and the care plan should show specific person centered interventions in the care plan to ensure the staff know what triggers the resident and how to handle the situation; -All employees should know what trauma informed care is and how to treat it; During an interview on 8/3/23 at 10:25 A.M., the Director of Nursing (DON) said: -Trauma informed care should be assessed on admit and care planned; -Staff should be trained on what trauma informed care is and which residents have a diagnosis of PTSD or past trauma; -Nursing staff need to know the resident's triggers so they don't re-traumatize the resident; During an interview on 8/3/23, at 10:32 A.M., the administrator said: -All residents should be assesses for past trauma upon admission; -All residents with a diagnosis of PTSD should be assessed for trauma upon admission; -Trauma informed care should be care planned with person-centered interventions; -Staff should be trained in trauma informed care; -Staff should know what resident's have had a history of trauma or a diagnosis of PTSD so they won't re-trigger the resident; -He/she is not sure if staff have been trained on trauma informed care; -The SSD is responsible for assessing new residents for trauma on admission; During an interview on 8/3/23, at 3:44 P.M., the MDS coordinator said: -A trauma assessment should be done at the time of admission and as needed; -Trauma informed care should be care planned with specific person-centered interventions; -The nursing staff will tell him/her who has a history of trauma and he/she will care plan it;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of Resident # 1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff., dated 7/24/23 showed: - Brief interview of mental status (BIMS) score of 13, which indicates intact cognition; - Requires supervision with setup help only for bed mobility and transfer; - Independent with no setup help for locomotion on and off unit, toilet use, and personal hygiene; - Limited assistance with one person physical assist for dressing; - Independent with setup help only for eating; - One person physical assist in reference to physical help for bathing; - Occasionally incontinent of urine; - Diagnoses of bipolar disorder, hypertension, non-Alzheimer's dementia, Review of the resident's care plan, revised 6/27/23 showed: - Resident requires assistance with ADL'S, mobility, medication administration, and meal prep; - Having snacks available between meals is very important to the resident; - Resident has unplanned/unexpected weight loss related to diuretic use. Review of resident's physician order sheet, dated 7/20/22 showed: - An order for a regular diet; - An order for a high calorie snack twice a day. During an interview on 8/1/23 at 2:15 P.M., the resident said: - Staff does not offer him/her snacks at night; - Staff rarely offer snacks to him/her; - He/she would like to be offered snacks. During an interview with on 8/3/23 at 8:21 A.M., the resident said: - No snacks were provided to him/her in the evening of 8/2/23. 8. Review of Resident # 12's quarterly MDS., dated 5/31/23 showed: - BIMS score of 15, which indicates intact cognition; - Independent with no setup help for bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit, dressing, toilet use, and personal hygiene; - Independent requiring setup help only for eating; - One person physical assist in reference to physical help for bathing; - Diagnoses of type 1 diabetes, dementia, and depression. Review of the resident's care plan, revised 7/20/23 showed: - The resident is unable to return to the community and requires assistance with ADL'S, mobility, medication administration, and meal prep; - Having snacks available between meals is very important to the resident; - The resident is at risk for limited physical mobility; - An intervention of offering between meal and bedtime snacks for fluctuating blood sugars related to diabetes. Review of resident's physician order sheet, dated 10/29/22 showed: - An order for a regular diet; - An order for a protein snack at hour of sleep. During an interview on 8/2/23 at 7:43 P.M., Resident #12 said: - He/she had not received a snack; - He/she was not feeling well and would like a snack; - Staff commonly do not pass evening snacks. During an interview on 8/3/23 at 10:05 A.M. the Dietary Manager said: - Kitchen staff do not hand out evening snacks; - Snacks are supplied to nursing to hand out to residents; - Evening cook places stocked snack basket on shelf outside of kitchen in the evening for nursing; - Snacks consist of cookies, apple sauce, yogurt, puddings, chips, and peanut butter and jelly sandwiches, if requested; - Daytime snacks are provided if requested; - Does not know exact time evening snacks are passed. During an interview on 8/4/23 at 12:23 P.M., the Director of Nursing (DON) said: -She would expect the staff to go to each residents room and offer them a snack after dinner and document in point of care. 5. Review of Resident #2's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Required assistance of one staff with ADL's; -Occasionally incontinent of bladder; -Diagnoses included, high blood pressure, dementia and anxiety disorder. Review of the resident's care plan dated, 7/20/23, showed: -The resident has an ADL self care performance due to dementia; -Having snacks available in between meals is very important to the resident. During an interview on 8/1/23, at 4:29 P.M., the resident said: -He/she likes to have a snack at bedtime; -The staff does not pass snacks before bedtime. During a observation and interview on 8/2/23, at 7:03 P.M., showed: -No staff was passing snacks; -No snacks observed in his/her room; -The resident said he/she had not been offered a snack; -The resident said he/she would take one if it was offered. 6. Review of Resident #4's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Independent with ADL's; -Occasionally incontinent of bladder; -Diagnoses included, hypothyroidism (the thyroid gland does not produce enough thyroid hormone), arthritis and anemia (the blood does not have enough healthy red blood cells) and dementia. Review of the resident's care plan dated, 7/20/23, showed: -The resident has an ADL self care performance due to dementia; -Having snacks available in between meals is very important to the resident. During an interview on 8/1/23, at 9:15 A.M., the resident said: -He/she likes to have a snack at bedtime; -The staff do not pass snacks before bedtime; -If he/she wants a snack he/she has to ask for it; -The staff don't have time to pass the snacks. An observation on 8/2/23, at 7:51 P.M., showed: -No staff was passing snacks; -The resident rang his/her call light; -The resident asked Nurses Aide (NA) to bring him/her a snack; -NA A brought a basket to the resident's room and the resident chose a snack from the basket; -The resident closed his/her door. During an interview on 08/02/23 at 8:10 P.M., NA A said: -He/she works the 2:00 P.M. to 10:00 P.M. shift and he/she passes snacks when she gets here at 2:00 P.M.; -2:00 P.M. is the only time he/she passes snacks during the whole shift; -He/she said there is a place to chart snacks but sometimes he/she does not get the snacks charted because he/she is busy. During an interview on 08/02/23 at 8:17 P.M., CNA B said: -He/she passes snacks if he/she has time; -There was no designated person to make sure snacks got passed; -If the resident wants a snack they can ask the staff. Based on observations, interviews and record review, the facility failed to promote an environment respectful of the rights of each resident to make choices about significant aspects of their lives when staff did not offer evening (HS) snacks to all residents. This affected eight of 12 sampled residents, (#1,#2, #4, #9, #12 and #16) and other residents who attended the resident group interview. The facility census was 22. Review of the facility's policy for serving snacks between meal and bedtime, revised September 2010, showed, in part: - The purpose of this procedure is to provide the resident with adequate nutrition; - Review the resident's care plan and provide for any special needs of the resident; - The person performing this procedure should record the following information in the resident's medical record: the date and time the snack was served; the amount of snack eaten by the resident; if the resident refused the snack, the reasons why and the intervention taken. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/5/23 showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers; - Required set up with eating; - Upper and lower extremity impaired on both sides; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing), dementia and anxiety. Review of the resident's care plan, revised 7/20/23 showed: - Personalized care: having snacks between meals was very important. During an interview on 8/1/23 at 12:37 P.M., the resident said: - The staff do not come to his/her room every night and offer him/her a snack at bedtime; - He/she would take a snack at bedtime if it was offered. 2. Review of Resident #16's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers; - Required set up with eating; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - Diagnoses included stroke, COPD, and hemiparesis (muscle weakness on one side of the body). Review of the resident's care plan, revised 7/20/23 showed: - Personalized care: having snacks available between meals was very important. During an interview on 8/1/23 at 10:11 A.M. the resident said: - The staff do not come to his/her room each night and offer him/her a bedtime snack; - He/she would take a snack if it was offered. 3. Review of the resident council meeting notes showed: - May 2023; New business or concerns: better snack options on snack cart and passed out more often; - June 2023: New business or concerns: snacks are still not always being passed; - July 2023: New business or concerns: snacks are still not always being passed. 4. During the resident group interview on 8/2/23 at 10:04 A.M., the residents said: - The staff do not come to their room every night and offer them a snack at bedtime; - Four of the five residents said they would take a snack if it was offered to them. During an interview on 8/2/23 at 7:01 P.M., Licensed Practical Nurse (LPN) A said: - They have a little basket with snacks in them; - The staff pass the snacks out at the beginning of the 2:00 P.M. -10:00 P.M. shift but do not pass them out at bedtime unless a resident would ask for something. During an interview on 8/4/23 at 8:49 A.M., Certified Nurse Aide (CNA) A said: - He/she tried to pass the snacks at bedtime if they were not super busy, which seemed to be all the time now; - The snacks do not always get passed at bedtime; - If he/she had time to pass them, he/she did not go room to room and ask each resident, it's mainly if a resident asked for something to eat; - The new company has asked the staff to document meals and snacks. During an interview on 8/4/23 at 12:23 P.M., the Director of Nursing (DON) said: - She would expect the staff to go to each residents room and offer them a snack after dinner and document in point of care.

During an interview and record review, the facility failed to maintain a Department of Health and Senior Services (DHSS) approved surety bond that was equal or greater than one and one-half times the average monthly balance for the residents' personal funds for the last 12 consecutive months from July 2022 through June 2023. This has the potential to affect all residents who had money in the trust account. The facility census was 22. Review of the facility policy, Surety Bond, dated March 2021, showed: -Our facility has a current surety bond to assure the security of all residents' personal funds deposited with the facility; -A surety bond is an agreement between the facility, the insurance company, and the resident or the State acting on behalf of the resident, wherein the facility and the insurance company agree to compensate the resident for any loss of resident's funds that the facility holds, accounts for, safeguards, and manages; -This facility holds a surety bond to guarantee the protection of residents' funds managed by the facility on behalf of its residents; -All funds entrusted to the facility for a resident are covered by the surety bond; -The purpose of the surety bond is to guarantee that the facility will pay the resident for losses occurring from any failure by the facility to hold, account for, safeguard, and manage the residents' funds; -Inquiries concerning the financial security of personal funds managed by the facility should be referred to the administrator. Review of the facility's current bond, dated 7/1/23, was $20,000. Review of DHSS bond records showed the facility's current bond was $20,000. Review of the bond worksheet, completed on 8/2/23, showed: -An average monthly balance of $15,264.27 (determined by using the total of each ending balance for the last 12 months bank statements and divided by 12 months); -A required bond amount of at least $22,500. During an interview on 08/02/23 at 2:12 P.M., the Business Office Manager (BOM) said: -He/She did not know who monitored the bond; -He/She did not know the bond amount was not sufficient; -He/She had been the BOM since September 2021. During an interview on 08/02/23 at 2:22 P.M., the Administrator said: -He/She did not know who made sure the bond amount was sufficient; -He/She expected the BOM would monitor and notify if the bond needed increased; -He/She did not monitor the bond amount and was not aware that the bond was insufficient. The administrator later provided additional information of a surety bond that was effective July 1, 2023 in the amount of $30,000; however, it had not received DHSS approval.

Based on record review and interview, the facility failed to ensure they utilized the correct Skilled Nursing Facility Advance Beneficiary Notice of non- coverage (SNFABN) form (a form that provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility), for two of three residents sampled for beneficiary notifications (Residents #5 and #12). The facility census was 22. Review of the facility policy, Medicare Advance Beneficiary Notice, dated April 2021, did not address the utilization of the correct 2020 dated ABN form. Review of Resident #5's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 2/28/23. The resident signed the form on 2/16/23. The facility did not use the most updated form from 2020. The facility issued the old form dated 2018. Review of Resident #12's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 2/28/23. The residents' representative signed the form on 2/21/23. The facility did not use the most updated form from 2020. The facility issued the old form dated 2018. During an interview on 08/02/23 at 11:30 A.M., the Administrator said: -Staff should use the correct 2020 form; -He/She was not aware the ABN form was wrong. During an interview on 08/02/23 at 1:22 P.M., the Social Services Director said: -He/She completed the ABN forms with residents; -He/She was not aware of an updated form dated 2020; -He/She had been given the 2018 form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff failed to: properly clean resident room floors, properly strip and re-wax to maintain tiles around the base of resident toilets. Additionally, the facility failed to repair damaged base boards in resident room [ROOM NUMBER], fix a dragging door to restroom in room [ROOM NUMBER], and repair a damaged circular metal floor plate in the 500 hall; As well as failure to maintain the entrance to the facility by not removing spider webs, and a bird's nest from above main entry doors. This effected the quality of life for all residents in the facility. The facility census was 22. Review of the facility policy on floor cleaning and maintenance dated December of 2009, showed: - Floors shall be maintained in a clean, safe, and sanitary manner; - All floors shall be mopped/cleaned/vacuumed daily in accordance with our established procedures; - Floor cleaning procedures are maintained by the environmental services director; - No information on polishing or stripping waxed tile flooring. Review of the facility policy on cleaning and disinfecting residents' rooms dated August 2013, showed: - The purpose of the procedure is to provide guidelines for cleaning and disinfecting residents' rooms; - Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled; - No information on polishing or stripping waxed tile flooring. Observations on 8/1/23 at 8:19 A.M., showed: - Area above main entry doors blanketed with cobwebs and spider webs; - Area above main entry doors had bird nests on top of exposed fire suppression water line. Observations on 8/1/23 at 2:45 P.M., showed: - Floor tile around base of toilet in room [ROOM NUMBER] stained with a dark rust color and damaged; - Baseboard near sink in room [ROOM NUMBER] is torn off the wall, exposing damaged drywall and exposed glue; - Tile near corners of entry door into room [ROOM NUMBER] is dirty with dark, grimy, and unpolished coating. Observation on 8/2/23 at 7:15 P.M. showed: - Circular floor steel drain plate near the end the 500 hall was loosely secured to floor with duct tape. Observations on 8/3/23 at 8:00 A.M., showed: - Floor tile near corners of entry door into room [ROOM NUMBER] is dirty with dark, grimy, and unpolished coating; - Floor tile in room [ROOM NUMBER] has small scratches where the restroom door drags and scrapes the floor. During an interview on 8/3/23 at 8:09 A.M., Housekeeper A said: - Resident rooms and bathrooms are cleaned daily; - The buildup is because the tile has not been stripped and re-waxed; - Maintenance is in charge of stripping and re-waxing tile flooring; - Tile around toilets should not be stained; - Spider and cobwebs should be clean up when found; - Damaged or torn off baseboards should be fixed by maintenance after receiving a request. During an interview on 8/3/23 at 8:40 A.M., the Housekeeping Supervisor said: - Staff is aware of the grimy buildup around the toilets and doors; - Buildup is caused by wax not being properly stripped in the past; - Maintenance is responsible for stripping and re-waxing the tile flooring; - The discoloration and buildup around toilets and doors is not acceptable or homelike. During an interview on 8/4/23 at 11:37 A.M., the Maintenance Manager said: - The polish on the tile is getting old around some doors and areas of flooring; - Maintenance is responsible for stripping and re-polishing the floors; - Work orders should have been put in for damaged baseboards if he is not already notified of the damages; - He has not had the machine to properly strip the floor wax until one week prior to survey; - Residents deserve a homelike environment; - Torn running boards and dirty flooring is not homelike.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive plan of care which included measurable objectives and timeframe's for two sampled resident, (Resident #24 and Resident #9). Staff failed to implement a comprehensive person-centered plan of care that addressed hearing issues for Resident #9 and develop a plan of care to address Resident #24's diagnosis of a Post Traumatic Stress Disorder (PTSD, a disorder that develops in some people who have experienced a shocking, scary or dangerous event). The facility census was 22. Review of the facility's Comprehensive, Person-Centered Care Plan Policy, revised December 2016, showed: -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 comprehensive, person-centered care plan will include: o Measurable time tables o Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being; o Include the resident's stated goals upon admission and desired outcomes; o Identify problem areas; o Reflect the resident's expressed wishes regarding care; o Aid in preventing or reducing a decline in the resident's functional status; o Assessments of residents are ongoing and revised as needed. 1. Review of Resident 24's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Independent with bed mobility, transfers, dressing and personal hygiene; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), stroke, dementia, psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), and post traumatic stress disorder (PTSD, a disorder that develops in some people who have experienced a shocking, scary or dangerous event). Review of the resident's care plan, revised 7/20/23 showed it did not address the resident's diagnosis of PTSD. 2. Review of Resident #9's quarterly MDS dated [DATE] showed: - Cognitive skills intact; - Had minimal difficulty with hearing; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers; - Upper and lower extremity impaired on both sides; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing), dementia and anxiety. Review of the resident's care plan, revised 7/20/23 showed it did not address the resident's hearing issues. During a telephone interview on 8/3/23 at 3:41 P.M., the MDS/Care Plan Coordinator said the care plans should be resident centered and should address any issues a resident was having with their hearing. During an interview on 8/4/23 at 12:23 P.M., the DON said the residents care plans should address PTSD and the resident's hearing issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a discharge summary for two residents out of the two sampled closed resident records (Resident #15 and Resident #28). The facility census was 22. The facility did not provide a policy addressing discharge summaries. 1. Review of Resident #15's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 4/28/23 showed: - No cognitive impairment; - Assistance of one staff for Activities of Daily Living (ADL's); - Diagnosis included, high blood pressure and depression; - Resident planned to return to the community. Review of the resident's care plan, dated 4/21/23 showed: -The resident is a full code; -The resident would like to return home following his/her rehabilitation stay. Review of the nurses' notes dated 5/5/23 at 9:16 A.M. showed the resident left the facilty with a friend. Review the of resident's medical record did not show a discharge summary. During an interview on 8/3/23 at 5:40 P.M., the Director of Nursing (DON) said: -The resident did not have a discharge summary. There was a discharge nurses' note but no summary. Staff should complete a discharge summary after residents are discharged . 2. Review of Resident #28's admission MDS, dated [DATE] showed; - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility and transfers; -Required extensive assistance of one staff for dressing and toilet use; - Always incontinent of urine; - Always continent of bowel; - Diagnoses included high blood pressure, diabetes mellitus and repeated falls. Review of the resident's care plan, revised 5/31/23 showed: - The resident wanted to return home following their rehab stay. Review of the resident's medical record showed it did not contain a recapitulation of the resident's stay from admission on [DATE] until discharge on [DATE]. During an interview on 8/4/23 at 12:23 P.M., the DON said: - There should be a recapitulation in the resident's chart when a resident is discharged from the facility; - Social Services or nursing should make sure it's completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure that seven of 12 sampled residents (Residents #1, #20, #12, #2, #16 #19, #23), who required staff assistance, were provided with adequate assistance for activities of daily living (ADL's: tasks completed to care for oneself daily such as bathing, dressing, moving from a chair to bed, and personal hygiene), as well as failed to provide proper incontinence care for Residents #16, #23, The facility census was 22. Review of the facility ADL policy dated March 2018, showed: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, including walking), elimination (toileting), dining (meals and snacks) and communication (speech, language, and any functional communication systems). 1. Review of Resident # 1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 7/24/23 showed: - Brief interview of mental status (BIMS) score of 13, which indicates intact cognition; - Requires supervision with setup help only for bed mobility and transfer; - Independent with no setup help for locomotion on and off unit, toilet use, and personal hygiene; - Limited assistance with one person physical assist for dressing; - Independent with setup help only for eating; - One person physical assist in reference to physical help for bathing; - Occasionally incontinent of urine; - Diagnoses of bipolar disorder, and non-Alzheimer's dementia. Review of the resident's care plan, revised 6/27/23 showed: - Resident requires assistance with ADL's, mobility, medication administration, and meal prep; - Bathing preference of showers, two times a week; - Resident has limited physical mobility; - Resident has bladder incontinence related to Dementia. During an interview on 8/1/23 at 2:22 P.M., Resident #1 said: - He/she has not been receiving showers two times a week; - His/her showers have been missed multiple times, and missed showers occur monthly; - He/she is upset and does not like to feel unclean; - That showers were missed due to staff being busy. Review of undated facility shower schedule showed: - Resident #1 was scheduled to receive showers on Mondays and Fridays. Review of facility bathing task follow up report dated 4/1/23 to 7/31/23 (35 scheduled shower dates) showed: - Resident received showers on 4/14/23 (Friday), 4/29/23 (Saturday), 5/12/23 (Friday), 5/15/23 (Monday), 6/2/23 (Friday), 6/5/23 (Monday), and 6/23/23 (Friday); - The day of 6/20/23 showed Not applicable; - The dates of 4/27/23 (Thursday) and 5/24/23 (Wednesday) showed no shower received. 2. Review of Resident # 20's quarterly Minimum Data Set (MDS), dated [DATE] showed: - BIMS score of 15, which indicates intact cognition; - Independent requiring setup help only for bed mobility and eating; - Independent with no setup help for transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene; - One person physical assist in reference to physical help with bathing; - Occasionally incontinent of urine; -Diagnoses of a stroke, and hypertension. Review of the resident's care plan, revised 7/20/23 showed: - The resident is unable to return to the community and requires assistance with ADL's, mobility, medication administration, and meal prep; - Bathing preference of showers, two times a week; - Resident has limited physical mobility. During an interview on 8/1/23 at 12:45 P.M., Resident #20 said: - He/she does not get showers when he/she is supposed to; - He/she did not receive one of his/her showers as scheduled the week prior; - He/she feels dirty and upset about his/her showers being missed. Review of undated facility shower schedule showed: - Resident #20 was scheduled to receive showers on Tuesdays and Fridays. Review of facility bathing task follow up report dated 4/1/23 to 7/31/23 (35 scheduled shower dates) showed: - Resident received showers on 4/18/23 (Tuesday), 4/21/23 (Friday), 6/6/23 (Tuesday), 6/20/23 (Tuesday), 6/27/23 (Tuesday), 7/4/23 (Tuesday), 7/8/23 (Saturday), 7/11/23 (Tuesday); - The date of 5/24/23 (Wednesday) showed no shower received. 3. Review of Resident # 12's quarterly Minimum Data Set (MDS), dated [DATE] showed: - BIMS score of 15, which indicates intact cognition; - Independent with no setup help for bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit, dressing, toilet use, and personal hygiene; - Independent requiring setup help only for eating; - One person physical assist in reference to physical help for bathing; - Diagnoses of type 1 diabetes mellitus, (a metabolic disease, involving inappropriately elevated blood glucose levels),with diabetic neuropathy, (A type of nerve damage that can occur with diabetes), hypertension, dementia, and depression. Review of the resident's care plan, revised 7/20/23 showed: - The Resident is unable to return to the community and requires assistance with ADL's, mobility, medication administration, and meal prep; - Bathing preference of showers; - Resident is at risk for limited physical mobility; - Resident may have occasional balder incontinence and may need assistance with toileting and bathing. During an interview on 8/1/23 at 10:46 A.M., Resident #12 said: - He/she did not receive one of his/her showers the week prior; - His/her showers have been skipped a few times in the past; - He/she is frustrated over less employees to help. Review of undated facility shower schedule showed: - Resident #20 was scheduled to receive showers on Tuesdays and Fridays. Review of facility bathing task follow up report dated 4/1/23 to 7/31/23 (35 scheduled shower dates) showed: - Resident received showers on 4/7/23 (Friday), 4/14/23 (Friday), 4/28/23 (Friday), 5/15/23 (Monday), 5/29/23 (Monday), 6/5/23 (Monday), 6/12/23 (Monday), 6/17/23 (Saturday), 6/23/23 (Friday), 7/7/23 (Friday); - The day of 6/20/23 showed Not applicable; - The date of 5/24/23(Wednesday) showed no shower received. During an interview on 8/4/23 at 7:23 A.M. LPN C said: - He/she does not give showers; - Certified Nursing Assistants (CNA's) are responsible for providing showers to residents. During an interview on 8/4/23 at 7:49 A.M., CNA A said: - He/she has heard complaints from resident's not receiving their showers; - He/she feel's bad, but staff can get busy assisting residents, so showers get missed. During an interview on 8/4/23 at 12:23 P.M., the DON said: - He/she would expect residents to receive two showers a week or documentation showing they had refused. Review of the facility's Perineal Care policy, revised, February 2018, showed: -Wash and dry hands; -Female residents: wash the perineal area from front to back, separate all skin folds, using a new wipe/clean wash cloth for each cleaning; -Male residents: wash the perineal area from the urethral opening working outward, using a new wipe/clean cloth for each cleaning. Review of the facilty's Hand washing/Hand Hygiene Policy, revised, August 2019, showed: -Hand hygiene is the primary means of prevention of the spread of infections; -Wash hands when they become visibly soiled; -Gloves should be worn when anticipating contact with body fluids; -Wash hands with soap and warm water for 15 seconds; -Rinse and dry hands; -Use clean paper towel to turn off faucet. The facility did not provide a policy on shaving. 4. Review of Resident #2's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Required assistance of one staff for bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Uses a wheel chair for mobility; -Independent with eating; -Diagnoses included, orthostatic hypotension (low blood pressure upon standing), dementia and anxiety. Review of the resident's undated care plan showed: -ADL self care deficit related to dementia; -Dependent on staff of two for bed mobility; -Requires assistance of two staff with dressing; -Requires assistance of two staff for personal hygiene. Observation and interview on 8/01/23, at 10:12 A.M., showed: -The resident setting in his/her room in a recliner; -The resident had facial hair on his/her chin and under his/her lip; -The resident said he/she does not get regular showers; -The resident said he/she said would like to be shaved at least two or three times a week; -The resident said he/she said he/she needs help with shaving; -The resident said he/she said it makes him/her fell embarrassed to have facial hair; -The resident said he/she used to get showers on Tuesdays and Thursdays and now just once a week, if at all. During observation and interview on 08/02/23, at 8:07 A.M. showed: -The resident in his/her room setting in a recliner; -The resident still had facial hair on his/her chin and under his/her lip; -The resident said he/she still did not get a shower. During observation and interview on 08/04/23 at 8:15 A.M., showed: -The resident laying in bed talking to the staff; -The resident still had facial hair on his/her chin and under his/her lip. Review of Resident #2's bathing documentation in point click care (PCC, cloud-based electronic health records used by the facility), dated 4/10/2023 through 7/21/23 showed the resident had showers on the following days: - 6/2/23; -7/11/23; -7/20/23; -No other bathing documentation was found; -No documentation that the resident's facial hair had been shaved. 5. Review of Resident #19's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Independent with bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Uses a wheel chair for mobility; -Independent with eating; -The resident is on oxygen therapy; -Diagnoses included, high blood pressure, depression and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, revised 7/20/23, showed: -The resident has limited physical mobility due to weakness and COPD; -The staff will accommodate the resident's shower preference; -Independent with dressing and personal hygiene. Observation and interview on 8/01/23, at 10:36 A.M., showed: -The resident laying in bed in in his/her room; -The resident's hair was oily with debris in it; -The resident's glasses had dirt and debris on them; -The resident said he/she does not get regular showers; -The resident said he/she said would like to have at least two showers a week; -The resident said he/she said he/she needs help getting the water to the right temperature; -He/she needs help from the staff to washer his/her hair and his/her back; -The resident said he/she said it makes him/her feel unclean not having two showers a week. During observation and interview on 08/02/23, at 7:14 P.M., showed: -The resident in his/her room setting in a wheelchair; -The resident's hair was still oily with debris in it; -The resident's glasses still had dirt and debris on them; -The resident said he/she still did not get a shower. Review of Resident 19's bathing documentation in PCC, dated 4/5/2023 through 7/26/23 showed the resident had showers on the following days: - 4/12/23; -6/30/23; -7/26/23; -No other bathing documentation was found; -No documentation that the resident's hair had been washed. During an interview on 08/02/23 at 8:10 P.M., NA A said: -The residents should receive a shower on the days and times they choose; -The residents should be shaved when they choose; -The staff should clean the residents' glasses before they put them on; -Residents should have a shower at least once a week; -Sometimes showers do not get done because we don't have enough help. During an interview on 08/02/23 at 8:17 P.M., CNA B said: -Residents should have a shower as often as they choose, at least once or twice a week; -The residents should be shaved when they choose; -The staff ensure residents' glasses are clean; -Sometimes he/she is busy and does not have time to get the showers done. During an interview on 8/3/23 at 9:46 A.M., Licensed Practical Nurse (LPN) A said: -Residents should receive a shower on the days and times they choose; -Residents should be shaved whenever they choose; -Staff should clean and make sure resident are wearing glasses and/or hearing aides; -Residents should have a shower at least once a week; -If a resident refuses a shower it is documented and the staff try at another time. 6. Review of Resident #23's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Extensive assistance of two staff with bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Receiving Hospice services; -Diagnoses included, dementia, high blood pressure, kidney disease and diabetes ( too much sugar in the blood). Review of the resident's care plan, revised 1/25/23, showed: -ADL self care deficit related to dementia; -Total dependence of staff with dressing, personal hygiene, and transfers. During an observation on 08/02/23, at 07:34 P.M., showed: -CNA B and NA A entered the residents room; -CNA B and NA applied gloves; -CNA B and NA A are both wiping feces off the bottom of the resident; -CNA B and NA A position the resident on his/her back; -CNA B wiped feces off of his/her gloves and cleaned the front of the resident; -NA A did not change gloves and cleaned the front of the resident; -CNA B and NA A did not wash their hands before putting on gloves to start perineal care; -CNA B did not change gloves and wash hands before wiped the front of the resident; -NA A did not change gloves, wash hands and apply clean gloves before cleaning the front of the resident; -CNA B did not separate and clean all areas of the front skin folds where urine had touched. During an interview on 08/02/23 at 8:10 P.M., NA A said: -He/she should have washed his/her hands before applying gloves before starting perineal care; -He/she should have took off his/her dirty gloves after cleaning feces's off the resident, washed his/her hands and applied clean gloves; -He/she should have separated and cleaned all areas of the skin where urine had touched. During an interview on 08/02/23 at 8:17 P.M., CNA B said: -He/she should have washed his/her hands before applying gloves before starting perineal care; -He/she should have took off his/her soiled gloves after cleaning feces off the residnet, washed his/her hands and applied clean gloves; -He/she should not wipe soiled gloves off with a wipe; -He/she should have separated and cleaned all areas of the skin where urine had touched. During an interview on 8/3/23 at 9:46 A.M., Licensed Practical Nurse (LPN) A said: -Hand washing should be preformed and clean gloves applied to start perineal care; -He/she should not wipe soiled gloves off with a wipe; -Gloves should be changed after being soiled -He/she should not wipe soiled gloves off with a wipe; -He/she should have separated and cleaned all areas of the skin where urine had touched. 7. During an observation on 08/03/23, at 08:35 A.M., showed: -CNA A and CMT A entered the resident's room with the mechanical lift; -CNA A and CMT A washed their hands and applied gloves; -CNA A and CMT A removed the resident's wet incontinent brief; -CMT A used a wiped and wiped down the left groin and CNA A gave CMT A a clean wipe; -CMT A wiped down the right groin and wiped the front skin folds; -CMT A did not separate and clean all areas of the front skin folds where urine had touched. During an interview on 08/02/23 at 8:55 A.M., CMT A said he/she should have separated and cleaned all areas of the skin where urine had touched. During an interview on 08/02/23 at 8:56 A.M., CNA A said all skin folds and areas of the skin that have touched urine should be separated and cleaned. During an interview on 8/3/23 at 9:46 A.M., Licensed Practical Nurse (LPN) A said: -Hand washing should be performed and clean gloves applied to start perineal care; -He/she should not wipe soiled gloves off with a wipe; -Gloves should be changed after being soiled -He/she should have separated and cleaned all areas of the skin where urine had touched. 8. Review of Resident #16's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers and toilet use; - Dependent on the assistance of one staff for dressing and personal hygiene; - Required extensive assistance of one staff for bathing; - Upper extremity impaired on one side; - Lower extremities impaired on both sides; - Occasionally incontinent of urine; - Always incontinent of bowel; - Diagnoses included stroke, chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing) and hemiparesis (muscle weakness on one side of the body). Review of the resident's care plan, revised 7/2023 showed: - The resident had occasional bladder incontinence related to impaired mobility; resident is incontinent of bowel; - Check frequently and as required for incontinence. Wash, rinse and dry peri area. Observation and interview on 8/1/23 at 2:34 P.M., showed: - CNA B and Nurse Aide (NA) A entered the resident's room and the resident said he/she accidentally dumped the urinal in his/her lap and he/she was sitting in urine; - CNA B and NA A used the mechanical lift and transferred the resident from his/her electric wheelchair to the bed; - CNA B and NA A removed the lift pad, the resident's wet incontinent brief and wet pants and covered the resident with a blanket; - The resident repeated again that he/she had dumped the urinal in his/her lap and was sitting in urine; - CNA B and NA A said they didn't hear him/her say anything about sitting in urine and both uncovered the resident; - CNA B used a wiped and wiped down the skin folds, folded the same wipe and wiped down one side of the groin; - NA A used the same area of the wipe and wiped down the skin folds then up the other side of the groin; - CNA B and NA A did not separate and clean all areas of the front skin folds where urine had touched; - NA A and CNA B turned the resident on his/her side; - NA A used the same area of the wipe and cleaned different areas of the buttocks; - NA A and CNA B turned the resident onto his/her back and covered the resident. During an interview on 8/4/23 at 11:30 A.M., NA A said: - He/she should not use the same area of the wipe to clean different areas of the skin; - He/she should have separated and cleaned all areas of the skin where urine had touched; - He/she should not have folded the wipe. During an interview on 8/4/23 at 12:03 P.M., CNA B said: - He/she should have separated and cleaned all areas of the skin where urine had touched; - He/she should not fold the wipe, it should be one wipe per swipe; - He/she should not use the same area of the wipe to clean different areas of the skin. 9. Review of Resident #16's bathing documentation in point click care (PCC, cloud-based electronic health records used by the facility), dated April, 2023 showed: - 4/25/23- the resident had a shower. Review of the resident's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers and toilet use; - Dependent on the assistance of one staff for dressing and personal hygiene; - Required extensive assistance of one staff for bathing; - Upper extremity impaired on one side; - Lower extremities impaired on both sides; - Occasionally incontinent of urine; - Always incontinent of bowel; - Diagnoses included stroke, COPD and hemiparesis The facility did not provide any shower sheets or documentation for May, 2023. Review of the resident's bathing documentation in PCC dated June, 2023 showed: - 6/4/23- the resident had a shower; - 6/25/23- the resident had a shower. Review of the resident's bathing documentation in PCC dated July, 2023 showed: - 7/11/23- the resident had a shower; - 7/13/23- the resident had a shower; - 7/20/23- the resident had a shower. Review of the Resident's care plan, revised 7/20/23 showed; - Personalized care- the resident preferred showers. Observation and interview on 8/1/23 at 10:28 A.M., showed; - The resident sat in bed with an excess amount of dry flaky skin on the resident's face, shoulders and the front of his/her shirt; - The resident said he/she has only had about four showers in a month; - He/she would prefer to have at least two showers a week; - It made him/her feel frustrated and he/she asked who would want to feel like a giant ball of disgustedness? During an interview on 8/4/23 at 8:49 A.M., CNA A said: - The residents do not always get two showers a week; - The showers do not always get done because there's not enough staff. During an interview on 8/4/23 at 11:30 A.M., Nurse Aide (NA) A said: - The showers do not always get completed because he/she may be the only aide on the floor. During an interview on 8/4/23 at 12:23 P.M., the DON said: - She would expect the residents to get two showers a week or documentation which showed the resident had refused; - The staff should document the showers in the computer or on a shower sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff used proper techniques to reduce the possibility accidents or injuries when transferring two sampled residents (Resident #11 and Resident #12) during the use of a mechanical lift transfer. The facility census was 22. Review of the manufactures instructions for the Drive mechanical lift, dated July 2020 showed: -Keep the legs of the lift in the closed position while transferring the resident; -Do not lock the rear casters of the patient lift when lifting an individual; -Locking the rear castors could cause the patient lift to tip. 1. Review of Resident #23's quarterly MDS (a federally mandated assessment tool completed by facility staff), dated 5/17/23, showed: -Severe cognitive impairment; -Extensive assistance of two staff with bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Receiving Hospice services; -Diagnoses included, dementia, high blood pressure, kidney disease and diabetes (too much sugar in the blood). Review of the resident's care plan, revised, 1/25/23, showed: -ADL self care deficit related to dementia; -Total dependence on staff with dressing, personal hygiene, and transfers. Observation on 8/3/23, at 8:35 A.M., showed: -Certified Nurses Aide (CNA) A and Certified Medication Technician (CMT) A entered the resident's room with the Drive mechanical lift; -The lift pad was underneath the resident; -CNA A and CMT A connected the lift pad to the lift; -CMT A lifted the resident off the bed; -CMT A did not lock the rear castors and the legs of the lift were not spread to the widest position; -CMT A moved the lift to the wheel chair and spread the legs of the lift around the wheel chair; -CMT A locked the rear castors of the lift and lowered the resident into the wheel chair; -CNA A locked the wheels of the wheel chair and guided the resident into the wheel chair; -CMT A did not leave the rear castors of the lift unlocked according to the mechanical lift manufacturer's instructions. -During an interview on 8/2/3 at 8:55 A.M., CMT A said: -He/she was not sure about locking the rear brakes of the lift; -He/she said the manufacturer's instructions should be followed; -He/she should leave the rear castors unlocked when he/she lowered the resident into the wheel chair; -During an interview on 8/3/23 at 9:46 A.M., Licensed Practical Nurse (LPN) A, said manufacturer's instructions should be followed when using the mechanical lift. -During an interview on 8/4/23 at 10:22 A.M., the Director of Nursing (DON) said: -When staff raise or lower the resident, the brakes on the lift should be unlocked; -The staff should follow the manufacturer's instructions when operating the mechanical lift. Surveyor: Feigly, [NAME] 2. Review of the facility's manufacturer's guidelines for the drive sit to stand lift (a lift that allows residents who can bear weight to transfer from a sitting position to a standing position), dated 7/1/20, showed, in part: - When lifting a resident, the rear casters should be unlocked; - Make sure the legs are in the maximum open position; - When lowering the resident onto the desired surface, lock the rear casters of the lift; - The guidelines did not mention the strap that goes around the back of the resident's legs. Review of Resident #11's quarterly MDS, dated 5/24/23 showed: - Cognitive skills intact; - Required extensive assistance of one staff for bed mobility, dressing, and toilet use; - Dependent on the assistance of two staff for transfers; - Upper and lower extremities impaired on both sides; - Always continent of bowel and bladder; - Diagnoses included cerebral palsy, (CP, a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), Review of the resident's care plan, revised 7/20/23 showed: - The resident has limited physical mobility related to cerebral palsy; - Limited range of motion to all extremities; - One assist for toileting. The resident used a sit to stand lift. Observation on 8/1/23 at 11:47 A.M., showed: - The resident sat on the toilet; - CNA A raised the resident up in the sit to stand lift; - Did not have the strap around the resident's lower legs; - Certified Medication Technician (CMT) A pulled the resident's pants up; - CNA A backed out of the bathroom with the legs of the sit to stand lift closed; - CNA A moved across the room to the resident's electric wheelchair with the legs of the sit to stand lift in the closed position then opened the legs to go around the electric wheelchair, did not lock the rear brakes on the lift and lowered the resident into the chair; - CNA A and CMT A removed the lift sling from around the resident; - CNA A and CMT A placed one arm under the resident's armpit and grabbed the back of the resident's pants with their other hand and repositioned the resident back in his/her wheelchair. During an interview on 8/3/23 at 1:30 P.M., CMT A said: - He/she thought they were supposed to put the strap around the resident's legs; - The brakes should probably be locked when raising or lowering the resident; - The legs were closed when the resident was moved. During an interview on 8/4/23 at 8:49 A.M., CNA A said: - The legs of the sit to stand lift are supposed to be open when the resident is in the lift. They can close the legs to go into the bathroom and when they come out of the bathroom, they should open the legs of the lift; - They are supposed to use the strap around the resident's legs, but the resident does not like it; - The brakes on the sit to stand lift should be locked when they raise or lower the resident - When he/she repositioned a resident in the wheelchair, a gait belt ( a special belt placed around the resident's waist to provide a handle to hold onto during a transfer) should be used. He/she should not have placed their arm under the resident's armpit and grabbed the back of the resident's pants. During an interview on 8/4/23 at 12:23 P.M., the DON said: - When the resident is in the sit to stand lift, the legs of the lift should be open; - When staff raise or lower the resident, the brakes on the lift should be unlocked; - The staff should be using the strap that goes around the resident's legs; - She expected the staff to use the mechanical lift to reposition the resident in the wheelchair. The staff should not put their arms under the resident's armpits or grab the back of their pants to reposition them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure staff provided proper respiratory care for two of 12 sampled residents (Residents #14 and #19) when staff failed to: effectively clean oxygen concentrator filters, properly install oxygen concentrator humidifier bottles, properly label and date oxygen concentrator tubing bags, and additionally failed to follow a physician order by providing the accurate amount of ordered oxygen liters. The facility census was 22. Review of the facility's oxygen administration policy, dated October 2010, showed: - The purpose of the policy is to provide guidelines for safe oxygen administration; - Staff is to review the physician's order for oxygen administration; - A humidifier bottle is necessary when performing this procedure; - Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered; - Check the humidifying jar to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through; - The procedures did not include direction on dating and labeling when equipment was put in place. 1. Review of Resident # 14's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff., dated 5/17/23 showed: - Brief interview of mental status (BIMS) score of 15, which indicates no cognitive impairment; - Independent requiring setup help only for bed mobility and eating; - Independent with no help for transfers, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene; - One person physical assist in reference to physical help in part of bathing; - Diagnoses included chronic obstructive pulmonary disease-(A condition involving constriction of the airways resulting in difficulty and discomfort while breathing) (COPD), Asthma (A condition in which a person's airway becomes inflamed, narrowed, swollen, and produce extra mucus, which makes it difficult to breathe). - Use of oxygen and hospice care. Review of the resident's care plan, revised 7/26/23 showed: - Resident has Emphysema/COPD, (A condition that develops over time and involves the gradual damage of lung tissue, specifically the destruction of the alveoli (tiny air sacs). - Oxygen (O 2) via nasal cannula (NC) at four to six liters (L) at night and as needed. Review of the resident's physician order sheet (POS), dated 8/3/23 showed: - Directions to change O 2 tubing, humidifier bottle, and O 2 weekly; - Clean filter weekly and as needed; - Date tubing and replaced bag for tubing every Sunday night shift; - O 2 on at four-six liters at night and every shift; - No specified order to remove humidified bottle. Review of the resident's treatment administration record (TAR), dated July 2023, showed: - An order for a weekly change of O 2 tubing, humidifier bottle, date tubing and replaced bag, and O 2 filter cleaned on 7/30/23; -A physician's order for O 2 on at four-six liters at night and every shift; - All O 2 levels were not within the parameters of the physician orders on all dates in the month of July; - Documentation on the dates between 7/1/23 and 7/12/23, 7/14/23 thought 7/16/23, 7/19/23, 7/24/23, and 7/25/23 showed the resident on 2 liters of O 2; - Documentation on 7/13/23, 7/17/23, 7/18/23, 7/20/23 7/21/23, 7/22/23, 7/23/23, and 7/26/23 through 7/31/23 showed no documentation of O 2 administration. Observation on 8/1/23 at 10:33 A.M., showed: - Oxygen tubing dated 7/30/23; - Oxygen tubing bag dated 2/7/23; - The left side external filter coated with lint and debris; - Humidifier bottle unattached to the device. Observation on 8/2/23 at 7:36 P.M. showed: - Resident in bed with a nasal cannula (NC) on; - O 2 set to two and a half liters; - Humidified bottle was disconnected. During an interview on 8/2/23 at 7:36 P.M., the resident said: - The O 2 level is always at two and a half; - Staff do not adjust the level of O 2 at night. During an interview on 8/4/23 at 7:01 A.M., LPN C said: - Filters are supposed to be clean; - When tubing is changed and dated, the tubing bag should be changed and dated as well; - Humidifier bottles should be attached unless there is a physician order; - Physician orders for how many liters of O 2 a resident should receive should be followed; - O 2 compressor maintenance is complete by night shift nurses. During an interview on 8/4/23 at 7:13 A.M., CMT B said: - O 2 Administration and maintenance is handled by nurses. 3. Review of Resident #19's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Independent with bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Uses a wheel chair for mobility; -Independent with eating; -The resident is on oxygen therapy; -Diagnoses included, high blood pressure, depression and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, revised 7/20/23, showed: -The resident has limited physical mobility due to weakness and COPD; -The staff will accommodate the resident's shower preference; -The resident is on oxygen; -Independent with dressing and personal hygiene. Observation and interview on 8/01/23, at 10:36 A.M., showed: -The resident laying in bed in in his/her room with his/her oxygen on via nasal cannula; -The filter was caked with dust and debris; -The bag on the side of the oxygen concentrator was dated 6/25/23; -The oxygen tubing was undated; -The resident said the nurses are supposed to change it once a week: -The residnet was not sure when the tubing or the filter had been changed. Observation and interview on 8/03/23, at 2:16 P.M., showed: -The resident laying in bed in in his/her room with his/her oxygen on via nasal cannula; -The filter was caked with dust and debris; -The bag on the side of the oxygen concentrator was dated 6/25/23; -The oxygen tubing was undated. During an interview on 8/4/23 at 12:23 P.M., the DON said: - O 2 filters and tubing should be cleaned weekly and dated; - O 2 tube bags should also be changed with tubing; - Humidified water bottle should be attached to the concentrator; - Staff should follow physician orders for how many liters of O 2 a resident should receive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident # 1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 7/24/23 showed: - Brief interview of mental status (BIMS) score of 13, which indicates intact cognition; - Requires supervision with setup help only for bed mobility and transfer; - Independent with no setup help for locomotion on and off unit, toilet use, and personal hygiene; - Limited assistance with one person physical assist for dressing; - Independent with setup help only for eating; - One person physical assist in reference to physical help for bathing; - Occasionally incontinent of urine; - Diagnoses of bipolar disorder (A mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), hypertension, dementia, and asthma. Review of the resident's care plan, revised 6/27/23 showed: - Resident requires assistance with ADL'S, mobility, medication administration, and meal prep; - Bathing preference of showers, two times a week; - Resident has limited physical mobility; - Resident has bladder incontinence related to Dementia. During an interview on 8/1/23 at 2:22 P.M., Resident #1 said: - He/she has not been receiving showers two times a week; - His/her showers have been missed multiple times, and missed showers occur monthly; - He/she is upset and does not like to feel unclean; - That showers were missed due to staff being busy; - He/she uses a call light; - He/she has had incontinent incidents with bowel movements in the past and has had to wait lengthy times to be cleaned up; - He/she was upset about having to sit in fecal matter. Review of undated facility shower schedule showed: - Resident #1 was scheduled to receive showers on Mondays and Fridays. Review of facility bathing task follow up report dated 4/1/23 to 7/31/23 (35 scheduled shower dates) showed: - Resident received showers on 4/14/23 (Friday), 4/29/23 (Saturday), 5/12/23 (Friday), 5/15/23 (Monday), 6/2/23 (Friday), 6/5/23 (Monday), and 6/23/23 (Friday); - The day of 6/20/23 showed Not applicable; - The dates of 4/27/23 (Thursday) and 5/24/23 (Wednesday) showed no shower received. Review of resident call light wait times between the dates of 6/1/23 and 7/31/23 showed: - Eight instances where call light times exceeded 15 minute response times; - The eight instances and elapsed times are as follows: - 6/7/23 8:05 A.M. elapsed time of 20 minutes 33 seconds - 6/10/23 6:51 P.M. elapsed time of 18 minutes 12 seconds - 6/26/23 9:40 A.M. elapsed time of 17 minutes 49 seconds - 7/13/23 10:39 A.M. elapsed time of 15 minutes 45 seconds - 7/15/23 7:27 P.M. elapsed time of 15 minutes 52 seconds - 7/15/23 9:28 P.M. elapsed time of 21 minutes 56 seconds - 7/21/23 4:26 A.M. elapsed time of 20 minutes 02 seconds - 7/30/23 8:31 P.M. elapsed time of 17 minutes 23 seconds During an interview on 8/4/23 at 7:34 A.M., licensed practical nurse (LPN) C said: - More staff would help give residents the care they deserve; - Call lights should be answered before three to five minutes; - Call lights are not always answered that fast, particularly if staff is tied up assisting other residents; - Call light wait times over five minutes are unreasonable. During an interview on 8/4/23 at 7:49 A.M., certified nursing assistant (CNA) A said: - He/she has heard complaints about not receiving their showers; - Residents often miss getting their showers; - The facility dos not have enough staff to give residents the best practicable care; - Call light wait times often take longer than he/she would like due to low staff numbers; - Call light times go long when he/she is assisting other residents; - Call light wait times of longer than five minutes is unacceptable. 5. Review of Resident #2's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Required assistance of one staff for bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Uses a wheel chair for mobility; -Independent with eating; -Diagnoses included, orthostatic hypotension (low blood pressure upon standing), dementia and anxiety. Review of the resident's undated care plan showed: -ADL self care deficit related to dementia; -Dependent on staff of two for bed mobility; -Requires assistance of two staff with dressing; -Requires assistance of two staff for personal hygiene. Review of Resident #2's bathing documentation in PCC, dated 4/10/2023 through 7/21/23 showed the resident had showers on the following days: - 6/2/23; -7/11/23; -7/20/23; -No other bathing documentation was found; -No documentation that the resident's facial hair had been shaved was found. Review of the resident's call light record, dated 6/1/23 through 7/31/23 showed the call lights were on for the following amount of time: - 6/1/23 at 7:48 A.M., 18 minutes, 58 seconds; - 6/5/23 at 10:01 P.M., 22 minutes, 57 seconds; - 6/8/23 at 10:18 P.M., 17 minutes, 20 seconds; - 6/9/23 at 8:01 A.M., 24 minutes, two seconds; - 6/10/23 at 1:18 P.M., 23 minutes, seven seconds; - 6/11/23 at 9:37 P.M., 31 minutes, 11 seconds; - 6/13/23 at 7:04 A.M., 20 minutes, 33 seconds; - 6/13/23 at 10:17 A.M., 22 minutes, seven seconds; - 6/15/23 at 3:59 P.M., 28 minutes, 45 second; - 6/21/23 at 7:15 A.M., 17 minutes, 19 seconds; - 6/26/23 at 10:30 P.M., 23 minutes, 47 seconds; - 6/27/23 at 5:08 A.M., 20 minutes, 59 seconds; - 6/30/23 at 7:40 A.M., 17 minutes, 31 seconds; - 7/2/23 at 7:26 A.M., 23 minutes, 38 seconds; - 7/2/23 at 9:33 A.M., 20 minutes, 58 seconds; - 7/2/23 at 11:10 A.M., 18 minutes, 28 seconds; - 7/3/23 at 12:51 P.M., 17 minutes, 50 seconds; - 7/5/23 at 9:31 A.M., 18 minutes, four seconds; - 7/27/23 at 12:48 P.M.,18 minutes, three seconds. - 7/10/23 at 6:39 A.M., 27 minutes, 51 seconds; - 7/10/23 at 7:35 A.M., 21 minutes, 15 seconds; - 7/11/23 at 10:05 A.M., 17 minutes, six seconds; - 7/15/23 at 9:30 P.M., 19 minutes, 51 seconds; - 7/18/23 at 7:07 A.M., 17 minutes, 10 seconds; - 7/18/23 at 8:04 A.M., 18 minutes, 17 seconds; - 6/28/23 at 11:10 A.M., 21 minutes, 47 seconds; - 6/30/23 at 7:47 A.M., 17 minutes, 17 seconds; - 6/30/23 at 8:26 A.M., 25 minutes, 54 seconds; - 6/30/23 at 3:17 P.M., 16 minutes, six seconds; - 7/2/23 at 10:10 A.M., 30 minutes, 42 seconds; - 7/5/23 at 12:36 P.M., 26 minutes, 27 seconds; - 7/11/23 at 11:41 A.M., 17 minutes, 30 seconds; - 7/13/23 at 3:08 P.M., 16 minutes, 43 seconds; - 7/16/23 at 4:09 P.M., 19 minutes, 48 seconds; - 7/18/23 at 8:04 A.M., 18 minutes, 17 seconds; - 7/19/23 at 12:23 A.M., 27 minutes, 59 seconds; - 7/20/23 at 10:36 A.M., 33 minutes, 14 seconds; - 7/23/23 at 7:02 A.M., 36 minutes, 50 seconds; - 7/26/23 at 10:53 P.M., 30 minutes, 56 seconds; - 7/29/23 4:05 P.M., 27 minutes, eight seconds. Observation and interview on 8/01/23, at 10:12 A.M., showed: -The resident setting in his/her room in a recliner; -The resident had facial hair on his/her chin and under his/her lip; -The resident said he/she does not get regular showers; - The staff do not come to his/her room and offer him/her a bedtime: - He/She would take a bedtime snack if it was offered; - The facility does not have enough staff; -The resident said he/she said would like to be shaved at least two or three times a week; -The resident said he/she said he/she needs help with shaving; -The resident said he/she said it makes him/her fell embarrassed to have facial hair; -The resident said he/she used to get showers on Tuesdays and Thursdays and now just once a week; - Sometimes it takes over an hour for staff to answer his/her call light. During observation and interview on 08/02/23, at 8:07 A.M. showed: -The resident in his/her room setting in a recliner; -The resident still had facial hair on his/her chin and under his/her lip; -The resident said he/she still did not get a shower. An observation on 8/2/23, at 7:51 P.M., showed no staff was passing snacks. During observation and interview on 08/04/23 at 8:15 A.M., showed: -The resident laying in bed talking to the staff; -The resident still had facial hair on his/her chin and under his/her lip. 6. Review of Resident #4's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Independent with ADL's; -Physical help with part of bath; -Occasionally incontinent of bladder; -Diagnoses included: Hypothyroidism (the thyroid gland does not produce enough thyroid hormone), arthritis and anemia (the blood does not have enough healthy red blood cells) and dementia. Review of the resident's care plan dated, 7/20/23, showed: -The resident has an ADL self care performance due to dementia; -The resident would like to return home; -Having snacks available in between meals is very important to the resident. During an interview on 8/1/23, at 9:15 A.M., the resident said: -He/She likes to have a snack at bedtime; -The staff do not pass snacks before bedtime; -If he/she wants a snack he/she has to ask for it; -The staff do not have time to pass the snacks. An observation on 8/2/23, at 7:51 P.M., showed: -No staff were passing snacks; -The resident rang his/her call light; -The resident asked Nurses Aide (NA) to bring him/her a snack; -NA A brought a basket to the resident's room and the resident chose a snack from the basket; -The resident closed his/her door. 7. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Assistance of one staff with dressing; -Assistance of one staff with bed mobility; -Assistance of one staff for transfers; -Incontinent of bladder; -Diagnoses included, orthostatic hypotension (low blood pressure when standing up), dementia, and anxiety. Review of the resident's care plan, dated 11/2/22, showed: -Impaired cognitive function related to dementia; -Assistance of two staff for transfers with a gait belt; -The resident has a history of falls; -Encourage the resident to use call light. Review of the resident's call light record, dated 6/1/23 through 7/31/23 showed the call lights were on for the following amount of time: - 6/3/23 at 6:44 A.M., 22 minutes, seven seconds; - 6/3/23 at 5:01 P.M., 18 minutes, 53 seconds; - 6/11/23 at 11:09 A.M., 32 minutes, 18 seconds; - 6/17/23 at 4:50 P.M., 26 minutes, five seconds; - 6/21/23 at 8:43 A.M., 32 minutes, 43 seconds; - 6/24/23 at 12:40 P.M., 20 minutes, 18 seconds; - 6/25/23 at 8:28 A.M., 20 minutes, 10 seconds; - 6/26/23 at 6:46 A.M., 46 minutes, three seconds; - 6/28/23 at 7:17 A.M., 25 minutes, one second; - 7/2/23 at 7:35 A.M., 38 minutes, 32 seconds; - 7/3/23 at 10:05 A.M., 21 minutes, 16 seconds; - 7/3/23 at 4:59 P.M., 17 minutes, 27 seconds; - 7/7/23 at 10:12 A.M., 46 minutes, 30 seconds; - 7/8/23 at 11:16 A.M., 23 minutes, 59 seconds; - 7/12/23 at 8:27 A.M., 31 minutes, 36 seconds; - 7/15/23 at 5:44 P.M., 17 minutes, 28 seconds. 8. Review of Resident #19's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Independent with bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Uses a wheel chair for mobility; -Independent with eating; -The resident is on oxygen therapy; -Diagnoses included, high blood pressure, depression and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, revised 7/20/23, showed: -The resident has limited physical mobility due to weakness and COPD; -The staff will accommodate the resident's shower preference; -Independent with dressing and personal hygiene. Review of the resident's call light record, dated 6/1/23 through 7/31/23 showed the call lights were on for the following amount of time: - 6/5/23 at 5:44 P.M., 22 minutes, 43 seconds; - 6/9/23 at 8:46 P.M., 18 minutes, 53 seconds; - 6/12/23 at 11:16 A.M., 28 minutes, five seconds; - 6/18/23 at 7:53 P.M., 16 minutes, 32 seconds; - 6/24/23 at 4:10 P.M., 23 minutes, 39 seconds; - 6/29/23 at 9:37 A.M., 27 minutes, 28 seconds; - 7/2/23 at 12:51 P.M., 19 minutes, 10 seconds; - 7/10/23 at 10:39 A.M., 20 minutes, 51 seconds; - 7/10/23 at 11:26 A.M., 20 minutes, 25 seconds; - 7/13/23 at 10:07 P.M., 17 minutes, 35 seconds; - 7/14/23 at 9:54 P.M., 39 minutes, 52 seconds; - 7/17/23 at 3:25 P.M., 21 minutes, 31 seconds; - 7/18/23 at 12:34 P.M., 42 minutes, 57 seconds; - 7/19/23 at 8:30 A.M., 20 minutes, 54 seconds; - 7/20/23 at 10:04 A.M., 24 minutes, 22 seconds; - 7/22/23 at 7:42 A.M., 28 minutes, 15 seconds; - 7/23/23 at 4:55 P.M., 29 minutes, 12 seconds; - 7/26/23 at 7:37 A.M., 24 minutes, four seconds; - 7/27/23 at 12:48 P.M.,18 minutes, 36 seconds. Observation and interview on 8/01/23, at 10:36 A.M., showed: -The resident laying in bed in in his/her room; -The resident's hair was oily with debris in it; -The resident's glasses had dirt and debris on them; -The resident said he/she does not get regular showers; -The resident said he/she said would like to have at least two showers a week; -The resident said he/she said he/she needs help getting the water to the right temperature; -He/She needs help from the staff to wash his/her hair and his/her back; -The resident said it makes him/her feel unclean not having two showers a week. During observation and interview on 08/02/23, at 7:14 P.M., showed: -The resident in his/her room setting in a wheelchair; -The resident's hair was still oily with debris in it; -The resident's glasses still had dirt and debris on them; -The resident said he/she still did not get a shower. Review of his/her bathing documentation in PCC, dated 4/5/2023 through 7/26/23 showed the resident had showers on the following days: - 4/12/23; -6/30/23; -7/26/23; -No other bathing documentation was found; -No documentation that the resident's hair had been washed. During an interview on 08/02/23 at 8:10 P.M., NA A said: -The residents should receive a shower on the days and times they choose; -The residents should be shaved when they choose; -The staff should clean the residents' glasses before they put them on; -Residents should have a shower at least once a week; -He/She only passes snacks at 2:00 P.M. when the shift starts; -Call lights should be answered within five minutes; -Sometimes showers do not get done and call lights are not answered within a reasonable amount of time because there is not enough staff to help. During an interview on 08/02/23 at 8:17 P.M., CNA B said: -Residents should have a shower as often as they choose, at least once or twice a week; -The residents should be shaved when they choose; -The staff ensure residents' glasses are clean; -Call lights should be answered with in three to seven minutes; -Sometimes he/she is busy and does not have time to get the showers done and pass bedtime snacks. During an interview on 8/3/23 at 9:46 A.M., Licensed Practical Nurse (LPN) A said: -Residents should receive a shower on the days and times they choose; -Residents should be shaved whenever they choose; -Staff should clean and make sure resident are wearing glasses and/or hearing aides; -Residents should have a shower at least once a week; -If a resident refuses a shower it is documented and the staff try at another time; -Residents should be offered a snack at bedtime; -Call lights should be answered with in three to seven minutes. During an interview on 8/4/23 at 12:23 P.M., the Director of Nursing (DON) said: - He/she expects residents to receive two showers a week or documentation of resident refusal; - Showers should be documented; - The facility has enough staff to meet resident needs; - Call lights should be answered within 15 minutes; - He/she was unaware if random audits were being completed for call light response times. - The call lights should be answered within 15 minutes. The staff should be able to handle it because there's not a high acuity; - She expected staff to go to each room and offer the resident a snack at bedtime Based on observations, interviews and record review, the facility failed to provide adequate staffing to meet the needs of residents due to extended call light response times, which affected seven of 12 sampled residents, (Resident #1, #2, #5, #9, #11, #16 and #19), failed to provide showers for Resident #1, #2, #16 and #19, and failed to provide a bedtime snack for Resident #1, #2, #4, #9, #12 #16 and #19, and other residents who attended the resident group interview. The facility census was 22. Review of the facility's policy for answering call lights, revised March 2021, showed, in part: - The purpose of this procedure is to ensure timely responses to the resident's requests and needs; - If the resident needs assistance , indicate the approximate time it will take for you to respond; - If the resident's request requires another staff member, notify the individual; - If the resident's request is something you can fulfill, complete the task within five minutes if possible; - If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. Review of the facility's policy for serving snacks between meal and bedtime, revised September 2010, showed, in part: - The purpose of this procedure is to provide the resident with adequate nutrition; - Review the resident's care plan and provide for any special needs of the resident; - The person performing this procedure should record the following information in the resident's medical record: the date and time the snack was served; the amount of snack eaten by the resident; if the resident refused the snack, the reasons why and the intervention taken. Review of the facility ADL policy dated March 2018, showed: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, including walking), elimination (toileting), dining (meals and snacks) and communication (speech, language, and any functional communication systems). 1. Review of Resident #9's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/5/23 showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers; - Required set up with eating; - Upper and lower extremity impaired on both sides; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing), dementia and anxiety. Review of the resident's care plan, revised 7/20/23 showed: - The resident had limited physical mobility related to weakness; - The resident is a two person assist the sit to stand lift (a lift that allows residents who can bear weight to transfer from a sitting position to a standing position), for all transfers; - The resident is able to feed him/herself with set-up; - The resident required assistance with all activities of daily living (ADL's) including bathing; - Personalized care: having snacks between meals was very important. - The resident is non-weight bearing. Review of the resident's call light record, dated 6/1/23 through 7/31/23 showed the call lights were on for the following amount of time: - 6/2/23 at 10:57 A.M., 19 minutes, 23 seconds; - 6/4/23 at 9:25 P.M., 25 minutes, 40 seconds; - 6/5/23 at 10:47 A.M., 26 minutes, 35 seconds; - 6/6/23 at 1:24 P.M., 17 minutes, 31 seconds; - 6/8/23 at 6:01 P.M., 28 minutes, 31 seconds; - 6/8/23 at 6:41 P.M., 21 minutes, 47 seconds; - 6/9/23 at 12:50 P.M., 17 minutes, 27 seconds; - 6/9/23 at 6:34 P.M., 20 minutes, 35 seconds; - 6/10/23 at 12:47 P.M., 45 minutes, 44 seconds; - 6/11/23 at 10:33 A.M., 17 minutes, 30 seconds; - 6/11/23 at 12:56 P.M., 17 minutes, 38 seconds; - 6/12/23 at 8:02 A.M., 19 minutes, 38 seconds; - 6/13/23 at 8:53 A.M., 21 minutes, 20 seconds; - 6/14/23 at 1:06 P.M., 18 minutes, seven seconds; - 6/15/23 at 11:31 A.M., 19 minutes, 46 seconds; - 6/17/23 at 9:17 P.M., 32 minutes, 23 seconds; - 6/21/23 at 1:33 P.M., 21 minutes, seven seconds; - 6/23/22 at 6:26 P.M., 18 minutes, 15 seconds; - 6/24/23 at 7:24 A.M., 42 minutes, 41 seconds; - 6/26/23 at 9:35 P.M., 18 minutes, 19 seconds; - 7/3/23 at 6:00 P.M., 19 minutes, two seconds; - 7/4/23 at 8:29 A.M., 31 minutes, 23 seconds; - 7/8/23 at 9:31 A.M., 18 minutes, 20 seconds; - 7/8/23 at 10:53 A.M., 20 minutes, 24 seconds; - 7/9/23 at 11:40 A.M., 20 minutes, six seconds; - 7/11/23 at 9:02 A.M., 21 minutes, 25 seconds; - 7/16/23 at 11:00 A.M., 16 minutes, 41 seconds; - 7/18/23 at 11:22 A.M., 22 minutes, 45 seconds; - 7/20/23 at 9:46 A.M., 19 minutes, 17 seconds; - 7/2123 at 11:27 A.M., 30 minutes, ten seconds; - 7/22/23 at 8:10 A.M., 16 minutes, 54 seconds; - 7/23/23 at 7:30 P.M., 17 minutes, 29 seconds; - 7/24/23 at 11:29 A.M., 21 minutes, 25 seconds; - 7/24/23 at 11:54 A.M., 21 minutes, three seconds; - 7/30/23 at 3:20 P.M., 17 minutes, 52 seconds. During an interview on 8/1/23 at 12:36 P.M., the resident said: - The facility does not have enough staff right now; - It takes at least 30 - 45 minutes for his/her call light to get answered. It happens all hours of the day and night. It makes him/her angry but there is nothing he/she can do about it; - The staff do not go to his/her room every night and offer him/her a snack at bedtime. He/she would take a bedtime snack if it was offered. 2. Review of Resident #11's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of one staff for bed mobility, dressing, and toilet use; - Dependent on the assistance of two staff for transfers; - Upper and lower extremities impaired on both sides; - Always continent of bowel and bladder; - Diagnoses included cerebral palsy, (CP, a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), anxiety and depression. Review of the resident's care plan, revised 7/20/23 showed: - The resident has limited physical mobility related to cerebral palsy; - Limited range of motion to all extremities; - One assist for toileting; - Two assist with bed mobility. Review of the resident's call light record, dated 6/1/23 through 7/31/23 showed the call lights were on for the following amount of time: - 6/1/23 at 6:47 A.M., 28 minutes, 48 seconds; - 6/2/23 at 10:55 A.M., 22 minutes, 19 seconds; - 6/4/23 at 4:14 P.M., 35 minutes, one second; - 6/4/23 at 9:16 P.M., 17 minutes, 16 seconds; - 6/8/23 at 6:30 A.M., 20 minutes, 22 seconds; - 6/9/23 at 6:25 A.M., 17 minutes, 14 seconds; - 6/9/23 at 9:22 A.M., 18 minutes, 59 seconds; - 6/9/23 at 9:35 P.M., 18 minutes, 27 seconds; - 6/10/23 at 11:15 A.M., 31 minutes, 15 seconds; - 6/14/23 at 6:55 A.M., 27 minutes, one second; - 6/16/23 at 6:32 A.M., 27 minutes, 13 seconds; - 6/17/23 at 9:08 P.M., 22 minutes, 14 seconds; - 6/19/23 at 6:58 A.M., 38 minutes, 41 seconds; - 6/19/23 at 11:14 A.M., 19 minutes, 59 seconds; - 6/21/23 at 6:48 A.M., 18 minutes, 27 seconds; - 6/24/23 at 7:06 A.M., 18 minutes, 36 seconds; - 6/26/23 at 6:38 A.M., 50 minutes, 43 seconds; - 6/26/23 at 11:19 A.M., 18 minutes, 22 seconds; - 6/28/23 at 6:58 A.M., 19 minutes, seven seconds; - 6/29/23 at 4:32 P.M., 22 minutes, 47 seconds; - 7/2/23 at 6:46 A.M., 33 minutes, 18 seconds; - 7/2/23 at 9:57 P.M., 19 minutes, 27 seconds; - 7/7/23 at 7:35 A.M., 19 minutes, 15 seconds; - 7/10/23 at 11:01 A.M., 27 minutes, 24 seconds; - 7/12/23 at 7:16 A.M., 16 minutes, 28 seconds; - 7/15/23 at 6:44 A.M., 19 minutes, 37 seconds; - 7/15/23 at 3:39 P.M., 16 minutes 45 seconds; - 7/18/23 at 1:16 P.M., 16 minutes, 39 seconds; - 7/20/23 10:27 A.M., 20 minutes, 14 seconds; - 7/21/23 at 11:11 A.M., 30 minutes, 57 seconds; - 7/26/23 at 7:15 A.M., 19 minutes, four seconds; - 7/27/23 at 9:54 A.M., 42 minutes 11 seconds; - 7/29/23 at 10:01 P.M., 26 minutes, 36 seconds. During an interview on 8/1/23 at 11:57 A.M., the resident said: - The facility does not have enough CNA's and the ones they do have are working extra shifts; - Sometimes it takes 35 minutes for his/her call light to get answered. It made him/her upset and he/she has had an accident waiting for staff to toilet him/her. It made him/her angry and embarrassed; - He/she never gets offered a snack at bedtime and he/she would take it and save it for later. 3. Review of Resident #16's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers and toilet use; - Dependent on the assistance of one staff for dressing and personal hygiene; - Required extensive assistance of one staff for bathing; - Upper extremity impaired on one side; - Lower extremities impaired on both sides; - Occasionally incontinent of urine; - Always incontinent of bowel; - Diagnoses included stroke, COPD and hemiparesis (muscle weakness on one side of the body). Review of the resident's care plan, revised 7/2023 showed: - The resident had limited physical mobility related to a stroke - The resident had occasional bladder incontinence related to impaired mobility; resident is incontinent of bowel; - Check frequently and as required for incontinence. Wash, rinse and dry peri area; - The resident required the assistance of two staff for mechanical lift transfers; - Personalized care- the resident preferred showers; - The resident is non-weight bearing. Review of of the resident's bathing documentation in point click care (PCC, cloud-based electronic health records used by the facility), dated April, 2023 showed: - 4/25/23- the resident had a shower. The facility did not provide any shower sheets or documentation for May, 2023. Review of the resident's bathing documentation in PCC dated June, 2023 showed: - 6/4/23- the resident had a shower; - 6/25/23- the resident had a shower. Review of the resident's bathing documentation in PCC dated July, 2023 showed: - 7/11/23- the resident had a shower; - 7/13/23- the resident had a shower; - 7/20/23- the resident had a shower. Review of the resident's call light record, dated 6/1/23 through 7/31/23 showed the call lights were on for the following amount of time: - 6/1/23 at 7:13 A.M., 31 minutes, 24 seconds; - 6/1/23 at 10:52 A.M., 20 minutes, 22 seconds; - 6/2/23 at 10:25 A.M., 18 minutes, 48 seconds; - 6/2/23 at 4:01 P.M., 18 minutes, 32 seconds; - 6/4/23 at 6:46 A.M., 34 minutes, 30 seconds; - 6/4/23 at 10:43 A.M., 17 minutes, 12 seconds; - 6/5/23 at 12:57 P.M., 17 minutes, 23 seconds; - 6/5/23 at 4:34 P.M., 27 minutes, 12 seconds; - 6/6/23 at 7:23 A.M., 18 minutes, 51 seconds; - 6/7/23 at 6:58 A.M., 28 minutes, 50 seconds; - 6/7/23 at 7;34 A.M., 20 minutes, 59 seconds; - 6/8/23 at 6:57 A.M., 18 minutes, 23 seconds; - 6/9/23 at 10:53 A.M., 24 minutes, 53 seconds; - 6/10/23 at 8:30 A.M., 42 minutes, 36 seconds; - 6/12/23 at 7:38 A.M., 24 minutes, 22 seconds; - 6/13/23 at 7:29 A.M., 20 minutes, 42 seconds; - 6/19/23 at 8:38 A.M., 20 minutes, 19 seconds; - 6/19/23 at 12:56 P.M., 26 minutes, 31 seconds; - 6/20/23 at 6:28 A.M., 20 minutes, 45 seconds; - 6/20/23 at 8:37 A.M., 39 minutes, two seconds; - 6/21/23 at 7:08 A.M., 22 minutes, 41 seconds; - 6/21/23 at 12:56 P.M., 30 minutes, six seconds; - 6/22/23 at 7:09 A.M., 16 minutes, 51 seconds; - 6/27/23 at 8:55 A.M., 16 minutes, 54 seconds; - 6/27/23 at 11:52 A.M., 23 minutes, 25 seconds; - 6/28/23 at 7:23 A.M., 17 minutes, 59 seconds; - 6/28/23 at 11:10 A.M., 21 minutes, 47 seconds; - 6/30/23 at 7:47 A.M., 17 minutes, 17 seconds; - 6/30/23 at 8:26 A.M., 25 minutes, 54 seconds; - 6/30/23 at 3:17 P.M., 16 minutes, six seconds; - 7/2/23 at 10:10 A.M., 30 minutes, 42 seconds; - 7/5/23 at 12:36 P.M., 26 minutes, 27 seconds; - 7/11/23 at 11:41 A.M., 17 minutes, 30 seconds; - 7/13/23 at 3:08 P.M., 16 minutes, 43 seconds; - 7/16/23 at 4:09 P.M., 19 minutes, 48 seconds; - 7/18/23 at 8:38 A.M., 16 minutes, four seconds; - 7/19/23 at 8:45 A.M., 25 minutes, nine seconds; - 7/19/23 at 11:43 A.M., 19 minutes, 59 seconds; - 7/21/23 at 11:07 A.M., 25 minutes, 29 seconds; - 7/23/23 at 6:55 A.M., 21 minutes, 48 seconds; - 7/23/23 at 4:58 p.m., 22 minutes, 28 seconds; - 7/27/23 2:03 P.M., 17 minutes, three seconds. During an interview on 8/1/23 at 10:25 A.M., the resident said: - The staff do not come to his/her room and offer him/her a snack at bedtime. He/she would take the bedtime snack if it was offered; - The facility needs more staff; - He/she has only had about four showers in a month. He/she would prefer to have at least two showers in a week; - Sometimes it takes a while for his/her call light to get answered. Review of the resident council meeting notes showed: - May 2023; New business or concerns: better snack options on snack cart and passed out more often; - June 2023: New business or concerns: snacks are still not always being passed; - July 2023: New business or concerns: snacks are still not always being passed. During a group interview on 8/2/23 at 10:04 A.M., the residents said: - The residents said the staff do not come to their room every night and offer them a snack at bedtime; - Four of the five residents said they would take a snack at bedtime if it was offered; - The residents felt like the facility needed more staff. The showers do not always get completed and it takes a long tine for the call lights to get answered. During an interview on 8/2/23 at 7:01 P.M., Licensed Practical Nurse (LPN) A said: - He/she did not think it took very long for the call lights to get answered, within one to five minutes. He/she has had residents complain about how long it takes for call lights to get answered; - The staff pass snacks out at the beginning of the of the 2 -10 shift but do not pass any snacks out after dinner unless a resident asks for something to eat. During an interview on 8/3/23 at 1:30 P.M., Certified Medication Technician (CMT) A said: - The call lights probably do not get answered as quickly as they should, they do not have enough staff. He/she felt awful because the residents were not getting the care they needed; - He/she had worked the evening shift and has never seen any staff passing snacks at bedtime. During an interview on 8/4/23 at 8:24 A.M., LPN C said: - He/she did not know if or when bedtime snacks were passed; - They are short staffed right now but they do the best they can; - The showers do not always get done on the day shift; - Sometimes the call l

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. This had the potential to affect all residents. Facility census was 22. The facility did not provide a policy for RN coverage. Review of the facility's Payroll Based Journal data (PBJ- a report that provides staffing data set information submitted by nursing homes on a quarterly basis) for Quarter 2 2023 (January 1 to March 31) showed no RN hours on 1/1, 1/14, 1/15, 2/6, 2/11, and 2/12. Review of staffing sheets confirmed there was no RN hours on 1/1, 1/14, 1/15, 2/6, 2/11, and 2/12. Review of staffing schedules for May 2023 showed no RN on the following days: 5/3, 5/4, 5/8, 5/10, 5/11, 5/12, 5/13, 5/14, 5/16, 5/18, 5/19, 5/22, 5/26, and 5/30. Review of daily staffing sheets for May 2023 showed no RN hours on 5/13, 5/14, 5/19, 5/21, 5/27, and 5/28. Review of staffing schedules for June 2023 showed no RN on the following days: 6/1, 6/2, 6/6, 6/7, 6/8, and 6/12 through 6/30. Review of daily staffing sheets for June 2023 showed no RN hours on 6/3, 6/4, 6/6, 6/12, 6/14, 6/17, 6/18, 6/24, and 6/25. Review of staffing schedules for July 2023 showed no RN on the following days: 7/1 through 7/12, 7/14, 7/15, 7/16, and 7/19 through 7/31. Review of daily staffing sheets for July 2023 showed no RN hours on 7/4, 7/12, and 7/14. During entrance conference on 08/01/23 at 9:29 A.M., the Administrator said: -He/She had been the administrator since December 2022; -A new corporation took over the facility in July 2023; -The regional nurse was the interim Director of Nursing (DON) and had been there since the middle of June; -The previous DON quit; -The regional nurse was not full time and was the only RN; -There was no other RN's at the facility; -The facility did not have any nursing staffing waivers; -The facility did not have RN coverage eight hours a day, seven days a week; -He/She was aware of the requirement. During an interview on 08/02/23 at 11:30 A.M., the Administrator, DON, and [NAME] President of Clinical Operations said: -The regional nurse had been the interim DON for about a month and a half; -He/She worked full time Monday through Friday; -He/She did not clock in and could not provide payroll punches to verify hours worked. During an interview on 08/02/23 at 12:33 P.M., the DON said: -There were no other RN's employed at the facility; -He/She was aware of the requirement; -The facility had RN job openings posted with no applicants.

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 nine medication errors out of 25 opportunities for error which resulted in a medication error rate of 36%, which affected five sampled residents, (Resident #2, #6, # 9, #18, and #19). The Facility census was 22. Review of the facility's policy for administering medications, revised April 2019, showed: - Medications are administered in a safe and timely manner, and as prescribed; - The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the facility's policy for nasal administration, revised 8/20, showed in part: - Medications will be administered in a safe and effective manner. The guidelines in this policy detail how to administer nasal sprays or drops; - When required by manufacturer, prime the pump by holding the bottle upright and away from the resident while spraying into the air; - If possible, have the resident gently blow their nose to remove excess mucous; - Instruct the resident to hold their head in an upright position, tilted slightly forward; - Use the finger of your other hand to close the nostril that in not receiving medication by gently pressing the side of the nostril; - Keep the bottle upright and insert the spray tip into the nostril no more than 1/4 of an inch. Point the tip to the back and outer side of the nose; - Ask the resident to breathe out through their mouth; - Press the actuator or spray tip firmly and quickly while the resident breathes in through the nose and out through the mouth; - If another dose of the same nasal medication is required, repeat the procedure above; - Instruct the resident to avoid blowing their nose for 15 minutes. Review of the manufacturer's guidelines for Azelastine Hydrochloride nasal spray, revised November 2021, showed, in part: - Blow your nose to clear your nostrils; - Keep your head tilted downward toward your toes; - Place the spray tip about 1/4 inch to 12 inch into one side of the nostril. Hold bottle upright and aim the spray tip toward the back of your nose; - Close your other nostril with a finger . Press the pump one time and sniff gently at the same time, keeping your head tilted forward and down; - Repeat in your other nostril. 1. Review of Resident #6's physician order sheet (POS), dated August 2023, showed: - Start date -10/21/22 - Azelastine Hydrochloride solution 0.1% two sprays in each nostril twice daily related to allergies. Review of the resident's medication administration record (MAR) dated August 2023, showed: - Azelastine Hydrochloride solution 0.1% two sprays in each nostril twice daily related to allergies. Observation on 8/3/23 at 8:09 A.M., showed: - Certified Medication Technician (CMT) A gave the bottle of nasal spray to the resident; - He/She took the bottle gave him/herself one spray in each nostril; - The resident did not blow his/her nose beforehand and did not close one side the his/her nostril. He/She only gave one spray and CMT A did not give the resident any instructions. During an interview on 8/3/23 at 1:19 P.M., CMT A said: - He/She should have followed the manufacturer's guidelines for the administration of the nasal spray; - He/She should have made sure the resident blew his/her nose first and held one side of the nostril closed; - Should have instructed the resident and made sure two sprays were administered. During an interview on 8/4/23 at 12:23 P.M., the Director of Nursing (DON) said: - She expected staff to follow the manufacturer's guidelines to include blowing their nose and closing one side of the nostril; - Staff should make sure the amount the physician ordered was administered. 2. Review of the facility's policy for administering topical medications, revised October 2010, showed, in part: - The purpose of this procedure is to provide guidelines for the safe administration of topical medications; - Calculate the medication dose. Re-check the calculation; - Prepare the correct dose of medication. Review of the facility's policy for instillation of eye drops, revised January 2014, showed in part: - The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes; - Gently pull the lower eyelid down, instruct the resident to look up; - Drop the medication into the mid lower eyelid. (Do not touch the eye or eyelid with the dropper); - Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops. Instruct the resident not to blink or squeeze the eyelids shut, which forces the medicine out of the eye. Review of the website, www.drugs.com for administering of Restasis eye drops showed: - Turn the bottle upside down a few times to gently mix the medicine; - Tilt your head back slightly and pull down your lower eyelid to create a small pocket; - Look up and away from the dropper and squeeze out a drop; - Close your eye for two or three minutes with your head tilted down, without blinking or squinting; - Gently press your finger to the inside corner of the eye for about one minute, to keep the liquid from draining into your tear duct; - Do not touch the tip of the eye dropper or place it directly on your eye. Review of Resident #2's POS, dated August 2023, showed: - Start date - 7/31/23: Voltaren gel 1%, 2 grams, apply to neck and shoulders topically twice daily for pain related to arthritis (inflammation of one or more joints causing pain and stiffness that can worsen with age); - Start date - 10/18/22: Restasis 0.05% eye emulsion, instill one drop in both eyes twice daily related to dry eyes. Review of the resident's MAR, dated August 2023, showed: - Voltaren gel 1%, 2 grams, apply to neck and shoulders topically twice daily for pain related to arthritis; - Restasis 0.05% eye emulsion, instill one drop in both eyes twice daily related to dry eyes. Observation on 8/3/23 at 9:08 A.M., showed: - CMT A squirted an unknown amount of Voltaren Gel onto his/her gloved hand and rubbed it into the resident's neck and shoulders; - CMT A squirted more Voltaren Gel onto his/her gloved hand and applied it to the resident's hip per the resident's request; - CMT A removed gloves, washed his/her hands and applied new gloves; - CMT A applied one Restasis eye drop in the corner of the resident's right and left eye and the tip of the eye dropper touched the resident's eye lid sand eye lashes; - CMT A did not apply lacrimal pressure to either eye; - CMT A removed gloves and washed hands. During an interview on 8/3/23 at 1:19 P.M., CMT A said: - He/She should have measured out the Voltaren Gel; - The tip of the eye dropper should not have touched the resident's eye lashes or eye lids; - He/She did not know what lacrimal pressure was and was never taught how to do it. During an interview on 8/4/23 at 12:23 P.M., the Director of Nursing (DON) said: - The tip of the eye dropper should not touch the resident's eye lashes or eye lids; - Staff should apply lacrimal pressure and it should be at least one minute but would depend on what type of eye drop it was; - Staff should use the measuring stick for the Voltaren Gel. 3. Review of Resident #2's POS, dated August 2023, showed: - Start date - 7/31/23: Voltaren gel 1%, 2 grams, apply to neck and shoulders topically twice daily for pain related to arthritis; - Start date - 10/18/22: Restasis 0.05% eye emulsion, instill one drop in both eyes twice daily related to dry eyes. Review of the resident's MAR, dated August 2023, showed: - Voltaren gel 1%, 2 grams, apply to neck and shoulders topically twice daily for pain related to arthritis; - Restasis 0.05% eye emulsion, instill one drop in both eyes twice daily related to dry eyes. Observation on 8/4/23 at 8:45 A.M., showed: -CMT B squirted an 10 milliliters (ml) of Voltaren Gel into a medicine cup; -CMT B removed the Volteran Gel from the medicine cup with his/her right index finger and rubbed it on the resident's shoulders; -CMT B removed gloves, washed his/her hands and applied new gloves; -CMT B applied one Restasis eye drop in the corner of the resident's right and left eye and the tip of the eye dropper touched the resident's eye lids and eye lashes; -CMT B did not apply pressure to the inner corner of the left or right eye. 4. Review of the manufacturer's guidelines for Brimonidine eye drops, revised August 2021, showed, in part: -Do not touch the applicator tip to any part of the eye; -Keep the eye closed and apply pressure to the inner corner of the eye for 1 to 2 minutes. Review of the manufacturer's guidelines for Timolol Maleate eye drops, revised November 2022, showed, in part: -Do not touch the applicator tip to any part of the eye; -Keep the eye closed and apply pressure to the inner corner of the eye for 2 minutes. Review of Resident #9's POS, dated August 2023, showed: - Start date - 10/17/22: Brimonide (used to treat Glaucoma - a group of eye conditions that can cause blindness) 0.2%, eye drop, give one drop in both eyes twice daily; - Start date - 11/3/22: Timolol Maleate 0.5%, (used to treat Glaucoma) give one drop in both eyes, twice daily. Review of the resident's MAR, dated August 2023, showed: - Brimonide 0.2%, eye drop, give one drop in both eyes twice daily; -Timolol Maleate 0.5%, give one drop in both eyes, twice daily. Observation on 8/4/23 at 9:12 A.M., showed: -CMT B entered the resident's room; -CMT B washed his/her hands and applied gloves; -CMT B instructed the resident on the procedure; -The resident tilted his/her head back slightly and CMT B pulled down the lower lid of the right eye and administered one drop of Brimonidine eye drops; -The resident tilted his/her head back slightly and CMT B pulled down the lower lid of the left eye and administered one drop of the Brimonidine eye drops; -CMT B did no apply pressure to the inner corner of the left or right eye. Observation on 8/4/23 at 9:35 A.M., showed: -CMT B washed his/her hands and applied gloves; -CMT B instructed the resident on the procedure; -The resident tilted his/her head back slightly and CMT B pulled down the lower lid of the right eye and administered one drop of Timolol eye drops; -The resident tilted his/her head back slightly and CMT B pulled down the lower lid of the left eye and administered one drop of the Timolol eye drops; -CMT B did no apply pressure to the inner corner of the left or right eye; 5. Review of the manufacturer's guidelines for Trelegy Elipita Inhalation Powder , revised December, 2022, showed, in part: -Administer one inhalation once daily; -After inhalation, rinse the mouth with water without swallowing. Review of Resident #19's POS, dated August 2023, showed: - Start date - 5/19/23: Trelegy Elipta Inhalation Aerosol Powder Breath Activated, 100-62.5-25 micrograms (mcg)/ inhalation, give one inhalation orally one time daily for chronic obstructive pulmonary disease (COPD-a group of lung diseases that block air flow and make it difficult to breathe). Review of the resident's MAR, dated August 2023, showed: - Trelegy Elipta Inhalation Aerosol Powder, 100-62.5-25 micrograms mcg / inhalation, give one inhalation orally one time daily for COPD. Observation on 8/4/23 at 9:45 A.M., showed: -CMT B entered the resident's room with the inhaler in the box; -CMT B washed his/her hands and applied gloves; -CMT B took the inhaler out of the box and gave to the residnet; -The residnet exhaled a breath then administered one puff of the inhaler; -CMT B have the resident a cup of water; -CMT B did not instruct the residnet to swish and spit; -The resident took a drink of water and swallowed it. During an interview on 8/4/23 at 9:59 A.M., CMT B said: - He/she should did not know the Voltaren Gel had to be measured; - The tip of the eye dropper should not have touched the resident's eye lashes or any part of the resident's eye; - He/she said she should have applied pressure to the inner corners of both eyes for two minutes; -He/she should have instructed the resident to swish and spit out the water after the inhaler was given. 6. Review of the manufacturer's guidelines for Feluccas Nasal Spray (used to treat allergies) revised February 2023, showed in part: -Shake the bottle gently: -Blow nose; -Place the tip of the nozzle in one nostril and close the other nostril with your finger; -Repeat for other nostril. Review of Resident #18's POS, dated August 2023, showed: - Start date - 10/18/22: Fluticasone nasal spray 50 mcg / spray, give 2 sprays in both nostrils one time daily. Review of the resident's MAR, dated August 2023, showed: -Fluticasone nasal spray 50 mcg / spray, give 2 sprays in both nostrils one time daily. Observation on 8/4/23 at 10:12 A.M., showed: -LPN C entered the resident's room; -LPN C washed his/her hands and applied gloves; -LPN C instructed the resident to blow his/her nose; -LPN C shook the bottle of nasal spay: -The resident tilted his/her head back slightly and LPN C administered one spray into the left nostril and one spray into the right nostril; -LPN C did not close the other nostril while administering the nasal spray. During an interview on 8/4/23 at 10:28 A.M., LPN C said he/she should have closed the other nare when giving the nasal spray. During an interview on 8/4/23 at 12:24 P.M., the DON said: -He/she expects staff have the resident blow their nose; -Give spray in one nostril and close the other nostril.

Based on observations, interviews, and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) plan and failed to have a plan that contained all required elements. Facility census was 22. Review of the facility Quality Assurance and Performance Improvement (QAPI) Program Policy dated February 2020, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents; - The QAPI program will provide a means to measure current and potential indicators for outcomes of care and quality of life; - The QAPI program will provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators; - The QAPI program will reinforce and build upon effective systems and processes related to the delivery of quality care and services; - The QAPI program will establish systems through which to monitor and evaluate corrective actions; - The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program. The facility was unable to provide minutes for any QAPI meetings or a QAPI plan. During an interview on 8/4/23 at 10:50 A.M., the Administrator said: - There have not been any QAPI meetings since her arrival in December 2022; - Plans and policies for future QAPI procedures are being developed but have not yet been implemented.

Based on interview and record review, the facility failed to develop a comprehensive, data-driven quality assessment and assurance (QAA) activities and a quality assurance performance improvement (QAPI) program that focused on outcomes of care and quality of life when they failed to provide documentation and evidence of its ongoing QAA/QAPI program. The facility census was 22. Review of the facility Quality Assurance and Performance Improvement (QAPI) Program Policy dated February 2020, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents; - The QAPI program will provide a means to measure current and potential indicators for outcomes of care and quality of life; - The QAPI program will provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators; - The QAPI program will reinforce and build upon effective systems and processes related to the delivery of quality care and services; - The QAPI program will establish systems through which to monitor and evaluate corrective actions; - The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program. The facility was unable to provide minutes or sign in sheets for any QAPI meetings or QAA meetings. The facility was unable to provide a QAPI plan. Review of an undated facility list of QAA committee members., showed: - Named committee members as: Administrator, Director of Nursing, Medical Director, Business Office Manager, MDS Coordinator, Social Services/ Activities, Dietary Manager, Housekeeping/Laundry, Maintenance Director, Therapy Manager, and Dietician; - An unnamed position for a pharmacy representative; - Members are to meet quarterly. During an interview on 8/4/23 at 10:50 A.M., the Administrator said: - There have not been any QAPI meetings since his/her arrival in December 2022; - Plans and policies for future QAPI procedures are being developed but have not yet been implemented.

Based on interviews and record review, the facility failed to maintain a quality assessment and assurance (QAA) committee that meets at least quarterly and as needed and contains the minimum required members. The facility census was 22. Review of the facility Quality Assurance and Performance Improvement (QAPI) Program Policy dated February 2020, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents; - The QAPI program will provide a means to measure current and potential indicators for outcomes of care and quality of life; - The QAPI program will provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators; - The QAPI program will reinforce and build upon effective systems and processes related to the delivery of quality care and services; - The QAPI program will establish systems through which to monitor and evaluate corrective actions; - The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program. The facility was unable to provide minutes or sign in sheets for any QAPI meetings or QAA meetings. The facility did not provide a policy regarding their QAA committee. Review of an undated facility provided a list of QAA committee members., showed: - Named members for Administrator, Director of Nursing, Medical Director, Business Office Manager, MDS Coordinator, Social Services/ Activities, Dietary Manager, Housekeeping/Laundry, Maintenance Director, Therapy Manager, and Dietician; - An unnamed position for a pharmacy representative; - Members are to meet quarterly; - The infection preventionist was not noted. During an interview on 8/4/23 at 10:50 A.M., the Administrator said: - There have not been any QAPI or QAA meetings since his/her arrival in December 2022; - Plans and policies for future QAPI and QAA procedures are being developed but have not yet been implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow and review their infection control polices at least annually, and additionally failed to provide care in a manner to prevent infections or the possibility of acquiring infections when they did not change their gloves or wash hands between dirty and clean tasks which affected Resident #23. The facility additionally failed to ensure that new staff received tuberculin skin testing and that it was completed prior to new employees working, which could have an an negative impact on all residents. The facility census was 22. Review of the facility's Infection Prevention and Control Policy, with a revision date of October 2018, showed: -An infection and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -The elements of the infection and control program consist of procedures, surveillance, prevention and employee health and safety; -Ensuring staff adhere to proper techniques and procedures; -Pre-employment screening for infections required by law or regulation (such as TB); -The infection and control committee shall review the infection control policies at least annually. Review of the facility's Hand washing/Hand Hygiene policy, with a revision dated August 2019, showed: -All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -Wash hands with soap and water when hands are visibly soiled; -Wash hands or use an alcohol based sanitizer before and after direct contact with resides, before preparing or handling medications, before applying gloves and after removing gloves. 1. Review of Resident #23's quarterly MDS, (a federally mandated assessment tool completed by facility staff), dated 5/17/23, showed: -Severe cognitive impairment; -Extensive assistance of two staff with bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Receiving Hospice services; -Diagnoses included, dementia, high blood pressure, kidney disease and diabetes (too much sugar in the blood). Review of the resident's care plan, revised 1/25/23, showed: -ADL self care deficit related to dementia; -Total dependence of staff with dressing, personal hygiene, and transfers. During an observation on 08/02/23, at 07:34 P.M., showed: -Certified Nurses Aide (CNA) B and Nurses Aide (NA) A entered the residents room; -CNA B and NA applied gloves; -CNA B and NA A are both wiping feces off the bottom of the resident; -CNA B and NA A position the resident on his/her back; -CNA B wiped feces off of his/her gloves and cleaned the front of the resident; -NA A did not change gloves and cleaned the front of the resident; -CNA B and NA A did not wash their hands before putting on gloves to start perineal care; -CNA B did not change gloves and wash hands before wiped the front of the resident; -NA A did not change gloves, wash hands and apply clean gloves before cleaning the front of the resident; -CNA B did not separate and clean all areas of the front skin folds where urine had touched. During an interview on 08/02/23 at 8:10 P.M., NA A said: -He/she should have washed his/her hands before applying gloves before starting perineal care; -He/she should have took off his/her dirty gloves after cleaning feces's off the resident, washed his/her hands and applied clean gloves; -He/she should have separated and cleaned all areas of the skin where urine had touched. During an interview on 08/02/23 at 8:17 P.M., CNA B said: -He/she should have washed his/her hands before applying gloves before starting perineal care; -He/she should have took off his/her soiled gloves after cleaning feces off the residnet, washed his/her hands and applied clean gloves; -He/she should not wipe soiled gloves off with a wipe; -He/she should have separated and cleaned all areas of the skin where urine had touched. During an interview on 8/3/23 at 9:46 A.M., Licensed Practical Nurse (LPN) A said: -Hand washing should be preformed and clean gloves applied to start perineal care; -He/she should not wipe soiled gloves off with a wipe; -Gloves should be changed after being soiled -He/she should not wipe soiled gloves off with a wipe; -He/she should have separated and cleaned all areas of the skin where urine had touched. 2. A review of the facility's infection and prevention control program showed no documentation that an annual review of infection control policies and procedures had been done During an interview on 8/4/23 at 10:48 A.M., the Infection Preventionist (IP) said: -A review of infection control policies and procedures should be done at least annually; -He/she had not completed a review yet because he/she received his/her certificate as their infection Preventionist in May 2023; -He/she expects expects staff to use proper hand hygiene when providing perineal care on residents; -He/she expects the staff to change gloves and wash their hands when changing tasks. During an interview on 8/4/23 at 12:23 P.M., the Director of Nursing (DON) said: -Staff should wash hands and apply gloves before starting perineal care on a resident; - She expected staff to change gloves and wash their hands when gloves are soiled and when switching tasks; -Infection control should be reviewed weekly and monthly; -The IP should review the policies and procedures at least annually. During an interview on 8/4/23 at 12:40 P.M., the Administrator said: -Staff should wash hands and apply gloves before starting perineal care on a resident; - She expected staff to change gloves and wash their hands when gloves are soiled and when switching tasks; -Infection control should be reviewed weekly and monthly; -The IP should review the policies and procedures at least annually. Surveyor: [NAME] Stark 3. Review of the facilities Employee Screening for Tuberculosis (TB) policy dated August 2019, showed: - All employees are to be screened for latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening, prior to beginning employment; - Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made but prior to the employee's duty assignment; - Screening includes a baseline test for LTBI using either a TST or IGRA, individual risk assessment and symptom evaluation; - The decision to perform serial (e.g., annual) testing after baseline is based on individual risk factors of exposure both at work and outside of work; - The policy did not provide direction for timeframe's in which the skin test reaction must be read; - The policy did not provide direction for timeframe's in which secondary follow-up testing must be completed; - The policy did not provide direction for documentation of completed testing for staff. Review of 10 randomly sampled new employee personnel files showed: - No documentation of completed 2-step TB testing for one sampled employee; - Documentation showing 2-step TB testing was conducted after date of hire for 3 sampled employees. Interview on 8/4/23 at 9:46 A.M. the Business Office Manager said: - Two step TB testing should be completed for each new hired employee; - He/she was unable to locate TB testing record for sampled employee with missing TB test documentation; - Sampled employees with documented TB testing dates after hire dates had TB testing completed before their hire date, however the pre-hire TB test documentation was unable to be located and was not currently in the employee personnel files.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to promote an environment respectful of the rights of each resident to make choices about significant aspects of their lives when staff did not honor a resident's preferences for bedtime which affected one of 12 sampled residents (Resident #26) and failed to honor a resident's preference for smoking which affected Resident #5. The facility census was 30. Review of the facility's smoking policy for employees, revised May, 2019, showed, in part: - It is the policy of this facility to provide our employees with as near a smoke-free environment as possible and to ensure safe smoking practices for those who smoke; - Residents and visitors: While this policy applies primarily to our staff, certain smoking restrictions apply to our residents and visitors. Residents and visitors are not permitted to smoke in any area that is not designated as a smoking area. Smoking is not permitted in resident rooms. The facility did not provide a smoking policy for the residents. 1. Review of Resident #5's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/10/21, showed: - Cognitive skills intact; - Limited assistance of one staff for bed mobility, transfers, dressing, toilet use and personal hygiene; - Upper and lower extremities impaired on both sides; - Always continent of bowel and bladder; - Diagnosed included diabetes mellitus, low back pain, hemiparesis (muscle weakness or paralysis on one side of the body). During an interview on 8/24/21 at 1:49 P.M., the resident said: - He/she used to smoke but they don't let the residents smoke; - The staff can go out back and smoke whenever they want; - This is our home and we are not allowed to smoke but the staff can smoke; - It did not make sense to him/her, he/she felt like it would be their right to smoke or not smoke. During an interview on 8/27/21 at 11:44 A.M., the MDS Coordinator said: - If the resident wanted to smoke, should do a smoking assessment; - Did not know what the smoking policy was for the residents; - The care plan should address if the resident was a smoker and the facility was a non-smoking facility. During an interview on 8/27/21 at 2:43 P.M., Licensed Practical Nurse (LPN) A said: - The staff did not have assigned smoking breaks, they would just tell the charge nurse they were going to take a smoke break; - The residents are not allowed to smoke. During an interview on 8/27/21 at 4:39 P.M., the Interim Director of Nursing said: - The facility has been a non smoking home for the residents. 2. Review of Resident #26's quarterly MDS, dated [DATE], showed: - A BIMS score of 14, indicting no cognitive impairment; - Limited (one) staff assistance with bed mobility and transferring. Review of the resident's care plan showed: - Start date 2/23/21: Resident will live comfortably in his/her current permanent home; the facility will provide a home-like environment. - Start date 2/19/21: Requires assistance with activities of daily living (ADLs) and mobility; minimal one-person assist with gait belt and wheeled walker; - Start date 1/17/21: at risk for falls; remind to ask staff for assistance with ambulation; assist with one staff member for all ambulation; - The care plan did not address a reason why the resident could not go to bed right after supper; - A diagnosis of gastro-esophageal reflux disease with esophagitis (GERD, a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of the resident's current August 2021 physician's order sheet (POS) showed: - Omeprazole DR 20 milligrams (mg) capsule, give one capsule by mouth every day; - No order on the POS directing staff to keep the resident up for any amount of time after a meal. During an interview on 8/25/21 at 11:52 A.M., Resident #26 said he/she likes to go to bed right after supper. Staff decide when residents can go to bed. Staff tell him/her he/she is not supposed to go to bed too quick after supper. There is nothing else to do, so he/she so might as well go to bed. During an interview on 8/27/21 at 4:40 P.M., the interim Director of Nursing (DON) said if a resident would like to go to bed right after dinner, they should be able to. Some physicians like for residents to stay up for 30 minutes after dinner. She did not know why staff would tell the resident he/she had to stay up if no order to do so. During an interview on 8/27/21 at 5:19 P.M., Certified Nurse Aide (CNA) E said he/she normally works evening shift. The resident does frequently ask to go to bed after dinner. We encourage him/her to sit up after dinner for digestion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure they notified one of 12 sampled residents' (Resident #26) family when the resident fell. The facility's census was 30. Review of the facility's Falls-Clinical Protocol policy, revised March 2018, showed the plan did not direct staff when or who to notify when the resident falls. Review of the Resident Incident Review form, part of the facility's electronic medical record program, showed staff should document in the Actions Taken section of the form the name of the physician and family members they notified of the fall, the date/time contact initiated and the date/time responded. Staff also had a line on the form to put the name of the person completing the form. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/5/21, showed: - A Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment; - Independent with bed mobility, supervision only with transfers, walking in and out of his/her room; - Had not had any falls since last assessment completed or since admission. Review of the resident's face sheet showed: - admitted [DATE]; - Responsible party listed as his/her spouse; - Listed his/her children as his/her second and third contacts. Review of the resident's departmental notes, dated 8/25/21 at 12:14 A.M. showed: - At approximately 7:30 P.M., resident was found lying on his/her left side in front of his/her recliner; - Resident stated that his/her recliner tipped him/her out onto the floor. - Denies hitting his/her head but was resting the side of his/her head on the bedside table legs; - FYI placed to physician at this time, awaiting response; - No mention of staff attempting to contact the resident's family. Review of the Resident Incident Report, dated 8/24/21 at 7:30 P.M., showed: - Staff documented staff contacted the resident's physician but did not indicate the date and time contact initiated. - Staff did not document they notified the resident's family of the fall. During an interview on 8/25/21 at 12:06 P.M., the resident said he/she slid out of his/her recliner the previous day. He/she called his/her spouse and reported this. His/her spouse said no one had contacted him/her about the fall. The resident would like the facility to call him/her so he/she did not have to worry his/her spouse. During an interview on 8/27/21 at 6:27 P.M., the interim Director of Nursing said the nurse who completes the Resident Incident Report should contact the resident's family or next of kin to notify of any changes in condition, like a fall. If staff notified the family and the physician, they should document the date and time for each and who they spoke with. If not documented, she could assume staff did not do it.

Based on record review and interviews, the facility failed to ensure staff notified residents and/or their representative when there was a change in one sampled resident's (Resident #9) covered services when he/she was discharged from skilled nursing services and remained in the facility. The facility census was 30. The facility did not provide a policy for providing Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). Review of information provided surrounding Resident #9's discharge from skilled nursing services showed: - Episode start date of skilled nursing services: 5/28/21; - The resident's last covered date of skilled nursing services was 7/15/21; - The facility initiated the resident's discharge from physical therapy and the resident remained in the facility. - Staff did not provide or have the resident or his/her representative sign the SNF ABN to notify them of what services were no longer covered by Medicare if the resident continued to receive them. During an interview on 8/27/21 at 3:00 P.M., the administrator said she did not realize there was a separate form they needed to use if a resident remained in the facility with days of their skilled benefit remaining. She thought the form they had residents sign on admission covered that.

Based on observation, interview, and record review, the facility failed to ensure that an entrapment assessment was done prior to installing quarter side rails on the both sides of the resident's bed, and failed to do quarterly entrapment assessments. This affected one resident (Resident #7) of 12 sampled residents. The facility census was 30. 1. Review of the Bed Safety Policy dated 2001 and revised December 2007 showed: -To prevent deaths/injuries from the bed and related equipment, the facility shall: a. Maintenance staff shall inspect all of the resident beds and related equipment to identify risks and problems including potential entrapment risks. b. Review that gaps within the bed system are within the dimension regulation. The resident's weight, movement and bed position shall be considered as well. c. Ensure that the bed side rails are installed properly per the manufacturer guidelines to ensure proper fit. - The maintenance department shall provide a copy of the inspections to the Administrator and report to the Quality Assurance (QA) committee for appropriate action. - If side rails are used, there shall be an interdisciplinary assessment of the resident. 2. Review of Resident #7 admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 5/16/21 showed: - Brief Interview for Mental Status (BIMS, a cognitive assessment tool used to determine the resident's ability to make choices) score of 15, showed that the resident does not have cognitive deficit. - Diagnosis of Pneumonia (an infection of the lungs), thyroid disorder, and morbid obesity (grossly overweight). - Resident is dependent on staff to complete his/her Activities of Daily Living (ADLs', the act of taking care of oneself), for transfers, dressing, toileting, personal hygiene. - Resident is incontinent of bowel and bladder. - Physical restraints, quarterly side rails to both sides of his/her bed. 3. Observation on 8/24/21 at 4:59 P.M. showed quarter side rails installed on both side of the bed. 4. Review of the care plan dated 5/14/21 showed quarterly side rails was not addressed on the care plan for the resident's safety. 5. Review of the physician order sheet dated 8/2021 showed: - An order dated 5/12/21: Resident may use quarter side rails or U bars bilateral (both side of the bed) for positioning. Facility to complete entrapment assessment quarterly while bed rails or U-rails are in place. 6. Record review on 8/26/21 showed their was no entrapment assessment documented initially or quarterly. 7. During an interview on 8/26/21 at 7:34 A.M. the resident said: - He/she uses the side rails to help with positioning while in bed. 8. During an interview on 8/27/21 at 11:45 A.M. with the MDS Coordinator said: - Side rail use should be care planned. - He/she does the entrapment assessments. - The entrapment assessments should be done when ordered and quarterly. 9. During an interview on 8/27/21 at 4:38 P.M. with the Interim Director of Nursing (DON) said side rail use should be care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Review of Resident #234's MDS, dated [DATE], showed: - A Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment; - Extensive staff assistance with toilet use; - Staff checked None of the above to indicate the resident did not use any appliances, including indwelling catheters; - Urinary continence: Not rated, resident had a catheter. Review of the resident's care plan, dated 7/8/21 showed: - Staff indicated the resident had an indwelling catheter (Indwelling means inside the body; this catheter drains urine from your bladder into a bag outside your body) - Staff listed the goal as the resident will not develop complications from the catheter, such as an urinary tract infection (UTI) or trauma. Review of the resident's physician orders, dated 7/8/21, showed no order for an indwelling catheter. Review of the resident's progress notes showed: - 8/11/21, Licensed Practical Nurse (LPN) A wrote the resident was seen virtually by his/her physician who gave orders to discontinue to the indwelling catheter. During an interview on 8/27/21 at 10:24 A.M., the resident said: - He/she did have a catheter when he/she admitted to the facility. - Staff removed the catheter a few weeks ago, but he/she did not know the exact date. During an interview on 8/27/21 at 11:35 A.M. the MDS coordinator said anyone can update the care plan. Staff should update the care plan whenever there are any changes to resident's plan of care. During an interview on 8/27/21 at 4:40 P.M., the Director of Nursing said care plans should reflect the resident's care. If something is discontinued, it should be resolved on the care plan. Based on observation, interview and record review, the facility failed to ensure they used residents' comprehensive, person-centered assessment to develop and update residents' care plans to ensure the plan directed staff on how to provide care for each resident which affected one of 12 sampled residents (Resident #234). The facility census was 30. Review of the facility's Care Plans, Comprehensive Person-Center policy, revised December 2016, showed 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. - Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his/her plan of care. - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. - The Interdisciplinary Team (IDT) must review and update the care plan: A. When there has been a significant change in the resident's condition; B. When the desired outcome is not met; C. When the resident has been readmitted to the facility from the hospital stay; D. At least quarterly, in conjunction with the required quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the physician order for eye drops matched the mediation label on the eye drops. This affected one resident (Resident #5) out of 12 sampled residents. The facility census was 30. Review of the medication administration policy dated 2001 and revised April 2019 said: - Medications are administered according to the prescribers' orders, including any required timeframe. - Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and/or the need for additional staff training. - The person administering the medication will check the label 3 times to verify the right resident, right medication, right dosage, right time, and right method/route of administration before giving the medication. Review of the policy for installation of eye drops dated 2001 and revised January 2014 said: - The person administering the eye drops is to wash his/her hands and put on gloves. - Tilt the resident's head back slightly. - Gently pull the lower eyelid down and instruct the resident to look up. - Drop the medication into the mid lower eyelid. Do not touch the tip of the eye dropper to the eye or eyelid, recap the medication bottle. - Instruct the resident to slowly close his/her eyelid for even distribution of the medication. Instruct the resident's not to blink or squeeze the eye lids shut. 1. Review on 8/27/21 of Resident #5's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by the staff), dated 5/12/21 showed: - admitted [DATE]. - Brief Interview for Mental Status (BIMS, an assessment tool describing the resident's cognitive ability), score of 15, indicating the resident was not cognitively impaired. - Diagnoses of vision impairment requiring corrective lenses, hypertension (high blood pressure), and diabetes mellitus type 2 (a disease in which the ability to process blood sugar is impaired). - Activities of daily living (ADLs) the resident requires assistance of one staff for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. - Care area assessment (CAA) of visual function Review of the care plan dated 6/1/20 showed: - The resident's has impaired vision. - The care plan goal is for the resident to continue to use his/her tablet, watch television, and read without difficulty. - Interventions include to assess for vision changes and to administer eye drops and ointments as prescribed. Observation on 8/27/21 at 8:50 A.M. showed: - Certified Medication Technician (CMT) A checked the resident's eye drop order on the electronic medical records (EMR) and pulled the small Ziploc back containing the eyes drops from the cart. - CMT A checked the eye drop label against the order in the EMR. - CMT A said that the two do not match and does not administer the medication. Review of the order in the resident's EMR showed: - Prednisolone acetate 1%- Moxiflaoxcin 0.5%, give 1 drop 2 times per day for 21 days. Review of the labels on the eye drops showed: - Prednisolone Acetate 1% Instill 1 drop in affected eye 4 times daily for 7 days, then instill 1 drop 2 times daily for 7 days. - The prednisolone bottle has been opened and is dated on the bottom of the bottle 8/14. - An unopened moxiflaoxcin bottle from the cart with a label that reads: Instill 2 drops in affected eye 4 times daily for 7 days, then instill 1 drop 2 times daily for 7 days. Review 8/27/21 of the Physician Order Sheet (POS) dated August 2021 showed: - An order that reads: Prednisolone Acetate 1% - Moxiflaoxcin 0.5% Give 1 drop 2 times daily for 21 days, stop 8/31/21. Review 8/27/21 of the Medication Administration Record (MAR) showed: - The eye drops have been administered 2 times per day from 8/10/21 to 8/25/21, the A.M. dose was administered 8/26/21, the P.M. dose was not, however, the correct medication was not in the cart. Interview 8/27/21 at 9:11 A.M. with Resident #5 said: - He/she had cataract surgery 2 weeks ago. - He/she said that the CMT's place Prednisolone in his/her right eye. Interview 8/27/21 at 4:38 P.M. with the Interim Director of Nursing (DON) said: - The label's of the medications and the order should match.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation of the pharmacist's recommendations for two of 12 sampled residents, Resident #5 and Resident #21. The facility census was 30. The facility did not provide a policy for drug regimen reviews. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 8/10/21, showed: - Cognitive skills intact; - Limited assistance of one staff for bed mobility, transfers, dressing and personal hygiene; - Upper and lower extremity impaired on both sides; - Had seven insulin injections in the last seven days; - Had seven antidepressants in the last seven days; - Had seven diuretics in the last seven days; - Had seven opiods in the last seven days; - Diagnoses included anemia ( (low number of red blood cells to carry adequate oxygen to your body's tissues), diabetes mellitus, low back pain, hemiparesis (muscle weakness or paralysis on one side of the body). Review of the resident's physician order sheet (POS), dated 8/2021 showed an order for: - Nortriptyline 10 milligrams (mg.) one three times daily for depression. 2. Review of Resident #21's admissions MDS, dated [DATE], showed: - Cognitive skills intact; - Independent with bed mobility, eating, toilet use and personal hygiene; - Limited assistance of one staff for transfers; - Lower extremity impaired on one side; - Had seven anti-anxieties in the last seven days; - Had seven antidepressants in the last seven days; - Had seven diuretics in the last seven days; - Had seven opiods in the last seven days; - Diagnoses included atrial fibrillation (an irregular and often rapid heart rate), depression and high blood pressure. Review of the resident's POS, dated 8/2021, showed an order for: - Duloxetine 20 mg. twice daily for depression; - Sertraline 100 mg. daily for depression. During an interview on 8/27/21 at 4:39 P.M.,, The Interim Director of Nursing (DON) said: - Should have the drug regimen reviews but unable to locate them due to different DONs.

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 two medication errors out of 25 opportunities for error, a medication error rate of 8%, which affected two of 12 sampled residents, (Resident #5 and #27). The facility census was 30. Review of the facility's 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 administering topical medications, revised October 2010, showed, in part: - The purpose of this procedure is to provide guidelines for the safe administration of topical medications; - Prepare the correct dose of medication; - Apply medication: paste, cream, ointment or lotion:removed tongue blade from sterile wrapper. Place medication on the tongue blade and transfer to gloved hands. Warm the medication in gloved hands and apply gently to the skin. 1. Review of Resident #5's physician order sheet (POS), dated August 2021, showed: - An order for diclofenac sodium 1% gel, apply four grams four times a day on back for back pain. Review of the resident's electronic treatment administration record (eTAR), dated August 2021, showed: - Diclofenac sodium 1% gel, apply four grams four times a day on back for back pain. Observation on 8/25/21 at 3:39 P.M., showed: - Certified Medication Technician (CMT) B washed his/her hands, applied gloves, squirted an unknown amount of Diclofenac sodium 1% gel onto his/her gloved hands and rubbed into the resident's entire back. During an interview on 8/26/21 at 1:18 P.M., CMT B said: - He/she should have measured the diclofenac sodium gel. During an interview on 8/27/21 at 4:39 P.M., the Interim Director of Nursing (DON) said: - Staff should follow the physician's orders, if it said four grams, staff should measure it . 2. Review of the facility's policy for instillation of eye drops, January 2014, showed, in part: - The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes; - Gently pull the lower eyelid down and instruct the resident to look up; - Drop the medication into the mid lower eyelid; - Do not touch the eye or eyelid with the dropper; - Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops; - Instruct the resident not to blink or squeeze the eyelids shut, which forces the medicine out of the eye. Review of the website www. mayoclinic.org for ciprofloxacin eye drops showed: - Tilt the head back and pull the lower eyelid away from the eye to from a pouch. Drop the medicine into the pouch and gently close the eyes. Do not blink. Keep the eyes closed for one or two minutes to allow the medicine to come into contact with the infection. To keep the medicine as germ-free as possible, don not touch the applicator tip to any surface (including the eye). Review of Resident #27's POS, dated August 2021, showed: - Did not have an order for Ciprofloxacin 0.3% eye drop. Review of the resident's CMT electronic medication administration record (eMAR), dated August 2021, showed: - Start date: 8/21/21: Ciprofloxacin 0.3% eye drop, give two drops four times daily in left eye for infection. Stop date: 8/25/21. Observation on 8/25/21, at 3:44 P.M., showed: - CMT B washed his/her hands, applied gloves: - CMT B pulled the lower left eyelid down and administered two drops to the left eye; - CMT B touched the tip of the applicator to the resident's eye lashes and did not give the resident any instructions on keeping the eye closed. During an interview on 8/26/21 at 1:18 P.M., CMT B said: - He/she should not have touched the tip of the eye dropper to the resident's eye lashes and should have given the resident instructions on closing his/her eye. During an interview on 8/27/21 at 4:39 P.M., the Interim DON said: - Staff should not touch the tip of the eye dropper to the resident's eye lashes or eyelid; - Staff should apply lacrimal pressure (pressure applied to the inner aspect of they eye toward the nose) or follow the manufacturer's guidelines.

Based on record review and interview, the facility failed to ensure they conducted a complete criminal background check (CBC) through the Missouri State Highway Patrol (MSHP) for one of five staff members hired since the last full survey and who were selected for review. The facility census was 30. Review of the facility's Abuse Prevention Program policy, dated August 2006, showed: -The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. -The facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. -Comprehensive policies and procedures have been developed to aid the facility in preventing abuse, neglect, or mistreatment of the residents. The abuse prevention program provides policies and procedures that govern, as a minimum: -Protocols for conducting background checks 1. A review of Laundry Aide #1's personnel record file showed: -A hire date of June 17, 2021; -No record of a Family Care Safety Registry (FCSR) letter; -No request for a CBC through the MSHP. 2. During an interview on August 27, 2021 at 11:00 A.M., the Administrator, who is also acting as the Business Office Manager, said; -CBC and EDL should be run on all employees prior to the employee's start of employment; -All employees should have a letter from the FCSR stating the request for a CBC was received and the results of that CBC; -These results should also include a CBC run through the MSHP.

Based on record review and interviews, the facility failed to, within 14 days after a facility completes a resident's assessment, electronically transmit encoded, accurate, and complete Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) data to the Centers for Medicare and Medicaid Services (CMS) System for quarterly reviews as well as upon a resident's transfer, reentry, discharge and death, which affected one of 12 sampled residents (Resident #1) and three additionally sampled residents (Residents #235, #236 and #237). The facility census was 30. Review of the facility's MDS Completion and Submission Timeframes, revised July 2017, showed the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' system in accordance with current and federal guidelines. 1. Review of Resident #1's electronic medical record (EMR) showed staff opened a MDS in American Health Tech (AHT), their EMR system on 6/12/21. The MDS did not show the date staff submitted it. The Social Service Designee (SSD) signed the MDS on 6/11/21. No registered nurse (RN) not signed off on the MDS. 2. Review of Resident #236's EMR showed: - The last MDS staff opened in AHT was dated 1/30/21; discharge assessment, return not anticipated. - The MDS opened in AHT showed the resident discharged to an acute hospital on 1/30/21. - No staff signed off on the MDS. - Progress notes and the census screen indicated the resident discharged from the facility on 1/30/21. Review of CMS' Resident Viewer, used in the State Survey Agency's computer system to track MDS information for all residents in each facility on 8/27/21 showed Resident Viewer still reflected the resident as an open active resident who still resided in the facility. 3. Review of Resident #237's EMR showed: - The last MDS staff opened in AHT was dated 1/27/21; discharge assessment, return not anticipated. - MDS indicated the resident discharged on 1/27/21 to the community. Review of CMS' Resident Viewer, used in the State Survey Agency's computer system to track MDS information for all residents in each facility on 8/27/21 showed Resident Viewer still reflected the resident as an open active resident who still resided in the facility. 4. Review of Resident #235's EMR showed: - The last MDS staff opened in AHT was dated 2/7/21; discharge assessment; return not anticipated; - The open MDS indicated the resident was discharged on 1/27/21 to an acute hospital; - The EMR indicted staff discharged the resident from AHT on 2/8/21. Review of CMS' Resident Viewer, used in the State Survey Agency's computer system to track MDS information for all residents in each facility on 8/27/21 showed Resident Viewer still reflected the resident as an open active resident who still resided in the facility. 5. During an interview on 8/27/21 at 11:35 A.M., the MDS Coordinator said she has been the MDS coordinator in since July. The goal is to get the MDS submitted as quick as possible. She tries to get the MDS completed the day after the assessment reference date (ARD). She does know there are some MDS still open. She cannot go back and do those, but she can make sure the quarterly and annuals are done when they are supposed to be. Staff should submit the entry and discharge within 24 hours. As of today she has not seen any that there are some not showing as discharged from the system. She did not know Resident #1 had not had an MDS submitted since March. The SSD only completes sections C, D, E and Q. An RN must sign off them and generally that is the director of nursing (DON). During an interview on 8/27/21 at 4:40 P.M., the interim DON said MDS should be transmitted to CMS timely. She does not know why these were not submitted timely or why the SSD had been the only one to sign off on Resident #1's MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that staff developed, implemented and updated, person-centered care plans that included measurable objectives to meet the residents needs, condition and risks for 4 out of 12 sampled residents, (Resident #4, #5, #7, #23.)The facility census was 30. Review of the care plan policy dated 2001 and revised December 2016 showed: - The Interdisciplinary Team (IDT) 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 developed as a result of the comprehensive assessment. - The comprehensive, person-centered care plan will include: a. Measurable objectives and goals. b. Describe the services that are to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. c. Include the resident's stated goals upon admission and desired outcomes. d. Incorporate identified problem areas. e. Incorporate risk factors that are related to the identified problems. f. Reflect the standards of practice for problem areas and conditions. - The care plan will address areas of concern that are identified through the resident's assessment and will be evaluated before interventions are added to the care plan. - Assessments are ongoing and care plans are revised as needed when there is a significant change in the residents condition, the desired outcome has not been met, when the resident's has been readmitted , and at least quarterly. 1. Review of Resident #7's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by the staff) dated 5/16/21 showed: - The resident with a Brief Interview for Mental Status (BIMS, a cognitive assessment tool used to determine the resident's ability to make choices) score of 15, showed that the resident does not have cognitive deficit. - Diagnosis of pneumonia (an infection of the lungs), thyroid disorder, and morbid obesity (grossly overweight). - Resident is dependent on staff to complete his/her Activities of Daily Living (ADLs', the act of taking care of oneself), for transfers, dressing, toileting, personal hygiene. - Resident is incontinent of bowel and bladder. - Physical restraints, quarterly side rails to both sides of his/her bed. Review of the care plan dated 5/14/21 showed: - His/her quarter side rails were not care planned. Review of the physician order sheet dated August 2021 showed: - An order dated 5/12/21: Resident may use quarter side rails or U bars bilateral (both side of the bed) for positioning. Facility to complete entrapment assessment quarterly while bed rails or U-rails are in place. Record review on 8/26/21 of the resident's medical record showed: - There was no entrapment assessment documented initially. - There was no entrapment assessment documented quarterly. Observation on 8/24/21 at 4:59 P.M. showed: - The resident with quarter side rails installed on both side of his/her bed. During an interview on 8/26/21 at 7:34 A.M. the resident said: - He/she uses the side rails to help with positioning while in bed. During an interview on 8/27/21 at 11:45 A.M., the MDS Coordinator said: - Side rail use should be care planned. - He/she does the entrapment assessments. - The entrapment assessments should be done when ordered and quarterly. During an interview on 8/27/21 at 4:38 P.M. with the Interim Director of Nursing (DON) said side rail use should be care planned. 2. Review of Resident #4's facility face sheet, dated 8/26/21, showed: - A diagnosis of major depressive disorder, a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts, - A diagnosis of vascular dementia, a common form of dementia caused by an impaired supply of blood to the brain, such as may be caused by a series of small strokes. Review of the resident's care plan dated 8/4/21 showed: - At risk for side effects of anti-depressant medication. - No care plan to address the diagnosis and symptoms of depression. - No care plan for the diagnosis or symptoms of dementia. During an interview on 8/25/21 at 8:49 A.M., the Social Services Director (SSD) said Resident #4 does have confusion at times and requires assistance making decisions, such as when/how to put in dentures, and attending meals and activities. 3. Review of Resident #5's care plan, dated 6/1/20, showed: - Poor safety awareness: interventions included: refer to physical therapy for evaluation, use a wheelchair for long distance mobility, remind the resident to ask for assistance with ambulation and transfers, gripper socks to be worn when not wearing tennis shoe, and keep the call light in reach. Review of the resident's care plan, dated 3/18/21, showed: - The resident has a history of falling: Interventions included: monitor for changes in condition that may warrant increased supervision/assistance and notify the physician, the resident will ask for assistance for transfers to and from the bed, staff will ensure the resident's wheelchair is in appropriate position during transfers to and from bed and in locked position, wheelchair will be readily available for resident to safely transfer to if his/her legs were to give out during transfer to and from bed. Review of the resident's progress notes, dated 8/8/21 showed: - At 10:00 A.M., the resident fell in the bathroom; - No injuries noted during incident; - The resident stated he/she lost his/her balance when getting off the toilet. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Limited assistance of one staff for bed mobility, transfers, dressing, toilet use and personal hygiene; - Upper and lower extremities impaired on both sides; - Diagnosed included diabetes mellitus, low back pain, hemiparesis (muscle weakness or paralysis on one side of the body). The care plan did not address the resident's fall on 8/8/21. 4. Review of Resident #23's progress notes, dated 6/28/21 at 7:14 P.M., showed: - Wander guard (an electronic system that is installed at exit doors that alarms when someone wearing a monitoring bracelet nears or passes through an alarmed door) placed on the resident's left ankle due to recent elopement. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive skills severely impaired; - Required extensive assistance of one staff for bed mobility, transfers, dressing, and toilet use; - Frequently incontinent of bowel and bladder; - Diagnoses included dementia (inability to think, remember, or make decisions that interferes with doing everyday activities), weakness, and repeated falls; - The care plan did not address the use of a wander guard. Review of the resident's physician order sheet (POS), dated August, 2021, showed: - Check wander guard shiftly to left ankle. 5. During an interview on 8/27/21 at 11:44 A.M., the MDS Coordinator said: - He/she had just started approximately a month ago; - Would like to try and update the care plans weekly; - Care plans should be updated with each new fall with new interventions; - Care plans should address if a resident had a wander guard and if the resident had eloped. During an interview on 8/27/21 at 4:39 P.M., the Interim Director of Nursing said: - Care plans should include the wander guard, elopement, and falls with new interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that the residents remained free from accident hazards because water from the tap is to hot, which affected 2 (Resident #7 and #19) out of 12 sampled residents, and staff did not use proper technique during transferring with a gait belt (a belt placed around the waist to aid in transferring the residents from one area to another), which affected two of 12 residents, (Resident #19 and #23). The facility census was 30. Review of the policy regarding checking water temperatures included: - The policy was not dated. - The dial thermometer is accurate to 1 to 2 degrees Fahrenheit, however should be calibrated on a regular basis. - The water being tested should run 3 to 5 minutes. - Insert the stem of the thermometer into the stream of running water, fully immersing the sensor. - The temperature should be ready to read after 10 to 15 seconds in the running water. Review of the water temperature log dated 7/28/21 showed: - Temperature of the dining room water temperature read 120 degrees Fahrenheit, kitchen dishwasher 145 degrees Fahrenheit and resident's rooms 100-512 water temperatures read 120 degrees Fahrenheit. Review of the water temperature log dated 8/6/21 showed: - Temperature of the dining room water read 120 degrees Fahrenheit, kitchen dishwasher 145 degrees Fahrenheit, and resident room [ROOM NUMBER]-512 120 degrees Fahrenheit. Review of the water temperature log dated 8/13/21 showed: - Temperature of the water in the dining room read 120 degrees Fahrenheit, kitchen dishwasher 150 degrees, and resident rooms 100-512 120 degrees Fahrenheit. 1. Review of Resident #7 admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by the staff), dated 5/16/21 showed: - Brief Interview for Mental Status (BIMS, an assessment tool used to determine the resident's cognitive status), score of 15, indicating that the resident is cognitively intact. - Activities of daily living (ADLs', activities that a resident is able to complete with no or minimal assistance), dependence on staff for transfers, dressing, toileting, and personal hygiene - Frequently incontinent of bowel and bladder. - Diagnosis of pneumonia (an infection of the lungs), weakness, morbid obesity, chronic obstructive pulmonary disease (COPD, a chronic lung disease that makes it hard to breath), acute and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). Review 8/26/21 of resident care plan dated 5/14/21 showed: - Resident requires assistance with ADLs' with 2 staff members. - He/she is dependent on staff for bed mobility, toileting use, transfers, and personal hygiene. Observation on 8/26/21 at 10:09 A.M. showed the resident's water was turned on at full capacity for 2 minutes and the water temperature was 125.2 degrees Fahrenheit taken mid stream. During an interview on 9/1/21 at 1:30 P.M., the maintenance supervisor and administrator said he checks the hot water weekly with his rounds. The previous week he had to turn one of the hot water heaters down after a repair but someone must have gone back and turned it back up. 2. Review of Resident #19 Quarterly MDS dated [DATE] showed: - BIMS score of 14, minimal cognitive deficit. - Activities of Daily Living (ADLs) show that resident needs assistance with one to two staff for transfers, bed mobility, walking in the resident's room and the hallway, dressing, toilet use, and personal hygiene. - Diagnoses of COPD (a chronic lung disease), hypertension (high blood pressure), weakness, and emphysema (a lung disease in which the air sacs of the lungs are damaged, causing breathlessness). - Shortness of air when the resident is lying flat and sitting. Review of the resident's care plan dated 3/23/21, showed: - The resident has a history of falling. - The goal is the resident will not have a major injury from a fall. - Interventions include monitoring for a change in condition, use a wheel chair for mobility, he/she needs 2 person's to assist in transfers, and to ensure that the resident is wearing non-skid foot wear. Observation on 8/26/21 at 9:45 A.M. showed: - Certified Medication Technician (CMT) A applied the gait belt around the resident's chest area. - CMT A did not check the gait belt for tautness. - CMT A grabbed the gait belt, hooking it in the back under the resident's arm with his/her left hand. - The gait belt slid up the resident's back and rested between the resident's shoulder blades. - CMT A transferred the resident from toilet to the wheelchair by grabbing the back of the gait belt and the gait belt slid between the resident's shoulder blades. - CMT A then removed the gait belt and placed it around his/her waist. - CMT A transferred the resident by himself/herself. Observation on 8/26/21 at 9:59 A.M. showed: - Resident washing his/her hands in the room sink, resident had the hot water and cold water halfway and as resident placed his/her hands under the water, he/she jerked his/her hands back, said ouch, it's hot and turned the hot water completely off. - The resident resumed washing his/ her hands with cold water. - CMT A washed his/her hands in the sink commenting that the water is hot. - The water temperature is tested after running at full capacity for 2 minutes. The temperature is measured midstream and 126.2 degrees Fahrenheit. During an interview 8/26/21 at 10:06 A.M. the resident said: - He/she did not like the gait belt. - It was uncomfortable. During an interview 8/27/21 at 8:46 A.M. CMT A said: - He/she was taught that they could apply the gait belt around the chest or the waist. - He/she should have tightened the gait belt when the gait belt slid. During an interview 8/27/21 at 10:28 A.M. Licensed Practical Nurse (LPN) A said: - He/she expected the CMT to keep the gait belt snug. - If he/she observed the CMT using the gait belt incorrectly, he/she would educate the CMT how to correctly apply and use a gait belt. During an interview on 8/27/21 at 4:38 P.M. the Interim Director of Nursing (DON) said: - He/she expected the gait belt to be placed either around the waist or the chest, dependant on the individual's body shape. - He/she expected the staff to apply the gait belt snuggly around the trunk area. The staff should place their hands front and back of the gait belt with four fingers flush against the resident's body and facing upward. - The staff should not have their hands or arms under the resident's arm. 3. Review of Resident #23's care plan, dated 3/19/20, showed: - The resident required the assistance of two staff for transfers; - The care plan did not specify what type of assistive device was required for the transfers. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive skills severely impaired; - Required extensive assistance of one staff for bed mobility, transfers, dressing, and toilet use; - Frequently incontinent of bowel and bladder; - Diagnoses included dementia (inability to think, remember, or make decisions that interferes with doing everyday activities), weakness, and repeated falls. Observation on 8/26/21 at 9:39 A.M., showed: - CNA B placed the gait belt around the resident's waist; - CNA B and CNA C reached under the resident's arms and grabbed the side of the gait belt with one hand and the back of the gait belt with their other hand and stood the resident up; - The gait belt was loose and slid up between the resident's shoulder blades in the back and CNA B and CNA C's hands were under the resident's arm pits; - CNA B and CNA C toileted the resident; - CNA B and CNA C grabbed the side of the gait belt and it slid up between the resident's shoulder blades in the back and up over the resident's breasts and under his/her arm pits; - The resident's shirt was pulled up in the front and back; - CNA B and CNA C transferred the resident to the side of the bed and removed the gait belt and assisted the resident to lay down. During an interview on 8/27/21 at 3:03 P.M., CNA B said: - The gait belt should be snug around the waist or above the resident's breasts and it should not slide up; - Should place his/her hands on the front and back of the gait belt with four fingers pointing up; - His/her arm should not be under the resident's arm pits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to assure that staff provided proper respiratory care when the staff failed to date oxygen tubing, failed to properly clean oxygen concentrator filters, and failed to cover nebulizer masks and bilevel positive airway pressure (BiPAP) masks. Which affected four of 12 sampled residents, (Resident #7, #19, #17 and #21) . The facility census was 30. 1. The facility did not provide a policy . 2. Review of Resident #7's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by the staff), dated 5/16/21 showed: - Brief Interview for Mental Status (BIMS, an assessment tool used to determine the resident's cognitive status), score of 15, indicating that the resident is cognitively intact. - Activities of daily living (ADLs', activities that a resident is able to complete with no or minimal assistance), dependence on staff for transfers, dressing, toileting, and personal hygiene - Frequently incontinent of bowel and bladder. - Diagnosis of pneumonia (an infection of the lungs), weakness, morbid obesity, chronic obstructive pulmonary disease (COPD, a chronic lung disease that makes it hard to breath), acute and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). - Oxygen therapy and bilevel positive airway pressure (BiPAP, a machine used to help the resident breath better). Review of Resident #7's care plan dated 5/14/21 showed: - The resident is to receive oxygen therapy at 5 liters per nasal cannula (delivery system for the oxygen), with a goal of no shortness of breath, and interventions administer oxygen as ordered, and ensure that the supply is available at all times. Review of the physician order sheet (POS) dated August 2021 showed: - Oxygen at 5 liters per nasal cannula continuously. - BiPAP at BMP (breaths per minute) 10/8 with 5 liters of oxygen to keep the oxygen saturations (the amount of oxygen in the blood) at 91% or greater as needed; - Every Tuesday change oxygen tubing (tubing that delivers oxygen from the machine to the resident), date and initial with paper tape before applying new tubing to the concentrator. Date and place a new, clean bag on the concentrator. Clean the concentrator filter. Observation of Resident #7's room on 8/24/21 at 4:46 P.M. showed: - Oxygen tubing is not dated. - BiPAP mask is not covered, lying on the case for the machine that is on the over the bed table (OTBT); - Nebulizer mask is resting on the nebulizer machine with no cover over the mask. - Oxygen concentrator (machine that produces oxygen), filter with a white and gray matter that looks like lint covering the face of the filter. Observation of Resident #7 on 8/26/21 at 7:35 A.M. showed: - BiPAP mask is resting on the BiPAP machine case, uncovered. 3. Review of Resident #19 Quarterly MDS dated [DATE] showed: - BIMS score of 14, minimal cognitive deficit. - ADLs' show that resident needs assistance with one to two staff for transfers, bed mobility, walking in the resident's room and the hallway, dressing, toilet use, and personal hygiene. - Diagnosis of COPD (a chronic lung disease), hypertension (high blood pressure), weakness, and emphysema (a lung disease in which the air sacs of the lungs are damaged, causing breathlessness). - Shortness of air when the resident is lying flat and sitting. Observation of Resident #19 on 8/25/21 at 8:24 A.M. showed the residents Oxygen tubing not dated. Review of Resident #19's care plan dated 8/9/21 showed: - Shortness of air with a goal to complete his/her ADLs' without shortness of breath. Intervention includes assessing the resident's respiratory status, provide oxygen per physician's order as needed, notify the physician of condition changes, change his/her oxygen tubing and humidifier per the facility protocol. Review of the Physician Order Sheet dated August 2021 for Resident 19 showed: - May use oxygen at 2 liters per nasal cannula and titrate (adjust) if needed. - No order to change the oxygen tubing. - There is no documentation on the medication administration record (MAR), or treatment administration record (TAR) that the oxygen tubing has been changed. 4. Review of Resident #17 quarterly MDS dated [DATE] showed: - admit date [DATE]. - BIMS no score indicating severe cognitive impairment. - Resident is dependant on staff for ADLs cares; bed mobility, locomotion in his/her Broda chair, dressing, eating, toilet use, and personal hygiene. - Shortness of air. Observation of Resident #17 on 8/25/21 11:58 at A.M. showed: - The resident has oxygen on, the tubing is not dated. - Nebulizer mask resting on the nebulizer machine and not covered. Review of Resident #17's care plan showed: - The resident's oxygen use is not on the current plan of care. Review of the Physician Order Sheet dated August 2021 showed: - An order to change the oxygen tubing every Tuesday, date and initial with paper tape before applying the new tubing to the oxygen concentrator. Date and place new, clean bag on the oxygen concentrator. Clean the concentrator filter. Review of the Treatment Administration Record dated August 2021 showed: - Documentation that the resident oxygen tubing was changed on 8/17/21 and 8/24/21. During an interview on 8/27/21 at 10:28 A.M. with Licensed Practical Nurse (LPN) A said: - The oxygen tubing should be dated and the nebulizer masks should be covered. - If he/she encountered tubing that wasn't dated, he/she would change the tubing, date and initial it. During an interview on 8/27/21 at 4:38 P.M. with the Interim Director of Nurses (DON) said: - Oxygen tubing and nebulizer tubing should be dated. - Oxygen tubing and nebulizer tubing should be changed weekly on the night shift. - The Nebulizer and BiPAP masks should be covered. - The oxygen concentrator filter should be checked for cleanliness and cleaned if they are dirty. 5. Review of Resident #21's admission MDS, dated [DATE], showed: - Cognitive skills intact; - Independent with bed mobility, eating, toilet use and personal hygiene; - Limited assistance of one staff for transfers and dressing; - Lower extremity impaired on one side; - Diagnoses included atrial fibrillation (an irregular and often rapid heart rate) and high blood pressure. Review of the resident's care plan, dated 8/20/21, showed it did not address the use of oxygen. Observation on 8/24/21 at 1:03 P.M., showed: - The oxygen tubing was not dated. Review of the resident's POS, dated 9/21, showed: - An order for oxygen at two liters per nasal cannula while in bed to keep oxygen saturation at the appropriate level. During an interview on 8/27/21 at 2:43 P.M., LPN A said: - The oxygen and nebulizer tubing is changed weekly and should be dated.

Based on observations, interviews, and record review, the facility failed to ensure staff properly stored and discarded resident medications, stock medications, and treatment supplies. Staff failed to date medications when opened and failed to ensure medications are kept in a secure manner. Staff failed to ensure insulin Flexpens were dated when opened, which affected three of 12 sampled residents, (Resident #5, #10 and #28). The facility census was 30. 1. 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; - The expiration/beyond use date on the medication label is checked prior to administering.; - When opening a multi-dose container, the date opened is recorded on the container. Review of the facility's insulin administration policy, revised September 2014, showed, in part: - The purpose is to provide guidelines for the safe administration of insulin to residents with diabetes; - The policy did not address insulin pens dated when opened. 2. Review of Resident #5's physician order sheet (POS), dated August 2021, showed: - Novolog (fast acting insulin) Flexpen give per sliding scale:0-150- 0 units, 151-200- one unit, 201-250-two units, 251- 300-three units, 301-350-four units, 351- 400- five units, 401 and above give eight units and call the physician for diabetes mellitus; - Novolog Flexpen nine units three times a day for diabetes mellitus. Observation on 8/26/21 at 12:12 P.M., showed: - Certified Medication Technician (CMT) B administered 14 units of Novolog insulin to the resident and it did not have a date when it was opened. 3. Review of Resident #10's POS, dated August 2021, showed: - Novolog Flexpen, inject three units three times daily with meals for diabetes mellitus; - Novolog Flexpen inject three times daily with meals per sliding scale: 70-140- 0 units, 141-180-two units, 181- 220- four units, 221-260- six units, 261-300- eight units, 301-350- ten units, greater than 351- 12 units and notify the physician. Observation on 8/2621 at 1:04 P.M., showed: - CMT B administered 15 units of Novolog insulin to the resident and it did not have a date when it was opened. During an interview on 8/26/21 at 1:18 P.M., CMT B said: - The insulin should be dated when it was opened. 4. Review of Resident #28's POS, dated August 2021, showed: - Novolog Flexpen per sliding scale: 1-150- one unit, 151-250- two units, 251-300- three units, 301-350-four units, 350 or greater- five units for diabetes mellitus. Observation on 8/26/21 at 12:36 P.M., showed: - Licensed Practical Nurse (LPN) B administered four units of Novolog insulin to the resident and it did not have a date when it was opened. During an interview on 8/26/21 at 1:14 P.M., LPN B said: - Insulin should be dated when opened. During an interview on 8/27/21 at 4:39 P.M., the Interim Director of Nursing (DON) said: - Insulin should be dated when opened.

Based on observation, record review and interviews, the facility failed to ensure each resident received foods prepared in a way to conserve nutritive value, flavor and appearance and failed to serve foods that are a safe and appetizing temperature. The facility census was 30. The facility did not provide dietary policies. An observation of the lunch meal service on 8/26/2021 at 12:11 P.M. showed: -The lunch meal consisted of a marinated chicken breast, cooked broccoli, garlic breadstick, cottage cheese. -The broccoli was very mushy and had little flavor. An observation of the evening meal tray on 8/26/2021 at 5:28 PM showed: -The meal consisted of cheesy ham hashbrown casserole, garlic breadstick, lettuce salad with ranch dressing, and chocolate pudding with vanilla wafer cookies. -The casserole was 170.7 degrees, the breadstick 120.6 degrees, the lettuce salad 53.2 degrees, the pudding 54.6 degrees. -The casserole consisted of hashbrown potatoes, ground ham, a cream sauce and melted cheese on top. It tasted of very salty ham. The breadstick was soft and tasted good. The lettuce in the salad was wilted. The pudding tasted good. During an interview on 8/26/2021 at 5:35 P.M., Resident #1 stated he/she did not eat much dinner and the casserole was not good. During an interview on 8/27/2021 at 9:54AM, the son of Resident #4 said: -Neither the resident or himself have been interviewed about the resident's food preferences. -Resident #4 is a picky eater and is not offered many alternates. -Resident #4 gets served soup quite a bit and it is usually cold. Observation on 8/27/2021 of the lunch meal service at 12:07 P.M. showed: -Dietary Aide A was plating the meal from the steam table in the small kitchen off of the dining room. -The lunch meal consisted of 3 breaded chicken strips, macaroni and cheese, mixed vegetables and a cookie. -Dietary Aide A tested the temperatures of the food while on the steam table. The chicken strips were 150 degrees, the macaroni and cheese were 182 degrees, and the mixed vegetables were 170 degrees. -The mechanical soft chicken had not been prepared when Dietary Aide A began serving the residents in the dining room. The Dietary Manager took some chicken strips from the steam table back to the main kitchen to prepare the mechanical soft chicken. The Dietary Manager returned to the dining room with the mechanical soft chicken at 12:28 P.M -Dietary Aide A provided a hall tray after the last of the hall trays had been provided to residents eating in their rooms. The plate consisted of 3 breaded chicken strips, macaroni and cheese, and mixed vegetables. The chicken strips were 129.7 degrees, the macaroni and cheese was 132.6 degrees and the mixed vegetables were 133.1 degrees. The chicken strips were dry. The macaroni and cheese had a creamy consistency and tasted acceptable. The mixed vegetables were bland. During an interview on 8/27/2021 at 3:01 P.M., the Registered Dietician said staff have a menu substitution log. Staff record substitutions and he/she reviews it when he/she comes in monthly. Menu items could be substituted if there is a supply issue or a menu item did not turn out when cooking. This corporation locks the menu and he/she has spoken with dietary manager about making the scheduled menu and making enough of an alternate to offer the residents.

Based on observation and interviews the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public when they did not keep the parking lot in good repair and failed to maintain all areas of the facility. The facility census was 30. Observation on 8/24/21 starting at 11:00 A.M., through 8/27/21 showed: - The facility's front parking lot with large areas of missing concrete and only gravel. Some areas measured approximately three feet wide in some spots and at least 6 feet long. The concrete had deteriorated from around the joints in the concrete. - Window sill outside rotted on all windows on the west front outside of the building. The two located the furthest from the facility's entrance actually had wood missing, crumbling when touched and peeling away. - Egress doors located on the end of the 100 and 200 halls each had two windows, one large and one small, on the side of the door. The windows had metal frames around them had rusted with the worst places being the metal frame separating the large window from the small window. The rusted metal peeled up on the 200 hall, creating a hazard to any resident who approached the windows to look outside. - In the facility's basement, a moldy, musty smell could be smelled in the hallway. Both rooms were filled with large amounts of stored items. One had medical records, dishes, Christmas decorations. The floor around the medical records appeared to be wet. During an interview on 8/27/21 at 4:50 P.M., the administrator said the rooms in the basement were extremely cluttered. She did not know where the smell was coming from but it did smell musty and moldy. They had plans to go through both of the rooms, but corporate staff had not made it to the facility yet to help with that. During an interview on 9/1/21 at 1:30 P.M., the administrator and maintenance supervisor said they knew the parking lot had begun to crumble and it was on the list of things to fix, along with the outside windows. They did not know how to repair the rusted window frames without replacing the entire door and frame.

Based on observations, interviews, and record reviews, the facility failed to provide residents with Saturday mail delivery. This affected all of the residents residing in the facility. The facility census was 30. 1. Review of the undated Resident Rights policy showed: - The right to have communication with and access to people and services inside and outside of the facility. - The right to exercise his/her rights as a resident of the facility and as a resident of the United States. - The right to have access to a telephone, email, and mail. - The right to communication in person, by mail, email, and telephone with privacy. 2. No mail delivery policy was provided. 3. During the resident council meeting on 8/25/21 at 2:30 P.M. the resident's said: - They do not regularly get their mail delivered on Saturday's. - Five out of 11 residents said they would like to get their mail delivered on Saturday's. 4. During an interview on 8/27/21 at 10:28 A.M. Licensed Practical Nurse (LPN) A said: - Yes, the resident's get their mail delivered on Saturdays. - He/she does not know who is designated to deliver the mail on Saturday's. 5. During an interview with the Social Services Director (SSD) on 8/27/21 at 10:40 A.M. said: - At one time, Activities was delivering the mail on Saturday's, but he/she does not know if that is still occurring. - He/she said sometimes the Certified Nurses Assistant (CNA) will go to the mailbox and pass it on Saturdays. - Sometimes he/she comes in on Saturdays and pass the mail. - No one person is designated to pass mail. 6. During an interview with the Interim Director of Nursing (DON) on 8/27/21 at 4:38 P.M. said: - He/she is not at the facility often on the weekends and does not know if the mail gets passed to the residents on Saturdays. - The Administrator should be able to provide that information. 7. During an interview with the Administrator on 8/27/21 at 6:02 P.M. said: - The Activities Director delivers the resident's mail Monday through Friday. - Occasionally the Activities Director will go to the facility on a Saturday and will deliver the resident's mail to them. - There is not a person assigned to deliver the mail to the residents on Saturdays. - When the mail is not delivered to residents on Saturday, the mail is delivered on the following Monday.

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN), other than the Director of Nursing (DON), for eight consecutive hours per day, seven days a week. This affected all the residents in the facility. The facility census was 30. The facility did not provide a policy. 1. Review of the staffing schedule dated, July, 2021, showed two days where the facility did not have an RN working. Review of the staffing schedule dated, August, 2021, showed six days where the facility did not have an RN working. During an interview on 8/24./21, at 11:12 A.M., the Administrator said: - The Interim DON is the Corporate Nurse; - The new DON will start on 9/1/21. During an interview on 8/27/21, at 4:39 P.M., the Interim DON said: - The facility does not have an RN to work eight hours a day, seven days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure store food in a sanitary manner and failed to maintain the kitchen and dry storage area in a sanitary manner. This affects all residents who receive their food from the facility's kitchen. The facility census was 30. Observation on 8/24/2021 at 12:31 P.M. of the kitchen showed: -the floor under the dishwashing sink was dirty with debris and dark matter -a substance was splattered several places on the ceiling, near the center of the ceiling and above the door by the dishwasher -a black matter on the floor along the edging below the cabinets -the fire extinguisher is resting on the floor -the underside of the hood above the stove is dirty with grease and dust -the drain for the griddle is dirty with grease and food particles -vent over the hanging pots and pans is dusty -the large trash can near the stove does not have a lid -a frozen coffee drink belonging to staff in the large stand up freezer -an open package of sausage patties, unlabeled -empty used disposable drink cup in the dry storage room -open back of potato chips with no label -many flies throughout the kitchen -the vent in the ceiling over the dishwasher is coming away from the ceiling Observation on 8/26/2021 at 3:04 P.M. of the kitchen showed: Dry Storage room: -the floor is sticky with crumbs -several staff drinks on the shelves, among the food items -a paper bag from Dairy Queen, containing a wrapped sandwich, on the shelf with spices -an open roll of crackers with no label/date -an open bag of dry bean with no label/date -dust and dirt on outside of furnace -an open bag of graham cracker crumbs with no label/date Side by Side Refrigerator: -Open box of precooked bacon dated 8/9/2021 -a bag of carrots not dated -several heads of cabbage and cauliflower not dated -a plastic container of lettuce dated 8/16/2021 -bag of frozen eggs thawing in a pan at the bottom of the refrigerator, not dated Refrigerator with freezer on top: -Jar of salsa in refrigerator door with no date Side by Side Freezer: -open bag of breakfast sausage, no label/date -open gallon of ice cream with no label/date -open bag of hamburger patties with no label/date -open bag of breaded chicken strips with no label/date Counter/Preparation Area: -staff drinks on counter area near coffee machine -open package of English muffins with no date -the shelf storing the baking sheets was dirty with crumbs and dust -the top of the coffee machine is dirty with dust and crumbs, the labeled taped on top of the machine is coming off -the top of the toaster is dirty with crumbs and dust -the top of the inside of the microwave is dirty with food matter -there is no lid on the large trash can near the stove -fire extinguisher is resting on the floor -splatters of food on the outside of the food processor During an interview on 8/26/2021 at 3:48 P.M., Dietary Aide B said: -to make the sanitizing solution, he/she empties the red sanitation bucket then fills it up. When asked how much water is needed, he/she said until the bucket is almost full. He/she then adds one tablet from the bottle of Steramine 1-G tabs and allows the tablet to dissolve. -when asked how to test the strength of the solution, Dietary Aide B said he/she uses the strips in the container kept next to the sink. The test strip, when placed into the sanitizing solution, should darken various shades of purple, dependent on the strength of the sanitizing solution. He/she placed a strip in the solution and the strip did not change color. He/she attempted with a second strip, which did not change color. -Dietary Aide A then came to assist Dietary Aide B. Dietary Aide A said he/she uses 2 tabs in the red bucket for the sanitizing solution. Dietary Aide A then attempted to test the sanitizing solution 3 time. Each time, the test strip did not change color. -In reviewing the label of the test strips, it was found the test strips only measure 0-200ppm. The label on the sanitation tablets states the solution should measure between 200-400ppm. The test strips being used in the kitchen are not able to measure the strength of the sanitizing solution. In an interview with the Dietary Manager at 4:05 P.M., he/she said: -The test strips the kitchen staff were using prior had run out. He/she order more from the supplier, [NAME]. These are the strips he/she had been sent and the staff are now using. -The dietary manager agreed the strips the kitchen staff are currently using do not measure the sanitizing solution correctly. -Dietary Aide A tested the dishwashing solution in the dishwasher with the test strips. The solution in the dishwasher measured 50ppm. The label on the dishwasher solution indicates the solution measure 50ppm at minimum. An observation of the refrigerators in the small kitchen near the dining room on 8/27/2021 at 12:07 P.M. showed: Stainless Steel refrigerator: -A bottle of ranch salad dressing and a bottle of French salad dressing, neither with dates. Almond color refrigerator: -Staff and resident food and drink items stored together. -Multiple items not labeled with names or dates, including various drinks, celery, cucumbers, chocolate syrup. -A 500 milliliter (ml) bottle of Omnipaque solution. This medication is used before X-ray imaging tests (such as CT scans). Iohexol contains iodine and belongs to a class of drugs known as contrast media or dyes. It works by adding contrast to body parts and fluids in these imaging tests. -There is no temperature log for the freezer portion of the appliance. During an interview on 8/27/2021 at 3:01 P.M., the Registered Dietician said: -His/her expectation for food storage is the food must be covered, labeled with the name of the item and date the food was put into the refrigerator or freezer and then must be disposed of after 3 days.